West Coast Home Health

“Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness P&P included the use of volunteers in an emergency or other emergency staffing strategies including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This failure created the risk of not effectively utilizing the available personnel during the emergency events. Findings: Review of the agency’s emergency preparedness P&P was conducted on 9/13/19. However, the P&P did not address the use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. On 12/15/23 at 1445 hours, an interview and concurrent agency document review was conducted with the Administrator. The Administrator 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 staff, entities provided services under agreement, 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 12/14/23. The agency’s emergency management plan showed the communication plan will include the names and contact information of the staff, entities provided services under agreement, patients’ physician, and volunteers. However, the agency did not have the contact information of the staff, entities provided services under agreement, patients’ physician, and volunteers. On 12/15/23 at 1445 hours, an interview and concurrent agency document review was conducted with the Administrator. The Administrator 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 four of nine sampled patients (Patients 2, 3, 5 and 8), 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 4/2017 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 2’s clinical record was initiated on 12/12/23. The clinical record showed the SOC was 8/22/23. The patient was certified for home health services during the certification periods from 8/22/23 to 10/20/23, and 10/21/23 to 12/19/23. The POC, for the certification period from 8/22/23 to 10/20/23, cited SN visits 1W1 (one time a week for one week), 1Q2W8 (one every two weeks for eight weeks) to assess/evaluate co-morbid conditions that present themselves during the course of this episode to identify changes and intervene to minimize complications. However, there was no documented evidence the SN visited the patient one time a week during Week 7 (10/1 to 10/7/23) as cited in the POC. There was no documented evidence the physician was notified of the missed visit. In addition, the documentation showed the SN visited the patient during Week 6 (9/24/23 to 9/30/23) instead of Week 7 as ordered in the POC. On 12/15/23 at 1348 hours, an interview and concurrent clinical record review was conducted with the DNP. The DNP was asked as to why was there a visit during Week 6 instead of Week 7 as ordered. The DNP replied there might a reason why and would find it out. The DNP was also asked if there was a change of the SN visit frequency. The DNP replied she would check it out. The DNP was further asked if the physician was notified of the extra visit and the missed visit. The DNP replied she would check it out. The DNP was informed and acknowledged the findings. 2. Review of Patient 3’s clinical record was initiated on 12/13/23. The clinical record showed the SOC was 12/13/22. The patient was certified for home health services during the certification period from 12/13/22 to 2/10/23. The POC, for the certification period from 12/13/22 to 2/10/23 , cited SN visits 1W1, 1Q3W6, and 1Q2W2 to assess/evaluate co-morbid conditions that present themselves during the course of this episode to identify changes and intervene to minimize complications. However, there was no documented evidence the SN visited the patient one time a week during Week 4 (12/31 to 1/6/23) as cited in the POC. There was no documented evidence the physician was notified of the missed visit. 3. Review of Patient 5’s clinical record was initiated on 12/14/23. The clinical record showed the SOC was 1/23/23. The patient was certified for home health services during the certification period from 1/23/23 to 3/23/23. The POC, for the certification period from 1/23/23 to 3/23/23, cited SN visits 1W1, 1Q2W2, and 1Q3W6 to assess/evaluate co-morbid conditions that present themselves during the course of this episode to identify changes and intervene to minimize complications. However, there was no documented evidence the SN visited the patient one time a week during Week 5 (2/19 to 2/25/23) as cited in the POC. There was no documented evidence the physician was notified of the missed visit. On 12/15/23 at 1459 hours, an interview and concurrent clinical record review was conducted with the DNP. The DNP was informed and acknowledged the findings. 4. Review of Patient 8’s clinical record was initiated on 12/14/23. The clinical record showed the SOC was 3/20/23. The patient was certified for home health services during the certification period from 3/20/23 to 5/18/23. The POC, for the certification period from 1/23/23 to 3/23/23, cited SN visits 1W1 and 1Q2W8 to assess/evaluate co-morbid conditions that present themselves during the course of this episode to identify changes and intervene to minimize complications. Review of the clinical record showed the following SN visits: - For Week 2 (3/26/23 to 4/1/23), the SN had visited the patient two times on 3/27 and 3/30/23, instead of one time - For Week 3 (4/2/23 to 4/8/23), the SN had visited the patient one time on 4/7/23, instead of no visit. - For Week 4 (4/9/23 to 4/15/23), the SN had visited the patient two times on 4/12 and 4/14/23, instead of one time as ordered in the POC * Review of the Physician Order dated 4/20/23, showed an order for SN visits 2W1, 1W2, and 1Q2W2, effective 4/16/23. Review of the Event -Stage History Report showed the patient declined a visit on 4/21/23, for Week 5 (effective 4/16 to 4/22/23). The physician was notified. However, there were no documented evidenced the SN had attempted to visit the patient any other days during Week 5 to complete for the visit frequency of two times a week as ordered. On 12/15/23 at 1406 hours, an interview and concurrent clinical record review was conducted with the DNP. The DNP was informed and acknowledged the findings.”

“Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA’s governing body. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to include the data collected in monitoring the effectiveness and safety of services and quality of care; and identify opportunities for improvement, creating the risk of not providing quality of care to the patients. Findings: The agency’s P&P titled Improving Organizational Performance revised 4/2017 showed a procedure to adopt a structured framework for performance improvement to include data collection and analysis. Identify and set specific outcomes for measurable improvement. Review of the agency’s QAPI meeting minutes for 2021, 2022, and 2023 was conducted on 12/15/23 at 0958 hours. The QAPI meeting minutes showed the QAPI committee met quarterly to discuss patient admissions, re-admissions rate, pain management and infection control protocols. On 12/15/23 at 0958 hours an interview and concurrent document review was conducted with the DNP. The DNP was asked about the process of how they gather data for QAPI analysis. The DNP replied when the nurses reported an infection, the electronic system would pull out a report for the QAPI to track and trend. The DNP further stated the manager could see the data in real time and they would address those issues as they move through the day. The DNP stated they would be adding the issues quarterly and if they noticed a trend, they would address it before the quarterly meeting. Review of the Quality Improvement Event Summary showed the following: - an occurrence (fall) on 1/10/21 - an infection (urinary infection) on 5/30/21 - an infection (respiratory infection) on 10/13/22 - an occurrence (fall) on 9/7/22. Review of the QAPI meeting minutes for Quarter 2 (April to June 2021) showed the agenda included evaluation of new pain management, staff training on readmission reduction strategies, and mid year data review with a detailed minutes and analysis of the identified agenda. Review of the QAPI meeting minutes for Quarter 3 (July to September 2021) showed the agenda included continuation and expansion of pain management techniques, introduction to infection control initiatives and staff feedback, and protocol adjustments with detailed minutes and analysis of the identified agenda. However, the QAPI meeting minutes failed to include the incident of fall that was identified on 1/10/21. In addition, the infection control initiative was discussed on the Quarter 3 meeting. However, the discussion was not specific to the type of infection that was collected on 5/10/21. Review of the QAPI meeting for Quarter 4 (October to December 2022) showed the agenda includes comprehensive year - end review, setting goals and initiatives for 2023 and staff recognition and feedback with detailed meeting minutes and analysis of the identified agenda. However, the QAPI meeting failed to include the fall incident and the respiratory infection that was identified on 9/7/22 and 10/13/22. On 12/15/23 at 1129 hours, a follow-up interview with concurrent document review was conducted with the DNP. The DNP was asked to provide any other records or documents for the QAPI programs including the data or tools used. However, there was no additional document provided for review. The DNP was informed and acknowledged the findings.”

