Southern Star Home Healthcare, Inc.

“Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(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. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient’s medical and psychiatric condition and home environment. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness P&P and plan included procedures to inform the state and local emergency officials about the patients in need of evacuation from their residences due to an emergency situation. This created the risk of not meeting the health, safety, and security needs of their staff and patient population during an emergency or disaster situation. Findings: Review of the agency’s P&P for emergency preparedness program was conducted on 12/5/23. The Emergency Management Plan revised 10/2/23, showed if care cannot be provided to high risk patients, emergency transport to alternate care delivery sites will be arranged with community support agencies. However, the agency’s emergency preparedness P&P and plan failed to describe when and how information would be communicated to the emergency officials in the event a patient needed evacuation at any time due to an emergency situation based on the patient’s medical and psychiatric condition and home environment. On 12/6/23 at 0807 hours, an interview and concurrent record review was conducted with the IT Consultant. The IT Consultant was informed and acknowledged the finding.”

“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 interview and record review, the agency failed to ensure the emergency preparedness communication plan included the updated name and contact information of the patients’ physician, and volunteers. This failure had the potential to negatively impact the patients’ care needs during the emergency events. Findings: Review of the agency’s emergency preparedness communication plan was conducted on 12/5/23. The agency’s emergency management plan showed the agency will maintain a “calling tree” or chain of command for staff in the event of an emergency or disaster situation. When there are changes to the chain of command, the agency will ensure all copies of the chain of command are replaced with the most recent version. However, the agency did not have the contact information of the patients’ physician and volunteers. On 12/6/23 at 0807 hours, an interview and concurrent record review was conducted with the IT Consultant. The IT Consultant was informed and acknowledged the finding.”

“EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to ensure initial training on the emergency preparedness program was provided to the volunteers and contracted individuals providing the services under the arrangement; and documentation of all the emergency preparedness training was maintained. This failure created the risk of the HHA’s staff not knowing what to do in case of emergency. Findings: Review of the agency’s Emergency Management Plan revised 10/2/2023, was conducted on 12/5/23. The agency’s Emergency Management Plan showed the plan for managing interruptions in information management processes included training for staff and licensed independent practitioners on alternative procedures to follow when electric or paper information systems are unavailable. However, there were no documented evidence the initial emergency preparedness training was provided to the volunteers and contracted individuals. On 12/5/23 at 0807 hours, an interview and concurrent record review was conducted with the IT Consultant. The IT Consultant was informed and acknowledged the finding.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to ensure the care and services were provided as ordered for two of 11 sampled patients (Patients 2 and 6), creating the risk of not providing appropriate, consistent, and quality of care to these patients. Findings: The agency’s P&P titled Missed Visits revised 10/2022 showed a missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record. The procedure includes to notify the physician and clinical supervisor of the missed visit and reason for the missed visit. 1. Review of Patient 6’s clinical record was initiated on 12/5/23. The clinical record showed the SOC was 7/29/23. The patient was certified for home health services during the certification periods from 7/29/23 to 9/26/23, and 9/27/23 to 11/25/23. The POC, for the certification period from 9/27/23 to 11/25/23, cited SN visits 1W1 (one time a week for one week), 2W1, and 1W7 to perform assessment and observation of patient’s physical status including of all body systems. However, there was no documented evidence the SN visited the patient one time a week during Week 9 (11/18 to 11/24/23) as cited in the POC. There was no documented evidence of the physician’s notification about the missed visit. On 12/6/23 at 1411 hours, an interview and concurrent clinical record review was conducted with the IT Consultant. The IT Consultant was asked if the physician was notified of the missed visits. The IT Consultant replied they should but there was no documentation the physician was notified. The IT Consultant was informed and acknowledged the finding. 2. Review of Patient 2’s clinical record was initiated on 12/1/23. The clinical record showed the SOC was 10/21/23. The patient was certified for home health services during the certification period from 10/21/23 to 12/19/23. The POC for the certification period from 10/21/23 to 12/19/23, cited SN visits 1W1, 2W1, and 1W7 to perform comprehensive assessment, observation and evaluation of all body systems. Review of the SN notes showed the SN had visited the patient only one time during Week 2 (10/22 to 1028/23), instead of two times a week as cited in the POC. In addition, there was no documented evidenced the SN had visited the patient during Week 7 (11/26 to 12/2/23) as cited in the POC. There was no documented evidence of the physician’s notification about the missed visits. On 12/6/23 at 1358 hours, an interview and concurrent clinical record review was conducted with the IT Consultant. The IT Consultant 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 HHA failed to ensure the entries on the clinical record included the credential of the staff who completed the documents for eleven of eleven sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11) creating the risk of not having the complete and accurate information. Findings: Review of the agency’s P&P titled Entries into The Clinical Record revised 10/22 showed the clinical note will include the signature authorization of clinical documentation will include the staff member’s name and credentials (as specified on professional licenses and/or certification documents). 1. Review of Patient 1’s clinical record was initiated on 12/1/23. The clinical record showed the SOC was 10/12/23. The patient was certified for home health services during the period from 10/12/23 to 12/10/23. The SOC OASIS dated 10/12/23, showed the notes were electronically signed by the clinician. However, the title/credential was not included. 