Allbest Home Health Care, Inc.

“Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: Based on a review of the Agency’s Emergency Preparedness plan and Staff interview, it was determined the Agency failed to review and update its Emergency Preparedness plan biennially. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Emergency Preparedness plan was reviewed on 01/21/25. The plan lacked a date indicating when it was last reviewed and updated. 2. During an interview with the Administrator, and Clinical Manager on 01/22/25 at 3:40 PM, the Administrator stated the plan was last reviewed about 3 years ago. During the same interview, the Administrator confirmed the Agency failed to review and update its Emergency Preparedness plan biennially.”

“Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: Based on a review of the Agency’s Emergency Preparedness plan and Staff interview, it was determined the Agency failed to ensure the Emergency Preparedness plan contain an approach for handling events identified in the risk assessment. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The undated Emergency Preparedness plan was reviewed on 01/21/25. The plan included the “Hazard Vulnerability Analysis” (risk assessment) that included emergency events, such as “Ice Snow, Flooding, Earthquake”. The plan lacked a process to address how the Agency will manage these events. 2. The Agency’s undated Emergency Preparedness plan contained documentation that a “Winter storm/Severe winter weather” planned exercise was conducted on 12/23/22. Yet, the Agency failed to develop an emergency plan for managing a winter storm/ice snow. 3. During an interview with the Administrator, and Clinical Manager on 01/22/25 at 3:40 PM, the Administrator confirmed the Agency lacked plans to address the events identified above in the “Hazard Vulnerability Analysis”.”

“Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [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. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility 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 annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization 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 address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility 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. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility’s geographic area. This Standard is not met as evidenced by: Based on a review of the Agency’s Emergency Preparedness plan and Staff interview, it was determined the Agency failed to establish policies and procedures based on the risk assessment, review and revise the communication plan biennially. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The undated Emergency Preparedness plan was reviewed on 01/21/25. The plan included the “Hazard Vulnerability Analysis” (risk assessment) dated 2024 that contained the events; “Ice Snow, Flooding, Earthquake”. As of 01/21/25, the plan lacked policies and procedures based on “Ice Snow, Flooding, Earthquake”. 2. The undated Emergency Preparedness plan included a communication plan. The communication plan lacked a date, indicating when the plan was last reviewed and revised. 3. During an interview with the Administrator, and Clinical Manager on 01/22/25 at 3:45 PM, the Administrator confirmed the Agency failed to establish policies and procedures based on the risk assessment, review and revise the communication plan biennially.”

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on review of the Error Summary report and Staff interview, it was determined that in 15 of 166 reports submitted for the last 12 months, the Agency failed to submit a timely report, resulting in a warning. Findings include: 1. The Error Summary report for 01/01/24 to 12/31/24 (12 months), was reviewed on 01/21/25. The report included a warning for Error # -3330. The Error included 15 of 166 (9.04 %) assessments that were submitted late. 2. During an interview with the Administrator, Clinical Manager and Supervisor/Field RN on 01/23/25 at 10:00 AM, the Clinical Manager stated that the timeframe for submission of OASIS is within 30 days after completion. During the same interview, the Administrative Staff, confirmed that the Agency had late OASIS submissions.”