“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 initial assessments were conducted within 48 hours after referral for three of nine sampled patients (Patients 2, 5, and 8), creating the risk of not providing the necessary care and services timely to these patients. Findings: The agency’s P&P titled Initial and Comprehensive Assessment revised 4/2017, showed the initial assessment visit must be performed either within 48 hours of the referral, within 48 hours of the patients return home, on the start of care date ordered by the physician or at the patient/family request with the approval of the physician or (other licensed independent practitioner). 1. Review of Patient 2’s clinical record was initiated on 12/12/23. The clinical record showed the SOC was 8/22/23. The patient was certified for home health services during the certification periods from 8/22/23 to 10/20/23, and 10/21/23 to 12/19/23. Review of the HHA Patient Referral & Admission Order dated 8/17/23, showed a referral for HHA services. Review of the SOC OASIS dated 8/22/23, showed the RN had performed the comprehensive assessment, five days after the referral date. There was no documented evidence explaining why the SOC was 8/22/23, instead of the 48 hours after the referral date. On 12/15/23 at 1348 hours an interview and concurrent clinical record review was conducted with the DNP. The DNP was asked as to the timeline for them to visit the patient. The DNP replied it was late because it should be within 48 hours from the referral date. The DNP was informed and acknowledged the finding. 2. Review of Patient 5’s clinical record was initiated on 12/14/23. The clinical record showed the SOC was 1/23/23. The patient was certified for home health services during the certification period from 1/23/23 to 3/23/23. Review of the HHA Patient Referral & Admission Order dated 1/13/23, showed a referral for HHA services. Review of the SOC OASIS dated 1/23/23, showed the RN had performed the comprehensive assessment, 10 days after the referral date. There was no documented evidence explaining why the SOC was 1/23/23, instead of the 48 hours after the referral date. On 12/15/23 at 1459 hours, an interview and concurrent closed clinical record review was conducted with the DNP. The DNP was asked as to the date of the referral order. The DNP replied the order was on 1/13/23; however, the agency received the fax from the physician’s office on 1/18/23. The patient should have been seen within 48 hours from the received date. The DNP was informed and acknowledged the finding. 3. Review of Patient 8’s clinical record was initiated on 12/14/23. The clinical record showed the SOC was 3/20/23. The patient was certified for home health services during the certification period from 3/20/23 to 5/18/23. Review of the Patient Information Report showed a referral date of 3/14/23. Review of the SOC OASIS dated 3/20/23, showed the RN had performed the initial comprehensive assessment, six days after the referral date. There was no documented evidence explaining why the SOC was 3/20/23, instead of the 48 hours after the referral date. On 12/15/23 at 1406 hours, an interview and concurrent closed clinical record review was conducted with the DNP. The DNP was asked as to the timeline for them to visit the patient. The DNP replied within 48 hours from the referral date. The DNP was informed and acknowledged the finding.”

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the initial comprehensive assessment was completed accurately and consistently with the patient’s immediate needs for one of nine sampled patients (Patient 6). This failure created the risk of not identifying and addressing the care needs timely for this patient. Findings: Review of the agency’s P&P titled Initial and Comprehensive Assessment revised 4/2017 showed an initial patient assessment will be performed and documented in the patient’s clinical record by a RN, PT, or ST. During the initial comprehensive patient assessment, all baseline data to be used in measuring the patient’s progress towards goals and other relevant information will be documented in the patient’s clinical record , including physical assessment which included the blood pressure, temperature, pulse, respiration, skin, pain status, height/ weight, nutritional status, and other relevant date related to pertinent physical findings. Review of Patient 6’s closed clinical record was initiated on 12/14/23. The clinical record showed the SOC was 12/22/22. The patient was certified for home health services during the certification periods from 12/22/22 to 2/19/23, and 2/20/23 to 4/20/23. The Start of Care OASIS and SN visit note dated 12/22/22, showed no documented evidence the patient’s height and weight were assessed. On 12/15/23 at 1317 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 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 profile was updated to reflect the current medications for one of nine sampled patients (Patient 1). This failure created the risk for this patient not receiving the appropriate care and services necessary to improve the patient’s health conditions. Findings: Review of the agency’s P&P titled Medication Profile revised 4/2017 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. Review of Patient 1’s clinical record was initiated on 12/12/23. The clinical record showed the SOC was 8/25/23. The patient was certified for home health services during the certification periods from 8/25/23 to 10/23/23, and 10/24/23 to 12/22/23. The medication profile, for the certification period from 10/24/23 to 12/22/23, showed the medications included diclofenac (non-steroidal anti-inflammatory medication) 1% Topical Gel apply topically to effected sites four times daily and Refresh Digital (ophthalmic lubricant) 0.5% - 1% eye drops one drop to each eye up to four times daily as needed for dry eyes. On 12/13/23 at 1100 hours, a joint home visit was conducted with RN 2 to Patient 1’s home. Review of the patient’s medications with RN 2 showed the patient was no longer using diclofenac 1% Topical Gel apply topically to effected sites four times daily and Refresh Digital 0.5% - 1% eye drops one drop to each eye up to four times daily as needed for dry eyes. Further review of Patient 1’s medications showed Patient 1 was on vitamin D3 25 mcg one tablet PO daily and Macuhealth (nutritional vision supplement) one tablet PO daily. On 12/13/23 at 1100 hours, an interview and concurrent clinical record review was conducted with RN 2. RN 2 was informed of the findings.”

“Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the comprehensive assessment was updated within the last five days of every 60 days for one of nine sampled patients (Patient 2), creating the increased risk of not addressing the care needs for this patient. Findings: Review of Patient 2’s clinical record was initiated on 12/12/23. The clinical record showed the SOC was 8/22/23. The patient was certified for home health services during the certification periods from 8/22/23 to 10/20/23, and 10/21/23 to 12/19/23. The Recertification OASIS dated 10/18/22, showed the RN had performed the recertification comprehensive assessment. The assessment included the patient’s diagnoses of unspecified systolic congestive heart failure, edema unspecified and chronic kidney disease stage 3A. However, there was no documented evidence the RN had assessed the patient’s weight. On 12/15/23 at 1317 hours an interview and concurrent clinical record review was conducted with the DNP. The DNP was asked if the weight needed to be taken on the recertification assessment. The DNP replied yes. The DNP was also asked if the comprehensive assessment was complete. The DNP replied no. The DNP was informed and acknowledged the findings.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the POCs included specific information related to all pertinent diagnoses, patient - specific interventions, measurable outcomes and goals identified for nine of nine sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, and 9), creating the risk of not addressing the care needs for these patients. Findings: The agency’s P&P titled Care Planning Process revised 4/2017 showed to provide clinical direction to the clinicians providing direct patient care. The plan of care includes pertinent primary and secondary diagnoses, goals/outcomes to be achieved. Based on the specific assessment and conclusions, the plan of care will include but will not be limited to patient specific interventions and treatment. The plan of care will be based upon the physicians’ orders and services required to meet the patients needs. 1.a. Review of Patient 2’s clinical record was initiated on 12/12/23. The clinical record showed the SOC was 8/22/23. The patient was certified for home health services during the certification periods from 8/22/23 to 10/20/23, and 10/21/23 to 12/19/23. The POC, for the certification period from 8/22/23 to 10/20/23, cited SN to evaluate and develop plan of care to be countersigned by the physician. The POC also cited SN to assess and evaluate co-morbid conditions that present themselves during the course of the episode to identify changes and intervene to minimize complications. * Review of the HHA Admission Order dated 8/17/23, showed the admission diagnoses was for ataxia. The patient was homebound and requires home help because of severe ataxia. However, review of the POC failed to show documented evidenced of the patient diagnoses of ataxia was included in the POC. In addition, the POC failed to show documented evidenced of the specific intervention and goals to address the diagnoses of ataxia. * The POC cited SN to observed and assess cardiovascular system to identify changes and intervene to minimize the complications. The POC also cited SN to assess signs and symptoms if increase edema and possible respiratory complications. T he goals include cardiovascular exacerbations will be identified promptly and interventions initiated to minimize associated risk; the PCG will verbalize/demonstrate an ability to care for altered cardiovascular status, abnormal O2 saturation and increase in edema will be reported to the physician; increased pain or pain control measures will be identified and promptly reported to physician; and pain regimen will manage pain by the end of the episode. However, the POC failed to show documented evidence of the measurable goals for the patient altered cardiovascular status, abnormal oxygen saturation, an increase in edema, and pain control measures. Moreover, the POC also showed an orders for the licensed professional to report the outside established parameters for FBS less than 60 mg/dl and more than 250 mg/dl, and RBS less than 60 mg/dl and more than 350 mg/dl. However, review of the clinical record failed to show documented evidenced of the patient having history of blood sugar checking. On 12/15/23 at 1348 hours, an interview and concurrent clinical record review was conducted with the DNP. The DNP was asked if they needed to include the patients diagnoses of ataxia in the POC. The DNP replied yes, it should but was missed. The DNP was also asked if a specific intervention and measurable goals were created to address the diagnoses of ataxia. The DNP replied no, it was missed. The DNP was further asked if the POC included measurable goals for the patient cardiovascular status, oxygen saturation and increase edema. The DNP replied no. In addition, the DNP was also asked if they checked the patient blood sugar level. The DNP replied no, it was just a notification for the physician. The DNP was further asked if the patient was diabetic. The DNP relied No. The DNP reviewed the clinical record and acknowledged the findings. b. The POC, for the certification period from 10/21/23 to 12/19/23, cited SN to observe and assess cardiovascular system to identify changes and intervene to minimize the complications. The goals include cardiovascular exacerbations will be identified promptly and interventions initiated to minimize associated risk with edema; increased pain or pain control measures will be identified and promptly reported to physician; and pain regimen will manage pain by the end of the episode. However, the POC failed to include measurable goals for the patient cardiovascular status, increase in edema, and pain control measures. In addition, the POC also showed an order for the licensed professional to report the outside established parameters for FBS less than 60 mg/dl and more than 250 mg/dl, and RBS less than 60 mg/dl and more than 350 mg/dl. However, review of the clinical record failed to show documented evidenced of the patient having history of blood sugar checking. On 12/15/23 at 1317 hours, an interview and concurrent clinical record review was conducted with the DNP. The DNP was informed and acknowledged the findings. 2. Review of Patient 3’s clinical record was initiated on 12/13/23. The clinical record showed the SOC was 12/13/22. The patient was certified for home health services during the certification periods from 12/13/22 to 2/10/23. The POC, for the certification period from 12/13/22 to 2/10/23, cited SN to assess and evaluate co-morbid conditions that present themselves during the course of the episode to identify changes and intervene to minimize complications. The POC also cited SN to observe and assess respiratory and genitourinary status. The goal was for the patient and PCG to verbalized and demonstrate an ability to care for altered respiratory and genitourinary status by the end of the episode. The POC also showed the patients expressed goals includes respiratory symptom management. However, the POC failed to show documented evidenced of the measurable goals for the altered respiratory and genitourinary status. * Review of the SOC OASIS dated 12/13/23, showed the patient was assessed to have an indwelling/suprapubic catheter. The narrative notes showed the patient had a history of urinary retention and a chronic indwelling urinary catheter. However, the POC failed to show documented evidenced of the specific care and treatment to address the patients chronic urinary retention and indwelling urinary catheter use as identified in the initial comprehensive assessment. Moreover, the POC also showed an orders for the licensed professional to report the outside established parameters for FBS less than 60 mg/dl and more than 250 mg/dl, and RBS less than 60 mg/dl and more than 350 mg/dl. However, review of the clinical record failed to show documented evidenced of the patient having history of blood sugar checking. On 12/15/23 at 1513 hours, an interview and concurrent clinical record review was conducted with the DNP. The DNP was informed and acknowledged the findings. 