2. Review of Patient 6’s clinical record was initiated on 12/5/23. The clinical record showed the SOC was 7/29/23. The patient was certified for home health services during the certification periods from 7/29/23 to 9/26/23, and 9/27/23 to 11/25/23. The SOC OASIS dated 7/29/23, showed the notes were electronically signed by the clinician. However, the title/credential was not included. In addition, review of the Discharge OASIS dated 11/25/23, showed the notes were electronically signed by the clinician. However, the title/credential was not included. 3. Review of Patient 2’s clinical record was initiated on 12/1/23. The clinical record showed the SOC was 10/21/23. The patient was certified for home health services during the certification periods from 10/21/23 to 12/19/23. The SOC OASIS dated 10/21/23, showed the notes were electronically signed by the clinician. However, the title/credential was not included. On 12/6/23 at 1630 hours, an interview and concurrent clinical record review was conducted with the IT Consultant. The IT Consultant was informed and acknowledged the findings. The clinician was an RN. 4. Review of Patient 5’s clinical record was initiated on 11/30/23. The clinical record showed the SOC was 10/16/23. The patient was certified for home health services during the certification periods from 10/16/23 to 12/14/23. a. The SOC OASIS dated 10/16/23, showed the notes were electronically signed by the clinician. However, the title/credential was not included. On 12/6/23 at 1630 hours, an interview and concurrent clinical record review was conducted with the IT Consultant. The IT Consultant was asked as to the credentials of the clinician who completed the SOC OASIS. The IT Consultant replied, she was an RN, and would include her title in the electronic signature moving forward. The IT Consultant was informed and acknowledged the findings. b. Review of the Physicians Order dated 10/14, 10/16 and 11/7/23 showed the physician’s name. However, the order failed to include the physician’s electronic signature and the date the physician signed the order. In addition, review of the POC for the certification period from 10/16/23 to 12/14/23, showed the section of the attending physician signature and date signed was left blank. On 12/6/23 at 1358 hours, an interview and concurrent clinical record review was conducted with the IT Consultant. The IT Consultant was asked if the physician needed to sign and date the orders. The IT Consultant replied, the physician should have signed and dated the orders. The IT Consultant was informed and acknowledged the findings. 5. Review of Patient 9’s clinical record was initiated on 12/5/23. The clinical record showed the SOC was 2/22/23. The patient was certified for home health services during the certification periods from 2/22/23 to 4/22/23 and 4/23/23 to 6/21/23. Review of the clinical record showed the SOC OASIS dated 2/22/23, was completed. However, the section for the name and date of the clinician who completed the assessment was left blank. In addition, review of the Recertification OASIS dated 4/20/23, showed the section for the name and date of the clinician who completed the assessment was left blank. On 12/6/23 at 1511 hours, an interview and concurrent clinical record review was conducted with the IT Consultant. The IT Consultant was asked who performed the assessment. The IT Consultant stated he would provide the document. However, the document provided was still blank. The IT Consultant was informed and acknowledged the findings. 6. Review of Patient 4’s clinical record showed the SOC was 9/29/23. The closed clinical record showed the patient received home health services during the certification period from 11/28/23 to 1/26/24. Review of the patient’s recertification OASIS dated 11/25/23, showed the notes were electronically signed by a clinician. However, the clinician’s credential was not included. On 12/6/23 at 1304 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the findings. 7. Review of Patient 3’s clinical record showed the SOC was 11/2/23. The closed clinical record showed the patient received home health services during the certification period from 11/2/23 to 12/31/23. Review of the patient’s SOC OASIS dated 4/13/23, showed the notes were electronically signed by a clinician. However, the clinician’s credentials were not included. On 12/6/23 at 1345 hours, an interview and concurrent record review was conducted with RN 1. RN 1 was informed and acknowledged the findings. 8. Review of Patient 7’s closed clinical record showed the SOC was 7/10/23. The closed clinical record showed the patient received home health services during the certification periods from 7/10/23 to 9/7/23, and 9/8/23 to 11/6/23. Review of the Discharge Summary dated 11/4/23, showed the patient was discharged on 11/4/23, and the reason for discharge was no further care needed. Further review of the clinical record failed to show the name of the clinician completing the form, physician signature, and dates both clinicians signed the form. On 12/6/23 at 1130 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the findings. 9. Review of Patient 10’s clinical record was initiated on 12/4/23. The clinical record showed the SOC was 4/13/23. The patient was certified for home health services during the period from 4/13/23 to 6/11/23. Review of the patient’s SOC OASIS dated 4/13/23, showed the notes were electronically signed by a clinician. However, the clinician’s credentials were not included. On 12/6/23 at 1523 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed of the findings. 10. Review of Patient 8’s closed clinical record showed the SOC was 3/1/23. The closed clinical record showed the patient received home health services during the certification periods from 3/1/23 to 4/29/23 and 4/30/23 to 6/28/23. Review of the SOC dated 6/25/23, showed the patient was discharged on 6/25/23, and the reason for discharge was no further care needed. Further review of the clinical record failed to include the type of services and frequency of services received, and medications that the patient was on at the time of discharge. Review of the HHA’s record dated 8/7/23, showed a fax was sent to the patient’s physician on 8/7/23. However, further review of the clinical record failed to show documented evidence the transfer summary and medication list were sent to the physician. On 12/6/23 at 1130 hours, an interview and concurrent record review was conducted with RN 1. RN 1 was informed and acknowledged the findings. 11. Review of Patient 11’s closed clinical record was initiated on 12/4/23. The clinical record showed the SOC was 3/1/23. The closed clinical record showed the patient received home health services during the certification periods from 3/1/23 to 4/29/23. Review of the patient’s recertification OASIS dated 3/1/23, showed the notes were electronically signed by a clinician. However, the clinician’s credentials were not included. On 12/6/23 at 1304 hours, an interview and concurrent clinical record was conducted with RN 1. RN 1 was informed and acknowledged the findings.”