“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 a review of clinical records, and Staff interviews, it was determined that in 4 of 7 (Pts. #2, 4, 6 and 3) clinical records reviewed, the Agency failed to ensure Staff provide service indicated in the PsOC. Findings include: 1. Pt. #2 was admitted to Home Health Services on 04/04/24 with the diagnosis of Hemiplegia and Hemiparesis following other Nontraumatic Intracranial Hemorrhage affecting Left Non-Dominant Side. The clinical record was reviewed on 01/21/25. The clinical record included the POC effective 11/30/24 that required, the SN to provide service “1 X Week Every 2 Weeks for 8 Weeks”. The SN provided service on 12/20/24 (week of 12/15/24 to 12/21/24). The record lacked documentation the SN provided service during the week of 12/29/24 to 01/04/25. 2. Pt. #4 was admitted to Home Health Services on 07/18/24 with the diagnoses of Type 2 Diabetes Mellitus without Complications, Chronic Kidney Disease, and Hypertensive Heart Disease without Heart Failure. The clinical record was reviewed on 01/22/25. The clinical record included the POC effective 11/15/24 that required the SN to provide service “1-2 Week X 8 Weeks… Skilled Nurse to Notify MD of… Weight Loss/Gain of More Than 4 LBS/Week…” The record lacked documentation the SN conducted a visit during the week of 12/29/24 to 1/4/25; and the SN visit notes for 1 to 2 times a week from 11/19/24 to 12/26/24, and 01/07/25 lacked a weight. The POC effective 11/15/24 required, “… Skilled Nurse to Notify MD of… Blood Sugar More Than 250 Less Than 60…” The SN visit notes dated 11/19/24 and 12/26/24 contained, “Blood sugar checked by RN during weekly visits due to patient poor hand dexterity and inability to check own blood sugar. Patient takes oral anti-diabetic medications”. The SN visit notes dated 12/03/24 and 12/17/24 lacked documentation the RN checked the blood sugar. 3. Pt. #6 was admitted to Home Health Services on 05/10/24 with the diagnosis of Traumatic Subarachnoid Hemorrhage with Loss of Consciousness Status Unknown, Initial Encounter. The clinical record was reviewed on 01/22/25. The clinical record included the POC for the certification period of 5/10/24 to 07/08/24 that required; “Skilled Nurse To Notify MD of the Following Parameters: B/P More Than 160/90 And Less Than 90/60…” The SN visit note dated 06/13/24 included B/P 107/60. The record lacked documentation the SN rechecked Pt. #6’s B/P or reported the B/P less than 60. 4. Pt. #3 was admitted to Home Health Services on 10/01/24 with the diagnosis of Type 2 Diabetes Mellitus without complications and Hypertensive Heart disease. The clinical record was reviewed on 01/21/25. The POC for certification period of 11/30/24 to 01/28/25, required SN frequency of “1-2 week x 8 weeks”. The clinical record lacks SN visit for weeks of 12/08/24, 12/22/24 and 01/05/25, as ordered in the POC. 5. During interviews with the Administrator, Clinical Manager and Office Manager on 01/22/25 at 12:10 PM and with the Administrator, Clinical Manager and Supervisor/Field Nurse on 01/23/25 at 10:00 AM, the Administrative Staff confirmed that the Agency failed to provide services, as ordered in the PsOC.”