3. Review of Patient 5’s clinical record was initiated on 12/14/23. The clinical record showed the SOC was 1/23/23. The patient was certified for home health services during the certification periods from 1/23/23 to 3/23/23. The patients diagnoses includes Malignant Neoplasm of the body of the stomach. The POC, for the certification period from 1/23/23 to 3/23/23, cited SN to assess and evaluate co-morbid conditions that present themselves during the course of the episode to identify changes and intervene to minimize complications. The POC also cited SN to observe and assess respiratory, gastrointestinal and pain status. The goals were for the patient and PCG to verbalize and demonstrate an ability to care for altered respiratory, gastrointestinal status by the end of the episode and increased pain or pain control measures will be identified and promptly reported to physician. The POC also showed the patients expressed goals included to keep pain manageable, and receive supplies for Plurex catheter drainage. However, the POC failed to show documented evidence of the measurable goals for the patient altered respiratory, gastrointestinal and pain control measures. * Review of the SOC OASIS dated 1/23/23, under the section for Other Gastrointestinal issue showed the patient had gastric and lung Plurex catheter. However, the POC failed to show documented evidenced to address the specific care and treatment to address the patient’s gastric and Plurex catheter as identified in the initial comprehensive assessment. Further, review of the SOC OASIS, under the section of cardiovascular system, showed the patient was assessed to have +2 bilateral lower extremity edema. However, the POC failed to show documented evidenced of the specific intervention for cardiovascular system to address the patients bilateral lower extremity edema. Moreover, review of the SOC OASIS, under the section for the Respiratory system, showed the patient had shortness of breath. However, the POC failed to show documented evidenced to address the specific care and treatment to address the patients shortness of breath. Furthermore, the POC also showed an orders for the licensed professional to report the outside established parameters for FBS less than 60 mg/dl and more than 250 mg/dl, and RBS less than 60 mg/dl and more than 350 mg/dl. However, review of the clinical record failed to show documented evidenced of the patient having history of blood sugar checking. On 12/15/23 at 1459 hours, an interview and concurrent clinical record review was conducted with the DNP. The DNP was informed and acknowledged the findings. 4. Review of Patient 7’s clinical record was initiated on 12/13/23. The clinical record showed the SOC was 5/23/23. The patient was certified for home health services during the certification periods from 5/23/23 to 7/21/23. The POC, for the certification period from 5/23/23 to 7/21/23, cited SN to assess and evaluate co-morbid conditions that present themselves during the course of the episode to identify changes and intervene to minimize complications. The POC also cited SN to observe and assess pain level and effectiveness of pain control therapy; and to observe and assess gastrointestinal and altered respiratory status. The goals included an increase pain or ineffective pain control measures will be identified and promptly reported to physician; increased incidences or complications of nausea vomiting , exacerbations of gastrointestinal disease and respiratory exacerbation will be be identified promptly and interventions initiated to minimize associated risk; and the patient/caregiver will verbalized /demonstrate to care for altered respiratory status. The POC also showed the patients expressed goals was to manage pain. However, the POC failed to show documented evidenced of the measurable goals to address the patient’s pain level, gastrointestinal, and respiratory symptoms. On 12/15/23 at 1437 hours, an interview and concurrent clinical record review was conducted with the DNP. The DNP was informed and acknowledged the findings. 5. Review of Patient 8’s clinical record was initiated on 12/14/23. The clinical record showed the SOC was 3/20/23. The patient was certified for home health services during the certification periods from 3/20/23 to 5/18/23. The POC, for the certification period from 3/20/23 to 5/18/23, cited SN to assess and evaluate co-morbid conditions that present themselves during the course of the episode to identify changes and intervene to minimize complications. The POC also cited SN for observation and assessment of gastrointestinal status, effectiveness of pain management and of patients impaired nutrition related to malnutrition. The goal included gastrointestinal status will be evaluated and exacerbations identified with interventions implemented to minimize complications; patients/caregiver will verbalize/demonstrate ability to care for altered gastrointestinal status by the end of the episode; increased pain or pain control measures will be identified and promptly reported to physician; and the patient/caregiver will verbalize/demonstrate appropriate methods to maintain weight by the end of the episode. The POC also showed the patient’s goals for pain will be well managed, only reaching mild to moderate pain level within 3 weeks of pain medication. However, the POC failed to show documented evidenced of the measurable goals to address the patients, gastrointestinal, nutritional status, weight and pain level. * Review of the SOC OASIS dated 3/20/23, under the section for cardiovascular showed the patient was assessed to have bilateral lower extremity +3 edema. However, the POC failed to show documented evidenced of the specific intervention for cardiovascular system to address the patients bilateral lower extremity edema. Moreover, review of the SOC OASIS, under the section for the respiratory system, showed the patient had shortness of breath. However, the POC failed to show documented evidenced to address the specific care and treatment to address the patient’s shortness of breath. Furthermore, the POC also showed an orders for the licensed professional to report the outside established parameters for FBS less than 60 mg/dl and more than 250 mg/dl, RBS less than 60 mg/dl and more than 350 mg/dl. However, review of the clinical record failed to show documented evidenced of the patient having history of blood sugar checking. On 12/15/23 at 1406 hours, an interview and concurrent clinical record review was conducted with the DNP. The DNP was informed and acknowledged the findings. 6. Review of Patient 1’s clinical record was initiated on 12/12/23. The clinical record showed the SOC was 8/25/23. The patient was certified for home health services during the certification periods from 8/25/23 to 10/23/23 and 10/24/23 to 12/22/23. The POC, for the certification period from 8/25/23 to 10/23/23, cited SN to evaluate and develop plan of care to be countersigned by the physician. The POC also cited SN to assess and evaluate co-morbid conditions that present themselves during the episode to identify changes and intervene to minimize complications. Review of Patient 1’s H&P examination showed the patient had a history of acute diastolic heart failure and aortic valve disorder. * Review of the SN visit notes showed the patient was noted to have trace and 1+ edema to the lower left and right extremities. However, review of the clinical record failed to show the SN had weighed the patient to monitor for fluid shifts in relation to the heart failure. * The POC cited SN to observed and assess cardiovascular system to identify changes and intervene to minimize the complications. The POC also cited SN to provide skilled teaching related to altered cardiovascular status including signs and or symptoms of possible respiratory complications. However, further review of the POC failed to show documented evidence of the measurable goals for the patient altered cardiovascular status. In addition, the POC also showed an order for the licensed professional to report the outside established parameters for FBS less than 60 mg/dl and more than 250 mg/dl, RBS less than 60 mg/dl and more than 350 mg/dl. However, review of the clinical record failed to show documented evidenced the patient had a history of blood sugar checks. On 12/15/23 at 1215 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 9’s closed clinical record was initiated on 12/14/23. The clinical record showed the SOC was 10/18/23. The patient was certified for home health services during the certification periods from 10/18/23 to 12/16/23. The POC, for the certification period from 10/18/23 to 12/16/23, cited SN to evaluate and develop plan of care to be countersigned by the physician and assess and evaluate co-morbid conditions that present themselves during the episode to identify changes and intervene to minimize complications. Additionally, the POC cited the SN for observation and assessment of gastrointestinal status and to intervene to minimize complications. skilled nurse to provide teaching related to altered gastrointestinal status. Review of the SN visit note dated 11/2/23, showed the patient was noted to an ostomy for bowel elimination. However, review of the clinical record failed to show the POC addressed the patient’s ostomy. However, further review of the POC failed to show documented evidence of the measurable goals for the patient including goals to address the patient’s altered gastrointestinal status. In addition, the POC also showed an order for the licensed professional to report the outside established parameters for FBS less than 60 mg/dl and more than 250 mg/dl, RBS less than 60 mg/dl and more than 350 mg/dl. However, review of the clinical record failed to show documented evidenced the patient had a history of blood sugar checks. On 12/15/23 at 1351 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the finding. 