“State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This Element is not met as evidenced by: Based on interview and record review, the agency failed to provide the contact information for the State toll-free hot line, agency’s contact information, and agency’s hours of operation for seven of 11 sampled patients (Patient 1, 2, 4, 6, 7, 8, and 10), creating the risk of delayed complaint notification. Findings: 1. Review of Patient 1’s clinical record was initiated on 12/1/23. The clinical record showed the SOC was 10/12/23. The patient was certified for home health services during the certification period from 10/12/23 to 12/10/23. Review of the Patient Consent/Admission/Recertification Service Agreement dated 10/12/23, showed the Clients Rights and Responsibilities. The Clients Rights and Responsibilities showed the list of the contact information for filing a complaint. However, the contact information for CDPH, Licensing and Certification Program was for Los Angeles County instead of Orange County. 2. Review of Patient 2’s clinical record was initiated on 12/1/23. The clinical record showed the SOC was 10/21/23. The patient was certified for home health services during the certification period from 10/21/23 to 12/19/23. Review of the Patient Consent/Admission/Recertification Service Agreement dated 10/21/23, showed the Clients Rights and Responsibilities. The Clients Rights and Responsibilities showed the list of the contact information for filing a complaint. However, the contact information for CDPH, Licensing and Certification Program was for Los Angeles County instead of Orange County. 3. Review of Patient 6’s clinical record was initiated on 12/5/23. The clinical record showed the SOC was 7/29/23. The patient was certified for home health services during the certification periods from 7/29/23 to 9/26/23, and 9/27/23 to 11/25/23. Review of the Patient Consent/Admission/Recertification Service Agreement dated 7/29/23, showed the Clients Rights and Responsibilities. The Clients Rights and Responsibilities showed the list of the contact information for filing a complaint. However, the contact information for CDPH, Licensing and Certification Program was for Los Angeles County instead of Orange County. On 12/6/23 at 1630 hours, an interview and concurrent clinical record review was conducted with the IT Director. The IT director was informed and acknowledged the findings. 4. Review of Patient 4’s clinical record was initiated on 12/1/23. The clinical record showed the SOC was 9/29/23. The patient was certified for home health services during the certification periods from 9/29/23 to 11/27/23 and 11/28/23 to 1/26/23. Review of the signed Patient Consent/Admission/Recertification Service Agreement dated 9/29/23, showed the Clients Rights and Responsibilities. The Clients Rights and Responsibilities showed the contact information for filing a complaint. However, the contact information for CDPH, Licensing and Certification Program was for Los Angeles County instead of Orange County. On 12/6/23 at 1448 hours, and interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the finding. 5. Review of Patient 8’s closed clinical record was initiated on 12/5/23. The clinical record showed the SOC was 3/1/23. The patient was certified for home health services during the certification periods from 3/1/23 to 4/29/23 and 4/30/23 to 6/28/23. Review of the signed Patient Consent/Admission/Recertification Service Agreement dated 3/1/23, showed the Clients Rights and Responsibilities. The Clients Rights and Responsibilities showed the contact information for filing a complaint. However, the contact information for CDPH, Licensing and Certification Program was for Los Angeles County instead of Orange County. On 12/6/23 at 1300 hours, and interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the finding. 6. Review of Patient 7’s closed clinical record was initiated on 12/4/23. The clinical record showed the SOC was 7/10/23. The patient was certified for home health services during the certification periods from 7/10/23 to 9/7/23 and 9/8/23 to 11/6/23. Review of the signed Patient Consent/Admission/Recertification Service Agreement dated 7/10/23, showed the Clients Rights and Responsibilities. The Clients Rights and Responsibilities showed the contact information for filing a complaint. However, the contact information for CDPH, Licensing and Certification Program was for Los Angeles County instead of Orange County. On 12/6/23 at 1300 hours, and interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the finding. 7. Review of Patient 10’s closed clinical record was initiated on 12/4/23. The clinical record showed the SOC was 4/13/23. The patient was certified for home health services during the period from 4/13/23 to 6/11/23. Review of the signed Patient Consent/Admission/Recertification Service Agreement dated 4/13/23, showed the Clients Rights and Responsibilities. The Clients Rights and Responsibilities showed the contact information for filing a complaint. However, the contact information for CDPH, Licensing and Certification Program was for Los Angles County instead of Orange County. On 12/6/23 at 1523 hours, and interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the finding.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the RN conducted the initial assessment visit within 48 hours of the referral for one of 11 sampled patients (Patient 1), creating the risk of not identifying and addressing the care needs in a timely manner for this patient. Findings: Review of the agency’s P&P titled Initial and Comprehensive Assessment revised 5/23 showed the initial assessment visit must be performed wither within 48 hours of the referral, within 48 hours of the patient’s return home, on the start of care date ordered by the physician or at the patient/family’s request for approval of the physician. Review of Patient 7’s closed clinical record was initiated on 12/4/23. The clinical record showed the referral date was 6/24/23, and the SOC was 7/10/23. The patient was certified for home health services during the certification period from 7/10/23 to 9/7/23 and 9/8/23 to 11/6/23. However, further review of the clinical record showed the initial assessment visit was conducted by the RN on 7/10/23, 16 days after the referral date. There was no documented evidence explaining why the initial assessment visit was not conducted within 48 hours of the referral date. On 12/6/23 at 1512 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 verified