“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 a review of clinical records, Agency policy, and Staff interviews, it was determined that in 5 of 7 (Pts. #2, 4, 6, 1, and 5) clinical records reviewed, the Agency failed to ensure documentation entered into the clinical record was complete. Findings include: 1. Pt. #2 was admitted to Home Health Services on 04/04/24 with the diagnoses of Hemiplegia and Hemiparesis following other Non-Traumatic Intercranial Hemorrhage affecting Left Non-Dominant Side. The clinical record was reviewed on 01/21/25. The clinical record included the form titled; “Patient’s Emergency Plan” completed by the SN. The form lacked Pt. #2’s phone number, address, Physician’s information, pharmacy information, allergies, evacuation priority code, emergency contact person(s) information; fire, police, and nearest hospital information. All are required by the Agency’s form. 2. Pt. #4 was admitted to Home Health Services on 07/18/24 with the diagnoses of Type 2 Diabetes Mellitus without Complications, Chronic Kidney Disease, and Hypertensive Heart Disease without Heart Failure. The clinical record was reviewed on 01/22/25. The clinical record included the SN visit note dated 12/19/24 which lacked documentation of a skilled assessment of the patient’s cardiovascular system, temperature, respiratory status, endocrine status, pain, musculoskeletal system, mental/emotional status, nutrition status, gastrointestinal system, genitourinary system, and integumentary system. All are required by the Agency’s SN visit note. The form titled, “Patient Advance Directives Statement” completed by the SN, signed by the Pt. and dated 04/18/24. The form required the SN to place a check mark in sections throughout the form, indicating whether the Pt. wanted more information regarding Advance Directives, had an Advance Directive, if so what type and whether a copy was obtained. The sections mentioned above were left blank. The form titled “Advance Beneficiary Notice of Non-coverage (ABN) included the patient’s signature and dated 07/18/24. The form contained sections that required the SN to enter the service that Medicare may not pay, the reason, estimated cost of the service, and the option to choose whether the Pt. still wanted the service. The sections mentioned above were left blank. 3. Pt. #6 was admitted to Home Health Services on 05/10/24 with the diagnosis of Traumatic Subarachnoid Hemorrhage with Loss of Consciousness Status Unknown, Initial Encounter. The clinical record was reviewed on 01/22/25. The clinical record included the form titled, “Change in Beneficiary Elected Provider” completed by the SN, signed by the Pt. and dated 05/10/24. The form lacked the name of the supervising Physician and their NPI (National Provider Identifier); name of the previous Agency, contact person and the date of notification to the previous Agency. All information was required by the Agency’s form. __. The Agency’s policy titled; “Medical Record Entries and Authentication” was reviewed on 01/23/25. The policy included “… Procedure All entries in patient records will be… complete…” 4. Pt. #1 was admitted to Home Health Services on 10/08/24 with the diagnosis of Type 2 Diabetes Mellitus and Hypertensive Heart Disease. The clinical record was reviewed on 01/22/25 and 01/23/25. The clinical record contained an “Authorization and Agreement for Home Health Services”, form signed by Pt. #1 and dated at the SOC. The section on Advance Directives, required the SN to indicated whether the Pt. chooses to formulate an Advance directive or not, this section was left blank. 5. Pt. #5 was admitted to Home Health Services on 01/06/25 with diagnosis of Acute Combined Systolic and Diastolic Congestive Heart Failure and End stage renal disease. The clinical record was reviewed on 01/22/25. The clinical record contained an “Authorization and Agreement for Home Health Services”, form signed by Pt. #2 and dated at the SOC. The section on Advance Directives, required the SN to indicated whether the Pt. chooses to formulate an Advance directive or not, this section was left blank. 7. During interviews with the Administrator, Clinical Manager and Office Manager on 01/22/25 at 12:10 PM and with Administrator, Clinical Manager and Supervisor/Field RN on 01/23/25 at 10:00 AM, the Administrative Staff confirmed ….”

“Written notice within 4 business days CFR(s): 484.50(a)(4) Provide written notice of the patient’s rights and responsibilities under this rule and the HHA’s transfer and discharge policies as set forth in paragraph (d) of this section to a patient-selected representative within 4 business days of the initial evaluation visit. This Element is not met as evidenced by: Based on a review of the Agency’s Pt. admission folder, observation during home visits and Staff interviews, it was determined in 3 of 3 (Pts. #1, 2 and 3) home visits conducted, the Agency failed to provide Pts. information regarding the Agency’s transfer policies. Findings include: 1. The Patient’s admission folder was reviewed on 01/22/25. The folder contained a form that included a statement that the Agency provides information regarding the Agency’s transfer policy. However, the folder lacked any documentation regarding the Agency’s transfer policy. 2. The following home visits were conducted on 01/21/25 and 01/22/25: Pt. #1 SOC 06/17/24 Pt. #2 SOC 04/04/24 Pt. #3 SOC 10/01/24 During the home visits, the home folders was observed and contained a form that Staff provided information of the Agency’s transfer policy. However, the folder lacked any information pertaining to the Agency’s transfer policy. 3. During interviews with the Administrator, Clinical Manager and Office Manager on 01/22/25 at 12:10 PM, and with the Administrator, Clinical Manager and Supervisor/Field Nurse on 01/23/25 at 10:00 AM, the Clinical Manager confirmed that the Agency failed to provide information regarding transfer policies.”