8. Review of Patient 4’s closed clinical record was initiated on 12/13/23. The clinical record showed the SOC was 4/20/23. The patient was certified for home health services during the certification periods from 4/20/23 to 6/18/23, with diagnoses, including CHF and cardiomyopathy. The POC, for the certification period from 4/20/23 to 6/18/23, cited SN to evaluate and develop plan of care to be countersigned by the physician and assess and evaluate co-morbid conditions that present themselves during the episode to identify changes and intervene to minimize complications. Additionally, the POC also showed an orders for the licensed professional to report the outside established parameters for FBS less than 60 mg/dl and more than 250 mg/dl, RBS less than 60 mg/dl and more than 350 mg/dl. However, further review of the POC failed to show documented evidence of the measurable goals for the patient including measurable goals to address the patient’s CHF or cardiomyopathy. Review of the SN visit note dated 4/20/23, showed the patient’s reported weight was 180 lbs, and teaching was done to keep and monitor a daily weight log. Moreover, further review of the clinical record failed to show the patient’s weight was documented into the clinical record to monitor for fluid shifts in relation to the heart failure. Additionally, review of the clinical record failed to show documented evidenced of the patient having history of blood sugar checking. On 12/15/23 at 1337 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the finding. 9. Review of Patient 6’s closed clinical record was initiated on 12/14/23. The clinical record showed the SOC was 12/22/22. The patient was certified for home health services during the certification periods from 12/22/22 to 2/19/23, and 2/20/23 to 4/20/23. The POC, for the certification period from 4/20/23 to 6/18/23, cited SN to evaluate and develop plan of care to be countersigned by the physician and assess and evaluate co-morbid conditions that present themselves during the episode to identify changes and intervene to minimize complications. Additionally, the POC also showed an orders for the licensed professional to report the outside established parameters for FBS less than 60 mg/dl and more than 250 mg/dl, and RBS less than 60 mg/dl and more than 350 mg/dl. However, further review of the POC failed to show documented evidence of the measurable goals for the patient including measurable goals. Additionally, review of the clinical record failed to show documented evidenced of the patient having history of blood sugar checking. On 12/15/23 at 1317 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the findings.”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on clinical record review and interview, the agency failed to ensure the coordination of care for three of nine sampled patients (Patients 2, 8, and 9), creating the risk of not providing necessary care and services to these patients. Findings: The agency’s P&P titled Monitoring Patients Response/Reporting to Physician revised 4/2017 showed clinicians will establish and maintain ongoing communication with the physician to ensure safe and appropriate goals including but not limited to care interventions and treatments. The patients physician will be contacted on the same day when there is a significant changes in the patients condition, changes that have occurred regarding diagnosis, prognosis or treatment. 1. Review of Patient 2’s clinical record was initiated on 12/12/23. The clinical record showed the SOC was 8/22/23. The patient was certified for home health services during the certification periods from 8/22/23 to 10/20/23, and 10/21/23 to 12/19/23. Review of the SN notes dated 11/29/23, under the section of narrative notes, showed the patient had a s/p fall in the morning. The patient sustained skin tears on the left forehead and left knee and weeping from a small laceration on the left lower extremity. The narrative note also showed a lower extremity edema +2 and would reach out to the physician about adding diuretic to treat. Further review of the SN notes dated 11/29/23, under the section for care coordination showed the supervisor was updated on the status. However, review of the clinical record failed to show documented evidenced of the physician was notified of the patient’s incident of fall with injury, +2 edema of the lower extremity, and medications. On 12/15/23 at 1317 hours, an interview and concurrent clinical record review was conducted with the DNP. The DNP was asked if the fall with injury was considered a change of condition. The DNP replied of course. The DNP was also asked if the physician was notified. The DNP replied no documentation of the notification or coordination. The DNP was informed and acknowledged the findings. 2. Review of Patient 8’s closed clinical record was initiated on 12/14/23. The clinical record showed the SOC was 3/20/23. The patient was certified for home health services during the certification periods from 3/20/23 to 5/18/23. Review of the SN notes dated 4/7/23, showed the patient was assessed to have poor appetite/hydration, rectal bleeding, +3 edema on the bilateral lower extremities. In addition, the section for narrative notes showed the patient was lethargic. The Supervisor and the MSW was notified. However, review of the closed clinical record failed to show documented evidenced of the physician was notified of the patient’s changes in condition. On 12/15/23 at 1406 hours, an interview and concurrent clinical record review was conducted with the DNP. The DNP was informed and acknowledged the findings. 3. According to the National Pressure Injury Advisory Panel (NPIAP), 2019, pressure injury status can change rapidly. and improvement of deterioration indicated by change in pressure injury dimensions, tissue quality or wound exudate levels, signs of infection, or other complications all provide indications of the effectiveness of the current treatment plan. Pressure injury assessment includes an evaluation of the pressure injury size and physical characteristics. A two week period is recommended for evaluating progress toward healing. However, weekly assessments or more frequently provide an opportunity for the health professional to assess the pressure injury more regularly, detect possible complications as early as possible, and adjust the treatment plan accordingly. Pressure injury status can change rapidly. Improvement or deterioration indicated by change in pressure injury dimensions, tissue quality or wound exudate levels, signs of infection or other complications all provide indications of the effectiveness of the current treatment plan. signs of deterioration should be address immediately. Review of Patient 9’s clinical record was initiated on 12/14/23. The clinical record showed the SOC was 10/18/23. The patient was certified for home health services during the certification periods from 10/18/23 to 12/16/23. Review of the POC for the certification period from 10/18/23 to 12/16/23, cited SN visits 1W1 and 1Q2W8. The POC also cited the following: SN to assess and evaluate comorbid conditions including vital signs and oxygen saturation and other conditions that present themselves during the course of the episode to identify changes and intervene to minimize complications. SN to observe and assess integumentary status to identify changes and intervene to minimize complications; SN to provide skilled teaching related to altered skin integrity including pathophysiology, nutrition, medication regimen, and wound care. SN to report significant changes in status to physician for early intervention. Medical treatments provided as follows: cleanse unstageable decubitus ulcer to coccyx with normal saline, pat dry with gauze then apply small amount Calazime paste to wound and cover with hydrocolloid dressing. SN/ CG to change every three to five days and if soiled or dislodged. Goals, including: Wound status will improve as evidenced by a decrease in size drainage, absence of infection, and decreased pain. Review of the SN visit note dated 10/18/23, showed the patient had an unstageable pressure ulcer to the coccyx, measured at 1.7 cm x 2 cm, non-blanchable, noting maceration around necrotic tissue with a small open area. Further review of the clinical record showed the patient had non blanchable discolored area, small maceration around necrotic tissue with a small open area. In addition, the nurse also noted a pressure injury of the sacral region, Stage 2. The SN noted wound care and extensive teaching were provided to the patient and caregiver. Review of the SN visit note dated 11/2/23, showed the wound was assessed to have no change in status, no wound measurements were taken because it was not due, and wound care was not provided because caregiver completed care. In addition, the nurse documented the caregiver stated the wound had gotten bigger the last week, and a strong gangrenous odor was present and photos were taken. Further review of the clinical record failed to show the nurse had reassessed or measured the wound, or taken measures after the caregiver had reported a change in condition of the wound. On 12/15/23 at 1357 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the findings.”