the above 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 accurately and consistently with the patient’s immediate needs for one of 11 sampled patients (Patients 1). This failure created the risk of not identifying and addressing the care needs for this patient. Findings: Review of the agency’s P&P titled Initial and Comprehensive Assessment revised 10/2022 showed the comprehensive patient assessment will be completed within five calendar days of the patients start of care. The comprehensive assessment for each patient must be completed in its entirety by the same clinician. During the initial comprehensive assessments, all baseline data to be used in the measuring patients progress toward goals and other relevant information will be documented in the patients clinical record, including at least the physical assessment, blood pressure, temperature, pulse, respiration and other relevant data related to pertinent physical findings. Review of Patient 1’s clinical record was initiated on 12/1/23. The clinical record showed the SOC was 10/12/23. The patient was certified for home health services during the certification period from 10/12/23 to 12/10/23. Review of the SOC OASIS dated 10/12/23, showed the patient’s primary diagnosis was essential (primary) hypertension and other diagnosis was type 2 diabetes mellitus. However, review of the initial comprehensive assessment failed to show documented evidenced of the vital signs and blood sugar level assessed as part of the initial comprehensive assessment. On 12/6/23 at 1411 hours, an interview and concurrent clinical record review was conducted with the IT Consultant. The IT Consultant was asked if they needed to assess the patient’s vital signs and blood sugar level. The IT Consultant replied it should be documented. The IT Consultant was informed and acknowledged the finding.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure the medication profiles were updated to reflect the current medications for two of 11 sampled patients (Patients 3 and 5). This failure created the risk for the patients not receiving the appropriate care and services necessary to improve the patients’ health conditions. Findings: Review of the agency’s P&P titled Medication Profile revised 11/2022 showed the patients receiving medications will have a current, accurate medication profile maintained in the clinical record. Medication profiles will be updated for each change to reflect current medications, new and/or discontinued medications. 1. Review of Patient 3’s clinical record was initiated on 12/1/23. The clinical record showed the SOC was 11/2/23. The patient was certified for home health services during the certification period from 11/2/23 to 12/31/23. The medication profile, for the certification period from 11/2/23 to 12/31/23, showed the medications included Advair Diskus (corticosteriod and bronchodilator) 250 mcg - 50 mcg dose powder for inhalation one puff once a day, Ventolin HFA (bronchodilator) 90 mcg actuation aerosol inhaler one puff once a day, metformin (antidiabetic) 500 mg one tablet PO once a day, zolpidem (hypnotic) 10 mg one tablet PO once a day, vitamin D (supplement) 5000 iu one tablet PO once a day, and Welchol 625 mg (antilipemic) one tablet PO once a day. On 12/1/23 at 1208 hours, a joint home visit was conducted with the PT to Patient 3’s home. Review of the patient’s medications with the PT and patient showed the patient was taking Advair Diskus 250 mcg- 50mcg/ dose powder two puffs two times a day instead of one puff daily, Ventolin HFA 90 mcg/ actuation aerosol inhaler two puffs as needed instead of one puff daily, metformin 500 mg one tablet PO as needed depending on blood sugar levels instead of one tablet daily, Zolpidem 10 mg one tablet PO as needed instead of one tablet daily, and Welchol 625 mg three tablets two times a day instead of one tablet daily as per the medication profile. On 12/6/23 at 1345 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed of the findings. 2. Review of Patient 5’s clinical record was initiated on 11/30/23. The clinical record showed the SOC was 10/16/23. The patient was certified for home health services during the certification period from 10/16/23 to 12/14/23. The Medication Profile, for the certification period from 10/16/23 to 12/14/23, showed the medications included atorvastatin (anti-cholesterol) 80 mg one tablet PO daily. On 12/1/23 at 1104 hours, a joint home visit with the LVN 1 was conducted to Patient 5’s home. Review of the patient’s medications with LVN 1 and the PCG showed the patient was taking atorvastatin 80 mg one tablet at bedtime instead of one tablet daily. On 12/1/23 at 1207 hours, LVN 1 was asked if the medication profile was updated to reflect the timing of the medication. LVN 1 replied it did not match the medication profile. LVN 1 was informed and acknowledged the finding. Further review of the Medication Profile for the certification period from 10/16/23 to 12/14/23, showed the following: - sertraline HCL (antidepressant) 50 mg one tablet twice a day, - metoprolol succinate ER (antihypertensive) 25 mg one tablet once a day, - montelukast sodium (leukotriene receptor antagonist) 10 mg chewable tablet once a day, - atorvastatin (antilipemic) 80 mg one tablet oral once a day, - isosorbide mononitrate (antianginal) 30 mg one tablet twice a day, - Ferosul (iron supplement) 325 mg one table twice a day, - folic acid (supplement) one mg one tablet once a day, - diclofenac sodium (non-steroidal anti-inflammatory medication) topical gel 1% apply one to two grams topically to affected knees twice a day, - Ventolin HFA (bronchodilator) 90 mcg inhaler one puff twice a day, - Losartan potassium (antihypertensive) 50 mg one tablet once a day, - clopidogrel (antiplatelet) 75 mg one tablet once a day, - fish oil (supplement) 1000 mg one capsule daily, - dexlansoprazole DR (proton pump inhibitor) 30 mg one capsule once a day, - Januvia (antidiabetic) 100 mg one tablet once a day and - vitamin D (supplement) 1.25 mg (50,000) unit one capsule once a week. However, further review of the medication profile showed the section for the classification of each medication was left blank. On 12/6/23 at 1352 hours, an interview and concurrent clinical record review was conducted with the IT Consultant. The IT Consultant was asked if they needed to document the indications/classification for each medication in the profile. The IT Consultant replied it should be completed. The IT Consultant was informed and acknowledged the finding.”

