Vital Home & Healthcare Inc.

“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 the review of the Agency’s Emergency Preparedness Plan and staff interview, it was determined the Agency failed to have a current communication plan. Findings include: 1. The Agency’s Emergency Preparedness Plan was reviewed on 5/28/24. The plan lacked a current communication plan that includes the name and contact information of the current Clinical Director and Administrator. 2. During an interview with the Clinical Director on 5/30/24 at 10:45 AM. The Clinical Director confirmed the above finding.”

“EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: Based on a review of the Agency’s Emergency Preparedness Plan and staff interview, it was determined that the Agency failed to conduct a full-scale community-based exercise / facility-based exercise or provide documentation idicating Agency implemented the Emergency Preparedness plan since 2021. Findings include: 1. The Agency’s Emergency Preparedness Plan was reviewed on 5/28/24. The Emergency Preparedness Plan did not include documentation indicating the Agency implemented the plan or conducted full scale exercise since 2021. 2. During an interview with the Clinical Director on 5/30/24 at 10:45 AM. The Clinical Director confirmed the Agency failed to participate in full scale exercise since 2021.”

“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 for 3 of 10 (Pts. # 2, 7 and 10) clinical records reviewed, the Agency failed to ensure care and/or services were provided as ordered by the Physician, and as indicated in the POC. 3. Pt. #10 was admitted to home health service on 12/14/23 with the diagnoses of Stage 4 Pressure Ulcer of Sacral Region and Subsequent Leakage of Indwelling Urethral Catheter. The clinical record was reviewed on 5/29/24. The record contained the POC for the certification period of 12/14/23 to 2/11/24 requiring: “SN 1 WK 9... Skilled nurse to change foley catheter 16 FR/10 CC once a month.” The record included the SN visit note dated 12/21/23 for service provided during the week of 12/17/23 to 12/23/23. The SN visit note dated 12/21/23 included documentation the foley catheter was last changed on “11/20/2023”, and the SN did not change the foley catheter during the visit . The record lacked documentation the SN changed the foley catheter monthly as required in the POC. 4. During interviews with the Clinical Director on 5/30/24 at 8:35 AM and 9:15 AM, the Clinical Director confirmed care and/or services were not provided, as ordered by the Physician and/or indicated in the POC. Findings include: 1. Pt. #2 was admitted to home health services on 2/8/24 with primary diagnosis of Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris. The clinical record was reviewed on 5/29/24. The record included a POC effective 4/8/24 which required, “Orders and Treatment: MSW: MSW Evaluation and treatment for long-term planning and community resources… MSW evaluation 1 mo 1.” As of 5/30/24, the record lacked documentation that a MSW evaluation or visit was conducted. 2. Pt. #7 was admitted to home health services on 4/12/24 with a primary diagnosis of Acute and Chronic Respiratory Failure with Hypoxia. The clinical record was reviewed on 5/29/24. The record included a Physician order on 4/6/24, “the following services are medically necessary home health services: SN PT OT.” As of 5/30/24, the record lacked documentation that an OT evaluation or visit was conducted.”

“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 2 of 10 (Pts. #2 and 3) clinical records reviewed, the Agency failed to ensure the initial assessment visit was done within 48 hours of the referral date. 2. Pt. #2 was admitted to home health service on 2/8/24 with a primary diagnosis of Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris. The clinical record was reviewed on 5/29/24. The record contained a physician order dated 2/2/24 which included a referral for home health services. The SOC comprehensive assessment was conducted by the RN on 2/8/24. The record lacked a Physician ordered SOC date or documentation the Pt. was discharged from an inpatient facility. The record lacked documentation the Agency initiated services within 48 hours after the receipt of the referral. 3. During an interview with the Clinical Director on 5/30/23 from 8:35 AM to 9:45 AM it was stated that the initial comprehensive assessment should be conducted within 48 hours after the receipt of the referral. During the same interview, the above findings were confirmed. Findings include: 1. Pt. #3 was admitted to home health service on 5/20/24 with the primary diagnosis of Encounter for Surgical Aftercare Following Surgery on the Circulatory System. The clinical record was reviewed on 5/29/24. The record contained the “Home Health Referral/Order” completed by the Physician and faxed to the Agency on 5/17/24. The SOC comprehensive assessment was conducted by the RN on 5/20/24. As of 5/29/24, the record lacked documentation the Agency initiated service within 48 hours after receipt of the referral and/or a reason for the late SOC.”