“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 one of nine sampled patients (Patient 1), creating the risk of not providing the necessary information to this patient. Findings: Review of the agency’s P&P titled Care Planning Process revised 4/2017 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. Review of Patient 1’s clinical record was initiated on 12/12/23. The clinical record showed the SOC was 8/25/23. The patient was certified for home health services during the certification periods from 8/25/23 to 10/23/23, and 10/24/23 to 12/22/23. The POC, for the certification period from 10/24/23 to 12/22/23, cited SN visits 1W1, 1Q2W2, 2Q2W2, and 1w1 to assess/evaluate comorbid conditions including vital signs and oxygen saturation level and other conditions that present themselves during this episode to identify changes and intervene to minimize complications. On 12/13/23 at 1101 hours, a joint home visit with RN 2 was conducted to Patient 1’s home. RN 2 was asked for the written instructions regarding the SN visit schedule provided to the patient. RN 2 was unable to locate the visit calendar. RN 2 stated there should be a visit schedule with the patient’s folder. On 12/15/23 at 1415 hours, an interview was conducted with RN 1. RN 1 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 POC for three of nine sampled patients (Patients 1, 4, and 9), creating the risk of not providing appropriate, consistent, and quality care to these patients. Findings: Review of the agency’s P&P titled Monitoring Patient’s Response/ Reporting to Physician revised 4/2017 showed during the home visit, the clinician will monitor the patient’s response to care against the established goals. The patient’s physician will be contacted on the same day when any significant changes in the patient’s condition, changes in the patient’s expected response to treatment or medications. 1. Review of Patient 1’s clinical record was initiated on 12/12/23. The clinical record showed the SOC was 8/25/23. The patient was certified for home health services during the certification periods from 8/25/23 to 10/23/23, and 10/24/23 to 12/22/23. Review of the POC for the certification period from 10/24/23 to 12/22/23, cited SN visits 1W1, 1Q2W2, 1Q2W2, and 1W1. In addition, the POC cited licensed professional to report vital signs falling outside the parameters as follows: systolic BP less than 90 mmHg or greater than 170 mmHg and diastolic BP less than 50 mmHg or greater than 90 mmHg. Review of the SN visit note dated 11/14/23, failed to show the patient’s BP was assessed and documented into the clinical record. Review of the SN visit note dated 12/12/23, showed the BP was assessed as 157/97 mmHg. Further review of the clinical record showed the physician was not notified and a comment “DIAS: WNL.” On 12/15/23 at 1415 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the findings. 2. Review of Patient 9’s closed clinical record was initiated on 12/14/23. The clinical record showed the SOC was 10/18/23. The patient was certified for home health services during the certification period from 10/18/23 to 12/16/23. Review of the POC, for the certification period from 10/18/23 to 12/16/23, cited SN visits 1W1, and 1Q2W8. In addition, the POC cited licensed professional to report vital signs falling outside the parameters as follows: systolic BP less than 90 mmHg or greater than 170 mmHg and diastolic BP less than 50 mmHg or greater than 90 mmHg. Review of the SN visit dated 11/2/23, showed the patient’s BP was 85/62 mmHg. However, there was no documented evidence the physician was notified as per the POC. On 12/15/23 at 1357 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 4’s closed clinical record was initiated on 12/13/23. The clinical record showed the SOC was 4/20/23. The patient was certified for home health services during the certification period from 4/20/23 to 6/18/23. Review of the POC, for the certification period from 4/20/23 to 6/18/23, cited SN visits 1W1 and 1Q2W8. In addition, the POC cited SN to evaluate and develop plan of care to be countersigned by physician; and assess and evaluate comorbid conditions including vital signs and oxygen saturations and other conditions that present themselves during the course of this episode to identify changes and intervene to minimize complications. Review of the SN visit notes dated 5/4 and 6/2/23, showed pain was not subjectively assessed at the time of evaluation; pain was not objectively assessed; and there was no objective pain symptoms. Review of the clinical record showed the patient reported pain on the left ankle. However, review of the clinical record failed to show documented evidence a thorough assessment of the pain was completed. On 12/15/23 at 1337 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the findings.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the agency’s skilled staff prepared the accurate and complete clinical notes for seven of nine sampled patients (Patients 1, 2, 3, 4, 5, 7, and 9), creating the increased risk of substandard healthcare outcomes to these patients. Review of the agency’s P&P titled Clinical/ Service Data Collection revised 4/2017, showed documentation in the clinical/ service record will be timely, detailed, accurate, and reflect the care or services provided. 1. Review of Patient 1’s clinical record was initiated on 12/12/23. The clinical record showed the SOC was 8/25/23. The patient was certified for home health services during the certification period from 8/25/23 to 10/23/23 and 10/24/23 to 12/22/23. Review of the SN visit note dated 12/13/23, showed the RN would recommend dropping patient to palliative light. On 12/15/23 at 1415 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 stated they did not provide palliative care services. RN 1 was informed and acknowledged the findings. 2. Review of Patient 9’s clinical record was initiated on 12/14/23. The clinical record showed the SOC was 10/18/23. The patient was certified for home health services during the certification period from 10/18/23 to 12/16/23. Review of the SN visit note dated 10/18/23, showed the patient was admitted to palliative care so the patient could pursue catheter placement and drainage. On 12/15/23 at 1357 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 stated they did not provide palliative care services. RN 1 was informed and acknowledged the findings. 3.a. Review of Patient 4’s clinical record was initiated on 12/13/23. The clinical record showed the SOC was 4/20/23. The patient was certified for home health services during the certification period from 4/20/23 to 6/18/23. Review of the physician order dated 6/16/23, showed to discharge the patient from palliative services due to no medical management needs at this time. Review of the patient’s SN visit note showed reason for admission palliative admission and RN/ LVN two visits a month, CHHA not applicable, MSW not applicable, and chaplain not applicable. On 12/15/23 at 1337 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the findings. b. Review of the patient’s client coordination note report dated 6/18/23 showed a note RN attended to patient for assessment. Further review of the clinical record failed to show documented evidence VS, pain, or a complete head to toe assessment were completed for this patient. On 12/15/23 at 1337 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the findings. 4. Review of Patient 2’s clinical record was initiated on 12/12/23. The clinical record showed the SOC was 8/22/23. The patient was certified for home health services during the certification periods from 8/22/23 to 10/20/23, and 10/21/23 to 12/19/23. The POC for the certification period from 8/22/23 to 10/20/23 cited MSW visit 1W1. Review of the MSW Add - On Evaluation dated 8/23/23, showed a section for hospice services provided. The hospice service provided included hospice philosophy for patient care, needs and lifestyle maintenance, hospice team roles and accessibility of instrumental support, hospice bereavement services, revocation process signs and symptoms of death and dying, arranging transfer of the body, completion of death certificate, disposal of patient medications and respite options and process. However, review of the medical record failed to show documented evidenced for a physician’s referral for a hospice service. On 12/15/23 at 1348 hours an interview and concurrent clinical record review was conducted with the DNP. The DNP was asked if there was a referral for hospice service. The DNP replied no, the referral was for home health service. The DNP was informed and acknowledged the findings. 