Procare Home Health Services

“Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This Standard is not met as evidenced by: The agency’s QAPI binder was provided for review on 01/04/2024, and evidenced comparison scores for quarter 3 2023, which indicated the agency did not meet national and state averages for managing daily activities, improving at getting in/out of bed, improving at bathing, improvement in breathing, improving oral medication administration, and flu shot acceptance. Review failed to evidence performance improvement activities to address the areas the agency did not meet national and state averages. The review failed to evidence the agency’s program included a performance improvement project with documentation for the reason why the project was chosen and measurable progress achieved. Review of the discharge patient list noted 4 of these discharged patients was due to hospital admissions which were not included on the hospitalization log. Review of the hospitalization log evidenced an additional 11 patient hospitalizations in the last 6 months. The QAPI failed to evidence performance improvement actions to address the hospitalizations. Review failed to evidence the governing body was responsible for the implementation and maintenance of the QAPI program to include defining the data to be collected and the frequency of the data collection. During an interview on 1/4/2024, at 4:43 PM, the Administrator indicated the Governing Body missed their need to approve the data to be collected and the frequency of the data collection. The Administrator indicated all patients with hospitalization should be included in the data collection by logging Patient information on the hospitalization log and remained quiet when queried what performance improvement actions the agency has taken to address the hospitalizations. The Administrator indicated there was no documentation on what performance improvement project was chosen nor why the project was chosen or measurable progress achieved. The agency’s correction plan, submitted on 01/02/2024 to CMS, indicated this citation would be corrected as of 12/29/2023. 410 IAC 17-12-2(a)”

“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 record review and interview, the agency failed to coordinate care delivery to meet the patient’s needs, and involve the patient’s caregivers, as appropriate, in the coordination of care activities for 1 of 1 active pediatric patients. (Patient #5). The findings include: The Plan of Care for the certification period 11/1/23 to 01/16/24 for Patient #5, a pediatric patient, included orders for home health aides services only, to provide assistance with activities of daily living. The POC indicated aide services were ordered Monday through Friday, 8 to 10 hours per day, while the primary care givers are out of the home and at work. The POC failed to identify who provided the management and administration of the medications, feedings and fluids during the time the primary caregivers were out of the home. The record revealed Patient was a pediatric patient, who was to have no food or fluids by mouth; all medications, nutrition, and fluids were to be delivered via a gastrointestinal tube, surgically placed through the wall of the abdomen to the stomach, which bypasses the mouth, and delivers fluids, medications, and nutrition directly to the stomach. The record evidenced aide visit notes dated 12/15/23, 12/20/23, 12/21/23, 12/22, 23, 12/26/23, 12/28/23, 01/02/24, and 01/03/24, which included documentation by home health aide (HHA) 4 that the HHA “assisted with feeding.” During an interview on 01/04/24 at 12:04 PM Person N, Patient 5’s primary family caregiver, indicated the skilled nurse provided skilled care daily at 2 PM to administer Patient’s medications. The clinical record for Patient 5 failed to evidence skilled nurse services were provided. During an interview on 01/04/2024 beginning at 3:34 PM, the Clinical Manager (CM) indicated Patient 5’s medications were administered around noon daily and that Person N administered the medications. The CM indicated they go to the home every 2 months to complete the recertification assessments and then monthly to conduct home health aide supervisory visits and had not been to the home since the last supervisory visit dated 12/13/23. The CM further indicated skilled nursing was not ordered and relayed the agency did not have orders to provide nor assist with Patient’s medication administration. The CM further clarified that she did not make unpaid volunteer visits to Patient’s residence to administer the medications and or feedings, nor was she aware of another staff member making volunteer visits. 410 IAC 17-14-1(a)(1)(F)”

“Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient’s eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This Condition is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure the comprehensive assessment was patient-specific in 5 of 7 complete active clinical records reviewed with a comprehensive assessment (Patient #1, 2, 3, 5, and 7); the home health agency failed to complete the initial assessment within 48 hours of referral (See G0514); failed to complete the comprehensive assessment no later than 5 days after the start of care (See G0520); failed to review the medications for potential adverse effects (See G0536); failed to include the assessment of the primary caregiver and their willingness and availability to provide care (See G0538); and failed to conduct a comprehensive assessment at time of discharge (See G0550). The cumulative effect of these systemic problems has resulted in the home health agency’s inability to ensure provision of quality health care in a safe environment for the condition of participation 42CFR 484.55 Comprehensive Assessment. *A record review conducted on 12/5/23 for Patient 1 revealed a diagnosis of Multiple Sclerosis (MS). The comprehensive assessment (CA) failed to identify neurological condition, musculoskeletal condition or status related to MS diagnosis. The CA failed to identify safety measures related to MS diagnosis. In an interview with the Clinical Manager (CM) on 12/7/23 at 11:00 AM the CM indicated assessment of Patient 1 status related to their MS diagnosis was not completed. A document titled OASIS-E Start of Care dated 11/22/23 included a comprehensive assessment (CA) for Patient 1 which indicated they have a history of incontinence. Embedded in the CA was a pressure sore risk assessment which did not identify incontinence as a risk factor; resulting in a medium risk for pressure wounds. During a home visit with the Clinical Manager on 12/6/23 at 3:30 PM it was observed the Clinical Manager failed to perform an assessment of Patient 1 boney prominences, back, buttock or feet. During an interview with the Clinical Manager (CM) on 12/7/23 at 11:00 AM they indicated a complete skin assessment should be completed at every visit and they failed to complete a skin assessment during the visit on 12/6/23. *A clinical record review for Patient 3 was conducted on 12/5/23 which included a Comprehensive Assessment (CA) dated 11/15/23. Embedded in the CA was a nutritional risk assessment that indicated the Patient to take 3 or more medications. The CA failed to identify diagnosis or indications for medications. During an interview with the Clinical Manager (CM) on 12/7/23 at 11:15 AM the CM indicated Patient 3 does not take medications and the nutritional status was an oversite. *A record review conducted on 12/6/23 for Patient 5 indicated the presence of a gastrostomy/jejunostomy tube (g/j-tube) (a surgically placed soft, plastic tube placed through the skin of the abdomen into the midsection of the small intestine), by which Patient 5 is continuously obtains nutrition. The Comprehensive Assessment failed to indicate an assessment of the surrounding skin integrity, tube placement, stoma, size of the tube, or tolerance of continuous feeding. During an interview on 12/12/23 at 12:30 PM the Clinical Manager (CM) indicated the assessment should include placement, condition of stoma, and size of the tube. The CM further indicates this assessment was not completed for Patient 5. 1. Review of agency procedures titled “Wound Assessment and Documentation” dated 2000, stated “… Assess the wound location and its size … Assess the color of the wound bed …Assess wound odor … Assess the surrounding skin … Evaluate the response to treatment ….” 2. Clinical record review for Patient #2 evidenced an agency document titled “Start of Care” identified as the initial assessment, completed by the registered nurse, and dated 11/10/2023. Review indicated the patient had an ischemic ulcer to the right ankle with a scab and serous (clear to yellow) drainage. Review failed to evidence the assessment was comprehensive and patient-specific to include an assessment of the wound. During an interview on 12/6/2023, at 2:03 PM, the Clinical Manager indicated the wound measurement should include measurements, assessment of the surrounding skin and the wound base, and patient tolerance of the wound care. 3. A clinical record review for Patient #7 evidenced an agency document titled “Recertification” identified as the comprehensive assessment completed by the registered nurse on 12/1/2023, which indicated the patient had a gastrostomy (a tube surgically inserted to administer fluid, nutrition, and/or medication). Review failed to evidence the comprehensive assessment included the size, stoma (opening in the body) appearance, and patency of the tube. During an interview on 12/7/2023, at 12:54 PM, the Clinical Manager indicated the comprehensive assessment should include the verification of the placement, stoma appearance, size, and patency of the tube. 1. Review of an agency procedure titled “Wound Assessment and Documentation” dated 2000, stated “… Assess the wound location and its size … Assess the color of the wound bed …Assess wound odor … Assess the surrounding skin … Evaluate the response to treatment ….” 2. Clinical record review for Patient #2 evidenced a document titled “Start of Care” identified as the initial assessment and dated 11/10/2023 that indicated Patient had an ischemic ulcer to the right ankle with a scab and serous (clear to yellow) drainage. Review failed to evidence the assessment was comprehensive and patient-specific to include an assessment of the wound. During an interview on 12/6/2023, at 2:03 PM, the Clinical Manager indicated the wound assessment should include measurements, assessment of the surrounding skin and the wound base, and patient tolerance of the wound care. 3. A clinical record review for Patient #7 evidenced a document titled “Recertification” identified as the comprehensive assessment dated 12/01/2023, which indicated Patient had a gastrostomy (a tube surgically inserted to administer fluid, nutrition, and/or medication). Review failed to evidence the comprehensive assessment included the size, stoma (opening in the body) appearance, and patency of the tube. During an interview on 12/7/2023, at 12:54 PM, the Clinical Manager indicated the comprehensive assessment should include the verification of the placement, stoma appearance, size, and patency of the tube. 4. A record review conducted on 12/5/23 for Patient 1 revealed a diagnosis of Multiple Sclerosis (MS). The comprehensive assessment (CA) failed to identify a neurological condition, musculoskeletal condition or status related to MS diagnosis and failed to identify safety measures related to MS diagnosis. On 12/07/23 at 11:00 AM, the clinical manager indicated the assessment of Patient #1 and their status related to their MS diagnosis was not completed. The Start of Care comprehensive assessment (CA) for Patient 1, dated 11/22/23, indicated they had a history of incontinence. The assessment included a pressure ulcer risk assessment which did not identify incontinence as a risk factor for Patient’s skin integrity, resulting in an inaccurate score of at medium risk for pressure wounds. During a home visit observation with the Clinical Manager on 12/06/23 at 3:30 PM, the Clinical Manager failed to perform an assessment of Patient #1’s bony prominences, their back, buttocks nor their feet. During an interview on 12/7/23 at 11:00 AM, the clinical manager indicated a complete skin assessment should be completed at every visit and they failed to complete a skin assessment during the visit on 12/06/23. 5. A clinical record review for Patient #3 included a Comprehensive Assessment, dated 11/15/23, that included a nutritional risk assessment that indicated the Patient was to take 3 or more medications. The assessment failed to identify the diagnosis or indications for the medications. During an interview on 12/7/23 at 11:15 AM, the clinical manager indicated Patient 3 did not take medications and the nutritional status was an oversite. 6. A record review conducted on 12/6/23 for Patient 5 indicated the presence of a gastrostomy/jejunostomy tube (g/j-tube) (a surgically placed soft, plastic tube placed through the skin of the abdomen into the midsection of the small intestine), by which Patient 5 is continuously obtains nutrition. The Comprehensive Assessment failed to evidence an assessment of the surrounding skin integrity, tube placement, stoma, size of the tube, or tolerance of continuous feeding. During an interview on 12/12/23 at 12:30 PM, the Clinical Manager indicated the assessment should include placement, condition of stoma, and size of the tube and further indicated this assessment was not completed for Patient 5.”

“Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide’s performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure home health aides (HHA) successfully completed a competency evaluation program in 1 of 1 personnel record reviewed of home health aide with their first patient contact after 11/01/23 (HHA 3). The findings include: 1. The policy, revised 11/7/2023, titled “Competency Evaluation of Home Care Team Members” stated, “… The Home Health Aide must demonstrate evidence of: Successful completion of a training program totaling at least seventy-five (75) hours. At least sixteen (16) of those must have been devoted to supervised practical training. … OR Successful completion of a competency evaluation program. The Home Health Aide will have successfully completed the competency evaluation program if he/she demonstrates competency in a minimum of eleven (11) of the twelve (12) areas required in federal guidelines. … Documentation of individual Home Health Aide training and/or competency shall be maintained in the Home Health Aide’s personnel file…” 2. A personnel record review for HHA 3, first patient contact date 11/19/2023, failed to evidence any documentation regarding a completion of a HHA training program or completion of a competency evaluation. During an interview on 12/11/2023, at 2:09 PM, the Administrator indicated HHA 3 went with the Alternate Clinical Manager to evaluate competency but there was not any documentation for the competency. 3. During an interview on 12/11/2023, at 2:22 PM, the Administrator indicated there was no other documentation used to demonstrate the competency evaluation was completed for the HHA. The Administrator indicated the document titled “Orientation of the Home Health Aide” was the form the agency used and did not indicate HHA competency nor the specific areas completed. 410 IAC 17-14-1(l)(A)”