“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 clinical records review and staff interviews, it was determined the Agency failed to ensure the PsOC contained patient specific interventions and education. This was found in 3 of 10 (Pts. # 5, 7 and 8) clinical records reviewed Findings include: 1. Pt. #5 was admitted to home health services on 5/15/24 with diagnosis of Sepsis, Unspecified Organism. The clinical record was reviewed on 5/29/24. The clinical record contained a POC beginning 5/15/24. The POC lacked patient specific interventions of intravenous (IV) infusion interventions. The interventions lacked - location of infusion device, frequency of IV infusions, pre - post infusion flushes. 2. Pt. #7 was admitted to home health services on 4/12/24 with a primary diagnosis of Acute and Chronic Respiratory Failure with Hypoxia, and other diagnosis of but not limited to Abnormal Weight Loss. The clinical record was reviewed on 5/20/24. Pt. #7’s clinical record included a physician progress note which indicated that Pt. #7 had weight of 83 pounds and 9.6 ounces, and included orders placed for referral to dietician and high protein diet. The POC effective 4/12/24 lacked interventions addressing the nutritional status of Pt. #7. 3. Pt. # 8 was admitted to home health services on 8/29/23 with a primary diagnosis of Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 5/20/24. The record included a POC for the certification period of 8/29/23 to 10/27/23 lacked interventions related to heart failure monitoring. 4. During an interview with the Clinical Director on 5/20/24 at 9:15 AM and 9:45 AM, the above findings were confirmed. Findings include: 1. Pt. #5 was admitted to home health services on 5/15/24 with diagnosis of Sepsis, Unspecified Organism. The clinical record was reviewed on 5/29/24. The clinical record contained a POC beginning 5/15/24. The POC lacked patient specific interventions of intravenous (IV) infusion interventions. The interventions lacked - location of infusion device, frequency of IV infusions, pre - post infusion flushes. 2. Pt. #7 was admitted to home health services on 4/12/24 with a primary diagnosis of Acute and Chronic Respiratory Failure with Hypoxia, and other diagnosis of but not limited to Abnormal Weight Loss. The clinical record was reviewed on 5/20/24. Pt. #7’s clinical record included a physician progress note which indicated that Pt. #7 had weight of 83 pounds and 9.6 ounces, and included orders placed for referral to dietician and high protein diet. The POC effective 4/12/24 lacked interventions addressing the nutritional status of Pt. #7. 3. Pt. # 8 was admitted to home health services on 8/29/23 with a primary diagnosis of Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 5/20/24. The record included a POC for the certification period of 8/29/23 to 10/27/23 that lacked interventions related to heart failure monitoring. 4. During an interview with the Clinical Director on 5/20/24 at 9:15 AM and 9:45 AM, the above findings were confirmed.”