5. Review of Patient 3’s clinical record was initiated on 12/13/23. The clinical record showed the SOC was 12/13/22. The patient was certified for home health services during the certification periods from 12/13/22 to 2/10/23. The POC for the certification period from 12/13/22 to 2/10/23, cited SN to assess/evaluate co-morbid conditions and other conditions that present themselves during the course of the this episode to identify changes and intervene to minimize complications. * Review of the SN notes dated 1/17/23, under the section of narrative, showed in part, PRN visit “me” this morning for information provided by family. Patient was having increased episodes of lower back pain yesterday “in patient” sustained “in your skin care “to the left wrist. Upon “missing” arrival patient sitting comfortably in recliner and “more” apparent distress nursing assessment completed. Patient denies any pain at the time of nursing visit and reports that the pain was of “one time did not for long”. Patient reports “fully” catheter “peers” within normal limits. “Patience is standing “4 cm skin tear to the left wrist which “one care” was provided and patient “power” will continue to monitor. In addition, review of the SN notes dated 1/3/23, under the section of narrative, showed in part, the patient was currently on “palliative services” with the HHA. Caregiver reported the results had not been finalized and was waiting to see if the patient was a candidate for “anabiotic” treatment. The patient continued to have a good oral intake and had actually increase slightly and “wait” up to 155.8 lbs. The patient “slowest wait” last December 2022 was 150 lbs. * Review of the SOC OASIS dated 12/13/23, under the section of treatments/education, showed the RN reviewed the “Palliative” plan of care and goals moving forward. In addition, the section of Skilled Interventions and Discharge Plan showed to discharge from “palliative” to admit to hospice services when the patient and family were ready. Moreover, review of the SOC OASIS, under the section for Emergency Preparedness showed the RN filled out the emergency coordination note. However, review of the coordination notes failed to show documented evidence of the emergency preparedness was completed as written on the SOC OASIS. On 12/15/23 at 1513 hours, an interview and concurrent closed record review was conducted with the DNP. The DNP was asked if the SN documentations were accurate. The DNP replied it was inaccurate documentations. The DNP was informed and acknowledged the findings. 6. Review of Patient 5’s clinical record was initiated on 12/14/23. The Clinical record showed the SOC was 1/23/23. The patient was certified for home health services during the certification periods from 1/23/23 to 3/23/23. Review of the Physician Order dated 3/3/23 showed an order for discharge from the “palliative care.” However, review of the clinical record showed the patient was referred and admitted for home health services instead of palliative care services. On 12/15/23 at 1459 hours, an interview with concurrent closed clinical record review was conducted with the DNP. The DNP was asked if the order was accurate. The DNP replied it was inaccurate. The DNP was also asked if the patient was admitted under palliative services. The DNP replied no, they were home health service, not palliative services. The DNP was informed and acknowledged the findings. 7. Review of Patient 7’s clinical record was initiated on 12/13/23. The clinical record showed the SOC was 5/23/23. The patient was certified for home health services during the certification periods from 5/23/23 to 7/21/23. * Review of the Visit Note Report dated 7/21/23, showed the visit type was for RN Discharge from the agency data collection only - no visit made. However, on the section of the narrative note showed the RN made a visit to the patient today to discharge which was inconsistent. In addition, the SN narrative notes showed the patient was discharge from the “palliative” services which was inaccurate. * Review of the SN notes dated 6/22, 7/7/23 under the section of narrative showed the patient was on “palliative care” services. On 12/13/23 at 1357 hours, an interview and concurrent closed record review was conducted with the DPCS. The DPCS was asked as to the type of visit. The DPCS replied, No RN visit , it was a discharge from the system. However, on the narrative note showed the SN had a visit. The DPCS was also asked if the patient was on palliative services. The DPCS replied, it should be home health. The DPCS was further asked if the documentation is accurate. The DPCS replied, no. The DPCS was informed and acknowledged the findings. On 12/15/23 at 1437 hours, an interview and concurrent closed clinical record review was conducted with the DNP. The DNP 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 have the written agreements with Contractor 1 providing PT and OT services and failed to have a contracted provider to provide ST services as per the agency’s license. * The agency failed to ensure the pre-employment physical for two employees (RNs 2 and 3) were completed. * The agency failed to ensure a policy for wound care was in place. * The agency failed to show the current CDPH address in the patient handbook. * The agency failed to ensure the agency name in the patient handbook matched the license. 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 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. Review of the HHA’s licensed showed the HHA provided PT, OT, and ST services. Review of the written agreement between the agency and contractor was initiated on 12/15/23, showed no contractual agreement with Contractor 1 that provided PT and OT services. Further review of the agency’s documents failed to show a contractual agreement with ST services, as per their license. On 12/15/23 at 1315 hours, an interview and concurrent agency document review was conducted with the Administrator. The Administrator was informed and acknowledged the finding. 2. Review of the personnel file for RNs 2 and 3, was initiated on 12/15/23 at 1220 hours, with the Administrator. The review showed the following: a. Review of the personnel file for RN 2 showed the date of hire was 2/6/23. However, further review of the personnel file showed the health screen was conducted on 5/25/22, more than six months before employment as required. b. Review of the personnel file for RN 3 showed the date of hire was 4/15/20. However, further review of the personnel file failed to show a preemployment health screen was completed. On 12/20/23 at 1220 hours, an interview was conducted with the Administrator. The Administrator was informed and acknowledged the findings. 3. Review of the Patient Handbook included in the admission packet provided to patients was initiated on 12/12/23. Review of the Patient Handbook did not show the current CDPH address. On 12/12/23 at 1215 hours, an interview and concurrent record review was conducted with RN 1. RN 1 was informed and acknowledged the findings. 4. Review of Patient 9’s clinical record was initiated on 12/14/23. The clinical record showed the SOC was 10/18/23. The patient was certified for home health services during the certification periods from 10/18/23 to 12/16/23. Review of the POC for the certification period from 10/18/23 to 12/16/23, cited SN visits 1W1 and 1Q2W8. The POC cited medical treatments provided to the unstageable decubitus ulcer as follows: cleanse unstageable decubitus ulcer to coccyx with normal saline, pat dry with gauze, then apply small amount Calazime paste to wound and cover with hydrocolloid dressing. The POC also cited SN/CG to change every three to five days and if soiled or dislodged. On 12/15/23 at 1505 hours, an interview was conducted with the Administrator. The Administrator was asked for a wound care policy. The Administrator stated they did not have a policy for wound care but followed the nursing standards for wound care. On 12/15/23 at 1251 hours, an interview and conducted with RN 1. RN 1 was informed and acknowledged the finding. 5. Review of the agency license was initiated on 12/12/23, showed the name of West Coast Home Health. However, review of the Patients Handbook showed the agency name was West Coast Palliative Care instead of West Coast Home Health. In addition, the patient handbook included patient resources and important telephone numbers. The resources information included the agency name as West Coast Home Health & Palliative Care which was inconsistent with the license. On 12/15/23 at 0800 hours, an interview was conducted with the Administrator. The Administrator was asked if they provide palliative care. The Administrator replied no, they provided home health services.”