“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 on the SN visit schedule for three of eleven sampled patients (Patients 3, 4, and 5), creating the risk of not providing the necessary information to these patients. Findings: Review of the agency’s P&P titled Care Planning Process revised 11/22 showed the organization shall provide the patient and caregiver with a copy of written instructions outlining visit schedule, including the frequency of visits by personnel and personnel acting on behalf of the organization. 1. Review of Patient 4’s clinical record was initiated on 12/1/23. The clinical record showed the SOC was 9/29/23. The patient was certified for home health services during the certification periods from 9/29/23 to 11/27/23 and 11/28/23 to 1/26/23. The POC, for the certification period from 9/8/23 to 11/6/23, cited SN visits 1W9 for comprehensive skilled nursing assessment, observation, and evaluation of all body systems. On 12/1/23 at 0856 hours, a joint home visit with the LVN was conducted to Patient 4’s home. LVN 1 was asked for the written instructions regarding the SN visit schedule provided to the patient. LVN 1 stated they did not keep a visit calendar in the patient’s home. LVN 1 replied they had an agreement with the patient that they would call ahead of time prior to the visit. 2. Review of Patient 3’s clinical record was initiated on 12/1/23. The clinical record showed the SOC was 11/2/23 The patient was certified for home health services during the certification period from 11/2/23 to 12/31/23. The POC, for the certification period from11/2/23 to 12/31/23, cited SN visits 1W1, 2W2, and 1W7 for comprehensive skilled nursing assessment, observation and evaluation of all body systems. On 12/1/23 at 1208 hours, a joint home visit with the the PT was conducted to Patient 3’s home. The patient was asked for the written instructions regarding the visit schedule provided by the agency. The patient stated she did not know where it was. The PT verified there were no visit calendar available. On 12/6/23 at 1345 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the findings. 3. Review of Patient 5’s clinical record was initiated on 11/30/23. The clinical record showed the SOC was 10/16/23. The patient was certified for home health services during the certification period from 10/16/23 to 12/14/23. The POC, for the certification period from 10/16/23 to 12/14/23, cited SN visits 2W2 and 1W7 for comprehensive skilled nursing assessment, observation, and evaluation of all body systems. On 12/1/23 at 1104 hours, a joint home visit with LVN 1 was conducted to Patient 5’s home. LVN 1 was asked for the written instructions regarding the SN visit schedule provided to the patient. LVN 1 showed the visit schedule on the patients handbook; however, it was blank. LVN 1 was asked as to how would the patient know about the schedule of visits. LVN 1 replied they would call a day prior to the visit or two hours prior to the visit. LVN 1 was informed and acknowledged the finding. On 12/6/23 at 1352 hours, an interview and concurrent clinical record review was conducted with the IT Consultant. The IT Consultant was informed and acknowledged the finding.”

“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 interview and record review, the agency failed to ensure the SN provided care and services in accordance with the POCs for seven of 11 sampled patients (Patients 1, 2, 3, 4, 7, 10, and 11), creating the risk of not providing appropriate, consistent, and quality care to these patients. Findings: Review of the agency’s P&P titled Ongoing Assessments (undated) showed the ongoing assessments will be determined by the patients’ diagnoses, condition, desire for care, response to previous care, and care setting. The procedure includes during each visit, the clinician or other discipline will re-evaluate the patient according to the problems identified during the initial visit and subsequent visit. 1. Review of Patient 1’s clinical record was initiated on 12/1/23. The clinical record showed the SOC was 10/12/23. The patient was certified for home health services during the certification period from 10/12/23 to 12/10/23. The POC, for the certification period from 10/12/23 to 12/10/23, cited SN visits 1W1, 2W1, and 1W7 to perform comprehensive skilled nursing assessment. Review of the SN notes dated 10/16, 10/21, 10/23, 10/30, 11/6, 11/14, 11/22, and 11/29/23, showed the SN had performed body system assessment. However, the sections for mental/emotional status and sleep pattern were left blank. On 12/6/23 at 1411 hours, an interview and concurrent clinical record review was conducted with the IT Consultant. The IT Consultant was asked if they needed to assess the patient sleep pattern. The IT Consultant replied yes, they should and if there was no assessment, they were not following the POC. The IT Consultant was informed and acknowledged the finding. 2. Review of Patient 2’s clinical record was initiated on 12/1/23. The clinical record showed the SOC was 10/21/23. The patient was certified for home health services during the certification period from 10/21/23 to 12/19/23. The POC, for the certification period from 10/21/23 to 12/19/23, cited SN visits 1W1, 2W1, and 1W7 to perform comprehensive skilled nursing assessment, observation and evaluation of all body systems. Review of the SN notes dated 10/27, 10/31, 11/8, 11/15, and 11/22/23, showed the SN had performed body system assessment. However, the sections for mental/emotional status and sleep pattern were left blank. On 12/6/23 at 1358 hours, an interview and concurrent clinical record review was conducted with the IT Consultant. The IT Consultant was informed and acknowledged the finding. 3. Review of Patient 5’s clinical record was initiated on 11/30/23. The clinical record showed the SOC was 10/16/23. The patient was certified for home health services during the certification period from 10/16/23 to 12/14/23. The POC, for the certification period from 10/16/23 to 12/14/23, cited SN visits 2W2 and 1W7 to perform comprehensive skilled nursing assessment, observation, and evaluation of all body systems. The SN to assess mood/behavior changes and to report declines in patients psychosocial function, thought process, mood, affect and progressive disturbed sleep pattern. The POC also showed the patient’s cognitive functioning requires prompting (cuing, repetition, reminders) only under stressful or unfamiliar conditions. Review of the SN notes dated 10/19, 10/23, 10/26, 10/31, 11/7, 11/15, and 11/22/23, showed the SN had performed body system assessment. However, the sections for mental/emotional status and sleep pattern were left blank. On 12/6/23 at 1328 hours, an interview and concurrent clinical record review was conducted with the IT Consultant. The IT Consultant was informed and acknowledged the finding. 