“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 clinical records review and staff interviews, it was determined the Agency failed to ensure immunization screening was complete at the time of Start of Care. This was found in 10 of 10 (Pts. #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10) clinical records reviewed. 8. Pt. #3 was admitted to home health service on 5/20/24 with the primary diagnosis of Encounter for Surgical Aftercare Following Surgery on the Circulatory System. The clinical record was reviewed on 5/29/24. The record contained the SOC comprehensive assessment completed by the RN and dated 5/20/24. The assessment included a section that inquired into the patient’s “Pneumonia” and “Flu” immunization status. The RN placed a check mark next to “Yes” indicating, the Pt. received these immunizations. The record lacked the date the immunizations were given. 9. Pt. #9 was admitted to home health service on 8/11/23 with the primary diagnosis of Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 5/29/24. The record contained the SOC comprehensive assessment completed by the RN and dated 8/11/23. The assessment included a section that inquired into the patient’s “Pneumonia” and “Flu” immunization status. The RN placed a check mark next to “No” indicating, the Pt. had not received these immunizations. The record lacked documentation that the RN offered the vaccines or the Pt. had refused. 10. Pt. #10 was admitted to home health service on 12/14/23 with the diagnoses of Stage 4 Pressure Ulcer of Sacral Region and Subsequent Leakage of Indwelling Urethral Catheter. The clinical record was reviewed on 5/29/24. The record contained the SOC comprehensive assessment completed by the RN and dated12/14/23. The assessment included a section inquiring into the patient’s “Pneumonia” and “Flu” immunization status. The RN placed a check mark next to “Yes” indicating, the Pt. received these immunizations. The record lacked the date the were given. 11. During an interview with the Clinical Director on 5/29/24 at 1:15 PM and 5/30/24 at 8:35 AM, the Clinical Director stated the RN conducts the SOC/initial visit. During this visit, the RN inquires whether the Pt. had received the Influenza (Flu) and Pnuemonia vaccines and the dates the vaccines were given, and this information is entered in the clinical record, as required by the Agency’s SOC assessment form. If the Pt. does not recall when the vaccine was given, the RN is required to contact the Physician’s office for the dates the vaccines were given. During the inquiry if the Pt. responds “No”, this indicates the Pt. had not received the vaccines and the RN should offer the vaccines. 12. During interviews with the Clinical Director on 5/30/24 from 8:35 AM to 10:45 AM, the Clinical Director confirmed the above findings. 5. Pt. #2 was admitted to home health services on 2/8/24 with primary diagnosis of Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris. The clinical record was reviewed on 5/29/24. The SOC comprehensive assessment included a section that included the patient’s most recent immunization which was marked “Yes” for both the influenza and pneumonia vaccines but lacked the dates of its administration. 6. Pt. #7 was admitted to home health services on 4/12/24 with a primary diagnosis of Acute and Chronic Respiratory Failure with Hypoxia. The clinical record was reviewed on 5/29/24. The SOC comprehensive assessment included a section that included the patient’s most recent immunization which was marked “Yes” for the influenza vaccine but lacked the date of its administration; it was marked “No” for the pneumonia vaccine but lacked documentation the RN offered the vaccines, or the Pt. had refused. 7. Pt. #8 was admitted to home health services on 8/29/23 with a primary diagnosis of Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 5/29/24. The SOC comprehensive assessment included a section that included the patient’s most recent immunization which was marked “Yes” for both the influenza and pneumonia vaccines but lacked the dates of its administration. Findings include: 1. Pt. #1 was admitted to home health services on 4/19/24 with diagnosis of Venous Insufficiency. The clinical record was reviewed on 5/28/24. The clinical record contained a start of care nurse comprehensive assessment dated 4/19/24 that failed to include documentation on follow up for Pneumococcal Pneumonia vaccinations status when answered “no” on the assessment. 2. Pt. #4 was admitted to home health services on 5/8/24 with diagnosis of Pneumonia, Unspecified. The clinical record was reviewed on 5/28/24. The clinical record contained a start of care nurse comprehensive assessment dated 5/8/24 that failed to include date patient received Pneumococcal Pneumonia vaccination, when answered “yes” on recent immunization status assessment. 3. Pt. #5 was admitted to home health services on 5/15/24 with diagnosis of Sepsis, Unspecified Organism. The clinical record was reviewed on 5/29/24. The clinical record contained a start of care nurse comprehensive assessment dated 5/15/24 that failed to include documentation on follow up for Pneumococcal Pneumonia vaccinations status when answered “unknown” on the immunization assessment. 4. Pt. #6 was admitted to home health services on 9/2/22 with diagnosis of Spinal Stenosis, Lumbar Region Without Neurogenic Claud. The clinical record was reviewed on 5/29/24. The clinical record contained a start of care nurse comprehensive assessment dated 9/2/22 that failed to include date patient received Pneumococcal Pneumonia vaccination when answered “yes” on the recent immunization status assessment.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on clinical record reviews, Pt. education guide review and staff interviews, it was determined the Agency failed to ensure that for 2 of 10 (Pts. #2 and 9) clinical records reviewed, the Physician was notified of changes in patients’ weight. 2. Pt. #9 was admitted to home health service on 8/11/23 with the primary diagnosis of Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 5/29/24. The record contained the SN visit note dated 9/7/23 that included the Pt. weighed 152 pounds. The resumption of care comprehensive assessment dated 9/21/23 included the Pt. weighed 132 pounds. The SN visit note dated 9/28/23 included the Pt. weighed 152 pounds. The SN visit note dated 10/5/23 included the Pt. weighed 147 pounds, and “lung sounds: Dimished all lobes”. Pt. #9 was admitted to the hospital on 10/12/23 with the diagnosis of “Heart Failure”. The record lacked documentation the RN notified the Physician of the weight fluctuations and the patient’s status. 3. During an interview the Clinical Director on 5/29/24 at 3:05 PM, the Clinical Director stated: “The nurse is expected to weigh Pts. with heart failure or have nutrition problems. If the Pt. was not weighed prior to arriving at the patient’s home, then the nurse should weigh the Pt...” The Clinical Director read from an information guide inside the Agency’s “Patient Education Guide Congestive Heart Failure” folder, which included: “Weight gain of 3 or more pounds... Weight gain or loss of more than 5 pounds”. The Clinical Director stated these are the weight parameters that the nurse should use, if the Pt. exceeds these parameters the nurse should call the doctor during the home visit, and document this in the clinical record. 4. During interviews with Clinical Director on 5/30/24 at 8:35 AM and 9:15 AM, the Clinical Director confirmed the SN failed notifiy the Physician of weight changes, and/or other significant findings. Findings include: 1. Pt. #2 was admitted to home health service on 2/8/24 with a primary diagnosis of Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris and other a diagnosis of but not limited to Abnormal Weight Loss. The clinical record was reviewed on 5/29/24 and contained the following documents: RN Skilled Nursing Visit notes: on 4/25/24, recorded a weight of 120; on 5/8/24, recorded a weight of 111; on 5/16/24, recorded a weight of 125. The record lacked documentation the RN notified the physician regarding changes in Pt. #2’s weight.”