“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 completed discharge and transfer summaries within five days from the discharge order for seven of nine sampled patients (Patients 3, 4, 5, 6, 7, 8, and 9) to their primary care physicians. This failure created the risk for these patients to not receive the continuity in care and medical treatment. Findings: 1. Review of Patient 3’s clinical record was initiated on 12/13/23. The clinical record showed the SOC was 12/13/22. The patient was certified for home health services during the certification period from 12/13/22 to 2/10/23. Review of the Physicians’ order dated 2/10/23, showed to discharge the patient from home health services. Review of the Discharge - Transfer Summary Report dated 2/10/23, showed the patient’s admission and discharge dates, condition on discharge, vital signs, medication profiles, goals and outcomes, services provided, and the total number of visits provided per services. However, the RN failed to complete the component of the discharge summary such as the patient and family’s post discharge instructions and frequency of the services provided. On 12/15/23 at 1513 hours, an interview and concurrent closed clinical record review was conducted with the DNP. The DNP was informed and acknowledged the finding. 2. Review of Patient 5’s clinical record was initiated on 12/14/23. The clinical record showed the SOC was 1/23/23. The patient was certified for home health services during the certification periods from 1/23/23 to 3/23/23. * Review of the Physicians’ Order dated 3/3/23, showed an order for discharge from the “palliative care.” Review of the clinical record showed the Discharge- transfer summary was sent to the physician on 3/10/23. However, the Discharge-Transfer Summary Report was sent to the physician seven days after the discharge order instead of within five days from the order was written. * Review of the Discharge- Transfer Summary Report dated 3/7/23, showed the patient was discharged/transferred to a short term general hospital for in patient care. The Discharge- Transfer Summary Report also showed the patient’s admission and the last visit dates, condition on discharge, vital signs, medication list, goals and outcomes, services provided, and the total number of visits provided per services. However, the RN failed to complete the component of the discharge- transfer summary such as the patient and family’s post discharge instructions and frequency of the services provided. On 12/15/23 at 1459 hours, an interview and concurrent closed clinical record review was conducted with the DNP. The DNP was informed and acknowledged the findings. 3. Review of Patient 7’s clinical record was initiated on 12/13/23. The clinical record showed the SOC was 5/23/23. The patient was certified for home health services during the certification periods from 5/23/23 to 7/21/23. Review of the Physician’s order dated 7/21/23, showed to discharge the patient from home health agency Review of the Discharge - Transfer Summary Report dated 7/21/23, showed the patient’s admission and discharge dates, vital signs, condition on discharge, medication list, goals and outcomes, services provided and the total number of visits provided per services. However, the RN failed to complete the component of the discharge - transfer summary such as the patient and family’s post discharge instructions and frequency of the services provided. On 12/15/23 at 1437 hours, an interview and concurrent closed clinical record review was conducted with the DNP. The DNP was informed and acknowledged the finding. 4. Review of Patient 8’s clinical record was initiated on 12/14/23. The clinical record showed the SOC was 3/20/23. The patient was certified for home health services during the certification period from 3/20/23 to 5/18/23. Review of the Discharge - Transfer Summary Report dated 5/14/23, showed the patient’s admission and discharge dates, condition on discharge, vital signs, medication list, goals and outcomes, services provided, and the total number of visits provided per services. However, the RN failed to complete the component of the discharge - transfer summary such as the patient and family’s post discharge instructions and frequency of the services provided. Review of the SN visit note dated 5/14/23, showed the patient’s family decided to change to hospice services. The RN would complete “palliative “ discharge. The physician was aware. Review of the closed clinical record failed to show documented evidence of the physician order to discharge from the agency. On 12/15/23 at 1406 hours, an interview and concurrent closed clinical record review was conducted with the DNP. The DNP was informed and acknowledged the findings. 5. Review of Patient 9’s closed clinical record was initiated on 12/14/23. The clinical record showed the SOC was 10/18/23. The patient was certified for home health services during the certification period from 10/18/23 to 12/16/23. Review of the Discharge - Transfer Summary Report dated 11/5/23, showed the patient’s admission and discharge date, condition on discharge, vital signs, medication profiles, goals and outcomes, services provided, and the total number of visits provided per services. However, the RN failed to complete the component of the discharge summary such as the frequency of the services provided. Further review of the agency’s documents showed the discharge summary was sent on 11/12/23, to the physician, seven days after discharge. On 12/15/23 at 1351 hours, an interview and concurrent closed clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the findings. 6. Review of Patient 4’s closed clinical record was initiated on 12/13/23. The clinical record showed the SOC was 4/20/23. The patient was certified for home health services during the certification period from 4/20/23 to 6/18/23. Review of the Discharge - Transfer Summary Report dated 6/18/23, showed the patient’s admission and discharge date, vital signs, medication profiles, goals and outcomes, services provided, and the total number of visits provided per services. However, the RN failed to complete the component of the discharge summary such as the frequency of the services provided, discharge instructions, or the patient’s condition on discharge Further review of the agency’s documents showed the discharge summary was sent on 7/3/23 to the physician, 15 days after discharge. On 12/15/23 at 1337 hours, an interview and concurrent closed clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the findings. 7. Review of Patient 6’s closed clinical record was initiated on 12/14/23. The clinical record showed the SOC was 12/22/22. The patient was certified for home health services during the certification periods from 12/22/23 to 2/19/23, and 2/20/23 to 4/20/23. Review of the Discharge - Transfer Summary Report dated 3/15/23 showed the patient admission and discharge date, vital signs, medication profiles, services provided, and the total number of visits provided per services. However, the RN failed to complete the component of the discharge summary such as the frequency of the services provided, discharge instructions, goals and outcomes, or the patient’s condition on discharge Further review of the agency’s documents showed the discharge summary was sent on 3/29/23 to the physician, 14 days after discharge. On 12/15/23 at 1317 hours, an interview and concurrent closed clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the findings.”