4. Review of Patient 7’s closed clinical record was initiated on 12/4/23. The clinical record showed the SOC was 7/10/23. The patient was certified for home health services during the certification periods from 7/10/23 to 9/7/23 and 9/8/23 to 11/6/23. The POC, for the certification period from 7/10/23 to 9/7/23, cited SN visits 2W1 and 1W8. Further review of the POC showed the SN to weigh the patient weekly and/or as needed. However, review of the SN notes during this certification period failed to show documented evidence the patient was weighed weekly as per the POC. On 12/6/23 at 1512 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the finding. 5. Review of Patient 3’s clinical record was initiated on 12/1/23. The clinical record showed the SOC was 11/2/23. The patient was certified for home health services during the certification period from 11/2/23 to 12/31/23. The POC, for the certification period from 11/2/23 to 12/31/23, cited SN visits 1W1, 2W1 and 1W7. The SN to check oxygen saturation level via finger pulse oximeter (a electronic device that measures the saturation of oxygen carried in your red blood cells) every visit and report to the physician if oxygen saturation level less than 92%. The SN was to report to the physician for the presence of adventitious breath sounds, cyanosis, and increasing shortness of breath at rest or respiratory rate of less than 14 breaths per minute or greater than 24 breaths per minute. Review of the SN notes dated 11/6 to 11/29/23, showed the patient was noted to have wheezing. However, there was no documented evidence the SN reported to physician and/or provided any interventions to address the patient’s wheezing. Review of the SN notes during this certification period failed to show documented evidence the patient’s oxygen saturation levels were checked . On 12/6/23 at 1345 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the findings. 6. Review of Patient 11’s closed clinical record was initiated on 12/4/23. The clinical record showed the SOC was 3/1/23. The patient was certified for home health services during the certification period from 3/1/23 to 4/29/23. The POC, for the certification period from 3/1/23 to 4/29/23, cited SN visits 2W2 and 1W7 to perform comprehensive skilled nursing assessment, observations, and evaluation of all body systems. Review of the physician order dated 4/5/23, showed to monitor daily oxygen saturation level via pulse oximeter and report oxygen saturation level if below 92% at room air at rest. Review of the SN notes for this certification period failed to show documented evidence the patient’s oxygen saturation levels were checked. On 12/6/23 at 1324 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the finding. 7. Review of Patient 10’s closed clinical record was initiated on 12/4/23. The clinical record showed the SOC was 4/13/23. The patient was certified for home health services during the certification period from 4/13/23 to 6/11/23. The POC, for the certification period from 4/13/23 to 6/11/23, cited SN visits 2W2 and 1W7. Further review of the POC showed the SN to weigh the patient every visit and report weight gain of two pounds or more daily or five pounds or more weekly. Review of the SN notes during this certification period failed to show documented evidence the patient was weighed every visit. On 12/6/23 at 1425 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the finding.”

“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 agency’s skilled staff prepared accurate and complete clinical notes for three of eleven sampled patients (Patients 1, 5, and 11). This failure created the increased risk of substandard healthcare outcomes to these patients. Findings: The agency’s P&P titled Content of the Clinical Record revised November 2022 showed a clinical record will be maintained for each patient receiving care. The clinical record will contain sufficient information to describe the patients problems and needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among organization and contract personnel. 1. Review of Patient 1’s clinical record was initiated on 12/1/23. The clinical record showed the SOC was 10/12/23. The patient was certified for home health services during the certification period from 10/12/23 to 12/10/23. The POC, for the certification period from 10/12/23 to 12/10/23, showed the patient’s other diagnosis was type 2 diabetes mellitus. The PCG was capable and competent in checking the blood sugar BID. However, review of the SN notes dated 10/16, 10/21, 10/23, 10/30, 11/6, 11/11, 11/22, and 11/29/23, showed, the PCG was able to perform blood sugar check daily, which was inconsistent with the POC. In addition, review of the POC for the certification period from 10/12/23 to 12/10/23, showed the PCG assumed diabetes management such as glucometer calibration and diabetic foot examination/care which was validated by the SN on the start of care via return demonstration. However, review of the initial comprehensive assessment failed to show documented evidence the PCG’s competency on glucometer calibration and diabetic foot examination/care was validated by the SN on the start of care visit. On 12/6/23 at 1411 hours, an interview and concurrent clinical record review was conducted with the IT Consultant. The IT Consultant was asked if there were documentation of the glucometer calibration and diabetic foot examination on the initial comprehensive assessment. The IT Consultant replied it was not documented on the narrative notes. The IT Consultant was informed and acknowledged the finding. 2. Review of Patient 5’s clinical record was initiated on 11/30/23. The clinical record showed the SOC was 10/16/23. The patient was certified for home health services during the certification periods from 10/16/23 to 12/14/23. The POC showed the patient’s other pertinent diagnosis was type 2 diabetes mellitus. Review of the POC, for the certification period from 10/16/23 to 12/14/23, cited SN visits 2W2 and 1W7 to perform comprehensive skilled nursing assessment, observation, and evaluation of all body systems. The POC also showed SN to perform diabetic foot examination every visit. However, review of the SOC OASIS dated 10/16/23, showed the frequency of the diabetic foot examination was every week which was inconsistent with the POC. On 12/6/23 at 1328 hours, an interview and concurrent clinical record review was conducted with the IT Consultant. The IT Consultant was informed and acknowledged the finding. 3. Review of Patient 11’s closed clinical record showed the SOC was 3/1/23. The closed clinical record showed the patient received home health services during the certification period from 3/10/23 to 4/29/23. Review of the Discharge Summary dated 11/4/23, showed the patient was discharged on 4/26/23, and the reason for discharge was no further care was needed. However, further review of the clinical record failed to show documented evidence of the patient’s disposition, patient’s pulse rate and respiratory rate, summary of interventions, name of the clinician completing the form, physician’s signature, and dates both clinicians signed the form. On 12/6/23 at 1345 hours, an interview was conducted with RN 1. RN 1 was informed and acknowledged the findings.”

“Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the responsibility for the day-to-day operations by not implementing the agency’s P&P as evidenced by: * The agency failed to ensure the written agreements for four of the five contractors (Contractors 1, 3 , 4, and 5) included the required elements in the contracts as per Title 22. * The agency failed to ensure the pre-employment physical and TB screenings for four employees (RNs 1 and 3, LVN 2, and the CHHA) were completed as per the agency’s P&P. * The agency failed to ensure one employee’s (RN 3) competency assessment was completed as per the agency’ P&P. These failures had the potential to negatively impact the agency’s operational performance. Findings: 1. Review of the agency’s Job Description Summary for the Executive Director/Administrator (undated) showed the Executive Director/Administrator is responsible for planning, coordinating, managing, and directing all activities and programs of the HHA. According to California Code of Regulations, Title 22, Section 74719, when any service offered by the agency is not provided by employees, there shall be a written agreement meeting the requirements of this section. The agreement shall include at least the following: - The rights and responsibilities of the agency or individual providing services and of the contraction agency in the coordination, supervision, and evaluation of care and services provided. - The role, if any, of the agency and the contracted individual or agency in the patient admission process; development, review, and revision of the plan of care or treatment; patient care conferences; scheduling of visits or hours and discharge planning. Review of the written agreements between the agency and contractors was initiated on 12/5/23, and showed the following: - The written agreement between the agency and Contractor 1 providing biomedical waste services did not include the rights and responsibilities of the agency or individual providing services and of the contracted agency in the coordination, supervision, and evaluation of care and services provided. - The written agreement between the agency and Contractor 3 providing therapy services did not include the rights and responsibilities of the agency or individual providing services and of the contracted agency in the coordination and supervision of care and services provided. - The written agreement between the agency and Contractor 4 providing nutrition services did not include the rights and responsibilities of the agency or individual providing services and of the contracted agency in the supervision and evaluation of care and services provided. In addition, the written agreement did not include the role, if any, of the agency and the contracted individual or agency in the patient admission process; development, review, and revision of the plan of care or treatment; scheduling of visits or hours and discharge planning. - The written agreement between the agency and Contractor 5 providing medical social services did not include the role, if any, of the agency and the contracted individual or agency in the patient admission process and patient care conferences. On 12/6/23 at 1006 hours, an interview and concurrent document review was conducted with the IT Consultant. The IT Consultant was informed and acknowledged the findings. 2. Review of the agency’s P&P titled Personnel Record Contents revised 11/22 showed TB test to be done once a year if negative for TB. If TB test was positive, a chest x-ray with a negative result is valid for up to five years. In addition, the physician statement of health must be completed annually. Review of the personnel file for RNs 1 and 3, LVN 2, and the CHHA, was initiated on 1/6/23 at 1015 hours with the HR. The review showed the following: a. Review of the personnel file for RN 3 showed the date of hire was 4/22/21. However, further review of the personnel file showed the health screen was conducted on 11/2/21, more than 15 days after employment as required. b. Review of the personnel file for the CHHA showed the date of hire was 10/3/23. However, further review of the personnel file failed to show a preemployment health screen was completed. In addition, there was no documented evidence a TB test was completed for this CHHA. c. Review of the personnel file for LVN 2 showed the date of hire was 11/1/22. However, further review of the personnel file showed the pre employment health screen was completed on 9/25/21, more than six months before employment as required. d. Review of the personnel file for RN 1 showed the date of hire was 11/15/23. Review of RN 1’s personnel file showed the pre employment health screen was completed on 2/21/23, more than six months before employment as required. On 12/6/23 at 1645 hours, an interview was conducted with the HR. The HR was informed and acknowledged the findings. 3. Review of the agency’s P&P titled Competency Assessment revised dated 11/2022 showed the competence of all organization staff (employed, contract or volunteer) will be assessed during orientation, during the probationary period, and periodically throughout the course of the year, when job responsibilities change and during the annual performance evaluation. As part of the orientation process, a preceptor/ clinical/ assigned supervisor will be assigned to each new person using a competency skills performance checklist and orientation checklist, the preceptor/ clinical/ assigned supervisor will observe the new personnel performing the required skills and activities. Review of the personnel files for RNs 3 and 4 showed RN 3’s date of hire was 4/22/21, and RN 4’s date of hire was 4/28/21. * Review of RN 3’s orientation checklist was completed by RN 4 on 4/22/21, and RN 3’s Initial Competency Assessment Skills Checklist was completed by RN 4 on 4/27/21. However, RN 4 was hired on 4/28/21, five day after RN 3 was hired on 4/22/21. On 12/6/23 at 1015, an interview and concurrent personnel file review was conducted with the HR. The HR stated she was unsure why RN 4 would sign off RN 3’s orientation checklist when RN 4 was hired five days after RN 3. The HR was informed and acknowledged the findings.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on interview and record review, the HHA failed to send the discharge and transfer summaries for six of eleven sampled patients (Patients 6, 7, 8, 9, 10, and 11) to their primary care physicians. This failure created the risk for these patients to not receive the continuity in care and medical treatment. Findings: Review of the agency’s Discharge Summary revised 11/2022 showed the discharge summary and other relevant clinical record documents will be completed and submitted within 72 hours of discharge from service. A copy of the discharge summary will be provided to the patient’s primary care practitioner, or other health care professional who will be responsible for providing care and services to the patient after discharge from the organization within five business days of the patient’s discharge. 