“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 a review of clinical records, and Staff interviews, it was determined in 4 of 7 (Pts. # 1, 3, 7 and 2) clinical records reviewed, the Agency failed to ensure the initial assessment was done within 48 hours upon receipt of a referral. 4. Pt. #2 was admitted to Home Health Services on 04/04/24 with the diagnosis of Hemiplegia and Hemiparesis following other Nontraumatic Intracranial Hemorrhage affecting Left Non-Dominant Side. The clinical record was reviewed on 01/21/25. The clinical record included the SOC Assessment form completed by the SN and dated 04/04/24, indicating service was initiated. As of 01/21/25, the Agency lacked a referral for the SOC conducted on 04/04/24. 5. During interviews conducted on 01/22/25 at 12:10 PM with the Administrator, Clinical Manager, the Office Manager; and 01/23/25 at 10:00 AM with the Administrator, Clinical Manager, and the Supervisor/Field RN, the above findings were confirmed. Findings include: 1.Pt. #1 was admitted to Home Health Services on 10/08/24 with the diagnosis of Type 2 Diabetes Mellitus and Hypertensive Heart Disease. The clinical record was reviewed on 01/22/25 and 01/23/25. The record included the initial SOC assessment, dated 10/08/24. The record lacked documentation of an inpatient facility stay or physician ordered SOC date. As of 01/23/25, the Agency lacked a referral for the SOC conducted on 10/08/24. 2. Pt. #3 was admitted to Home Health Services on 10/01/24 with the diagnosis of Type 2 Diabetes Mellitus without complications and Hypertensive Heart disease. The clinical record was reviewed on 01/21/25. The record included the initial SOC assessment, dated 10/01/24. The record lacked documentation of an inpatient facility stay or physician ordered SOC date. As of 01/23/25, the Agency lacked a referral for the SOC conducted on 10/01/24. 3. Pt. # 7 was admitted to Home Health Services on 02/02/24 with the diagnosis of Type 2 Diabetes Mellitus, Essential (Primary) Hypertension and Cerebral Infarction. The clinical record was reviewed on 01/21/25. The record included the initial SOC assessment, dated 02/02/24. The record lacked documentation of an inpatient facility stay or physician ordered SOC date. As of 01/23/25, As of 01/21/25, the Agency lacked a referral for the SOC conducted on 02/02/24.”

“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 a review of clinical records and Staff interviews, it was determined in 2 of 7 (Pts. #2, and 6) clinical records reviewed, the PsOC lacked Pt. specific interventions. Findings include: 1. Pt. #2 was admitted to Home Health Services on 04/04/24 with the diagnosis of Hemiplegia and Hemiparesis following other Non-Traumatic Intercranial Hemorrhage affecting Left Non-Dominant Side. The clinical record was reviewed on 01/21/25. The clinical record included, in part, the Recertification Assessment form completed by the SN and dated 11/25/24 that contained, “Blood Sugar NA Pt. is not diabetic or prediabetic”. Yet, the POC effective 11/30/24 required, “Skilled Nurse to notify MD of the following parameters…Blood Sugar more than 250 less than 80.” The POC was inaccurate, requiring the SN to notify the MD for a Blood Sugar outside the parameters indicated above. 2. Pt. #6 was admitted to Home Health Services on 05/10/24 with the diagnosis of Traumatic Subarachnoid Hemorrhage with Loss of Consciousness Status Unknown, Initial Encounter. The clinical record was reviewed on 01/22/25. The clinical record included the POC for the certification period of 5/10/24 to 07/08/24 that required; “Skilled Nurse To Notify MD of the Following Parameters… Blood Sugar More Than 250 Less Than 60…” The SOC Assessment form completed by the SN and dated 05/10/24 contained, “Blood Sugar NA Pt. is not diabetic or prediabetic”. The POC was inaccurate, requiring the SN to notify the MD for a Blood Sugar outside the parameters indicated above. 3. During an interview with the Administrator, Clinical Manager, and the Office Manager at 10:15 AM and 10:45 AM, the Administrator confirmed the PsOC lacked Pt. specific interventions.”

“Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This Element is not met as evidenced by: Based on a review of clinical records, and Staff interviews, it was determined that in 5 of 7 (Pts. #2, 6, 1, 3 and 7) clinical records reviewed, the Agency failed to fully assess patients’ Influenza and/or Pneumococcal vaccine status at the SOC, as required by the Agency. Findings include: 1. Pt. #2 was admitted to Home Health Services on 04/04/24 with the diagnosis of Hemiplegia and Hemiparesis following other Non-Traumatic Intercranial Hemorrhage affecting Left Non-Dominant Side. The clinical record was reviewed on 01/21/25. The clinical record included the SOC Assessment form completed by the SN and dated 04/04/24. The form contained an “Immunization/ Screenings” section that included the Pt. received the Pneumonia vaccine but did not recall the date. The record lacked documentation the SN contacted the Physician and/or the referral source for the date the Pt. received the Pneumonia vaccine, as required by the Agency. 2. Pt. #6 was admitted to Home Health Services on 05/10/24 with the diagnosis Traumatic subarachnoid Hemorrhage with loss of consciousness, status unknown, initial encounter. The clinical record was reviewed on 01/22/25. The clinical record included the SOC Assessment form completed by the SN and dated 05/10/24. The form contained an “Immunization/ Screenings” section that included the Pt. received the Pneumonia vaccine but did not recall the date. The record lacked documentation the SN contacted the Physician and/or the referral source for the date the Pt. received the Pneumonia vaccine, as required by the Agency. 3. Pt. #1 was admitted to Home Health Services on 10/08/24 with the diagnosis of Type 2 Diabetes Mellitus and Hypertensive Heart Disease. The clinical record was reviewed on 01/22/25 and 01/23/25. The record included an “Influenza/Pneumococcal Vaccine Form”, signed by the RN and dated 10/08/24, and lacked documentation of Pt.’s Influenza and Pneumococcal vaccine status. 4. Pt. #3 was admitted to Home Health Services on 10/01/24 with the diagnosis of Type 2 Diabetes Mellitus without complications and Hypertensive Heart disease. The clinical record was reviewed on 01/21/25. The record included an “Influenza/Pneumococcal Vaccine Form”, signed by the RN and dated 10/01/24, and lacked documentation of Pt.’s Pneumococcal vaccine status. 5. Pt. # 7 was admitted to Home Health Services on 02/02/24 with the diagnosis of Type 2 Diabetes Mellitus, Essential (Primary) Hypertension and Cerebral Infarction. The clinical record was reviewed on 01/21/25. The record included an “Influenza/Pneumococcal Vaccine Form”, signed by the RN and dated 02/02/24, that Pt. received the Pneumonia vaccine but did not recall the date. The record lacked documentation the SN contacted the Physician and/or the referral source for the date the Pt. received the Pneumonia vaccine, as required by the Agency. 6. During an interview with the Administrator and Clinical Manager on 01/22/25 at 12:10 PM, the Clinical Manager stated if the Pt./patient’s representative do not remember the date the Pt. received a vaccine. The SN is required to contact the Physician and/or the referral source for the date the Pt. received the vaccine, and document the date in the clinical record. 7. During interviews with the Administrator, Clinical Manager and the Office Manager on 01/22/25 at 12:10 PM; and with the Administrator, Clinical Manager and the Supervisor/Field Nurse on 01/23/25 at 10:00 AM, the Administrative Staff confirmed the Agency failed to fully assess the patients’ Influenza and/or Pneumococcal vaccine status at the SOC, as required by the Agency.”