1. Review of Patient 8’s closed clinical record showed the SOC was 12/5/23. The closed clinical record showed the patient received home health services during the certification periods from 3/1/23 to 4/29/23, and 4/30/23 to 6/28/23. Review of the physician’s order dated 6/25/23, showed to discharge the patient from home health services today. Review of the Discharge Summary dated 6/25/23, showed the patient was discharged on 6/25/23, and the reason for discharge was no further care needed. * Further review of the clinical record failed to show the date when the physician signed the document. In addition, the clinical record failed to show documented evidence the discharge summary included the physician’s responsible for the home health care plan, types of services provided, medications that the patient was on at the time of discharge, and patient’s discharge condition; and failed to show the discharge summary was sent within five business days after the patient discharged. * Review of the HHA’s document dated 8/7/23, showed a successful fax to the patient’s physician. However, further review of the clinical record failed to show what documents were sent to the physician. On 12/6/23 at 1130 hours, an interview was conducted with RN 1. RN 1 was informed and acknowledged the findings. 2. Review of Patient 7’s closed clinical record showed the SOC was 7/10/23. The closed clinical record showed the patient received home health services during the certification periods from 7/10/23 to 9/7/23 and 9/8/23 to 11/6/23. Review of the Discharge Summary dated 11/4/23, showed the patient was discharged on 11/4/23, and the reason for discharge was no further care needed. * Review of the clinical record failed to show the name of the clinician completing the form, physician signature, and dates both clinicians signed the form. * In addition, review of the clinical record failed to show documented evidence the discharge summary included the physician responsible for the home health care plan, types of services provided, medications that the patient was on at the time of discharge, and patient’s discharge condition; and failed to show the discharge summary was sent after the patient discharged. Review of the HHA’s document dated 11/6/23 showed a successful fax to the patient’s physician. However, further review of the clinical record failed to show what documents were sent to the physician. On 12/6/23 at 1130 hours, an interview was conducted with RN 1. RN 1 was informed and acknowledged the findings. 3. Review of Patient 11’s closed clinical record showed the SOC was 3/1/23. The closed clinical record showed the patient received home health services during the certification period from 3/10/23 to 4/29/23. Review of the Discharge Summary dated 11/4/23, showed the patient was discharged on 4/26/23, and the reason for discharge was no further care needed. * Review of the clinical record failed to show the frequency of services, disposition, name of the clinician completing the form, physician’s signature, and dates when both clinicians signed the form. * In addition, review of the clinical record failed to show documented evidence the discharge summary included the physician who was responsible for the home health care plan, medications that the patient was on at the time of discharge, and patient’s discharge condition; and failed to show the discharge summary was sent after the patient discharged. Further review of the clinical record failed to show the agency sent a copy of the summary and list of medications to the physician. On 12/6/23 at 1345 hours, an interview was conducted with RN 1. RN 1 was informed and acknowledged the findings. 4. Review of Patient 10’s closed clinical record showed the SOC was 4/13/23. The closed clinical record showed the patient received home health services during the certification periods from 4/12/23 to 8/12/23. Review of the Discharge Summary dated 8/6/23, showed the patient was discharged on 8/6/23, and the reason for discharge was no further care needed. Review of the clinical record failed to show the frequency of the services, name of the clinician completing the form, physician’s signature, and dates when both clinicians signed the form. In addition, review of the clinical record failed to show documented evidence the discharge summary included the medications that the patient was on at the time of discharge, and patient’s discharge condition; and failed to show the discharge summary was sent after the patient discharged. Further review of the clinical record failed to show the agency sent a copy of the summary and list of medications to the physician. On 12/6/23 at 1425 hours, an interview was conducted with RN 1. RN 1 was informed and acknowledged the findings. 5. Review of Patient 6’s clinical record was initiated on 12/5/23. The clinical record showed the SOC was 7/29/23. The patient was certified for home health services during the certification periods from 7/29/23 to 9/26/23, and 9/27/23 to 11/25/23. Review of the Physician’s Order dated 11/25/23, showed an order for discharge. Review of the Discharge Summary dated 11/25/23, the section for Interventions/Instructions showed a written instructions were provided to the patient. However, the medication information given/attached was left blank. In addition, review of the clinical record failed to show documented evidence the discharge summary was sent to the physician within five days from the discharge. On 12/6/23 at 1430 hours, an interview and concurrent clinical record review was conducted with the IT Consultant. The IT Consultant was asked if the medication information/medications list was provided to the patient as it was left blank. The IT Consultant replied no, it was not provided. The IT Consultant was further asked if a discharge summary was sent to the physician. The IT Consultant stated he did not see it in the documentation. The IT Consultant was informed and acknowledged the findings. 6. Review of Patient 9’s clinical record was initiated on 12/5/23. The clinical record showed the SOC was 2/22/23. The patient was certified for home health services during the certification periods from 2/22/23 to 4/22/23 and 4/23/23 to 6/21/23. Review of the Physicians Order dated 4/20/23, showed an order to discharge the patient once the patient’s recovery and medical safety in view of the patient’s overall condition achieved. Review of the Discharge Summary dated 6/18/23, showed a written instructions were provided to the patient. However, the medication information given/attached was left blank. In addition, review of the clinical record failed to show documented evidence the discharge summary was sent to the physician within five days from the discharge. On 12/6/23 at 1500 hours, an interview and concurrent clinical record review was conducted with the IT Consultant. The IT Consultant was asked as to when the discharge order was given. The IT Consultant showed the latest discharge order was written on 6/18/23. The IT Consultant was also asked if the medication information/medications list was provided to the patient as it was left blank. The IT Consultant replied, no it was not provided. The IT Consultant was further asked if a discharge summary was sent to the physician. The IT Consultant stated he did not see it in the documentation. The IT Consultant was informed and acknowledged the findings.”