“Written notice of patient’s rights CFR(s): 484.50(a)(1)(i) (i) 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. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This Element is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure written notice of the patient’s rights and responsibilities were provided in a manner understandable 1 on 1 clinical record reviewed with English not the primary language. (Patient #2) The findings include: Based on observation, record review, and interview, the agency failed to ensure written notice of the patient’s rights and responsibilities were provided in a manner understandable 1 on 1 clinical record reviewed with English not the primary language. (Patient #2) The findings include: During an observation of care at the home of Patient #2 on 12/11/2023, at 3:12 PM, the patient was observed speaking Spanish, and the caregiver was observed translating for the patient to the Clinical Manager. The patient was observed to be verbal and alert and was not observed speaking English. A clinical record review evidenced an agency document titled “Start of Care” completed by the Clinical Manager and dated 11/10/2023, which indicated the patient’s primary language was Spanish and the patient was oriented to person, place, and time. Review failed to evidence the patient was provided patient rights and responsibilities in a language understood by the patient or by use of an interpreter. Review of an agency document titled “Admission Service Agreement” signed by the patient’s caregiver and the Clinical Manager and dated 11/10/2023, indicated the patient had been provided a copy of the patient’s rights and responsibilities and failed to indicate the patient’s caregiver translated the patient’s rights for the patient. Review of an undated agency document titled “Patient’s Bill of Rights and Responsibilities” in the agency patient handbook evidenced to be in English. Review failed to evidence the agency provided the patient the written notice of patient’s rights and responsibilities in a language understood by the patient. During an interview on 12/6/2023, at 1:56 PM, the Clinical Manager indicated the patient did not understand much English and the caregiver was used for interpretation for the patient. The Clinical Manager indicated the agency did not have a Spanish copy of the patient’s rights and responsibilities and there was no documentation the caregiver was used to interpret the patient’s rights for the patient. During an interview on 12/8/2023, at 10:01 AM, the patient’s caregiver the patient was not bilingual and needed an interpreter to understand English. 410 IAC 17-12-3(a) 1 (A)”

“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 record review and interview, the agency failed to ensure the initial assessment visit was conducted within 48 hours of referral in 3 of 5 active clinical records reviewed with start of care dates since the date of the last survey of 8/30/2023. (Patient #2, 6, 8) The findings include: 1. A clinical record review for Patient #2 evidenced a document faxed from Entity A on 11/3/2023, which was identified to be a referral order from Person B (physician) dated 11/3/2023, which indicated the patient needed home heath services for skilled nursing for wound care, physical therapy (PT), and occupational therapy (OT). Review indicated the patient had an ischemic wound (wounds that occur when there is poor blood flow to an area of the body) to the right ankle noting fat exposure. The assessment document titled “Start of Care,” completed by the registered nurse and dated 11/10/2023, failed to evidence the agency conducted the initial assessment visit within 48 hours of referral. During an interview on 12/6/2023, at 1:56 PM, the Clinical Manager indicated the agency did not see the referral until 11/10/2023. 2. A clinical record review for Patient #6 evidenced a document from Entity C (skilled nursing facility, SNF) identified as a referral for home health services dated 11/28/2023, which indicated the patient was his/her own responsible party and was to be discharged to home on 11/29/2023. Review indicated a referral order which indicated the physician ordered skilled nursing, PT, and OT services. Review on 12/5/2023 failed to evidence the agency had completed a comprehensive initial assessment. Review failed to evidence documentation of communication with the patient and the physician. Review evidenced a document titled “Physician Order” dated 11/30/2023, indicated the agency requested to start care on 12/4/2023. Review failed to evidence the attending physician was notified of the delay. During an interview on 12/7/2023, at 12:30 PM, the Clinical Manager indicated she would complete the comprehensive assessment that afternoon, 12/07/2023, indicated she was waiting for Patient’s family member to be present to complete the comprehensive assessment and had not communicated with Patient. The Clinical Manager indicated she had not communicated with the physician regarding the delay in the start of care but had written the physician order and had not yet sent the order to the physician. 3. A clinical record review for Patient #8 evidenced a document from Entity D (SNF) dated 11/30/2023, identified as a referral for home health physical therapy. Review of the electronic health record on 12/5/2023, indicated Patient’s start of care date was 12/4/2023. Review failed to evidence an initial assessment was completed. During an interview on 12/7/2023, at 12:18 PM, the Clinical Manager indicated PT 1 completed the initial visit on 12/4/2023 and had not documented the visit yet. The Clinical Manager indicated she was unsure why the PT did not provide the initial visit until 12/4/2023 which was greater than 48 hours from the referral. 410 IAC 17-14-1(a)(1)(A)”

“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 record review and interview, the agency failed to ensure the comprehensive assessment was completed within 5 days of the start of care in 3 of 4 active clinical records reviewed with therapy services ordered upon referral since the last survey on 8/30/2023. (Patients #2, 6, 9) The findings include: 1. Clinical record review for Patient #2, start of care 11/10/2023, evidenced a referral order from Person B (physician) dated 11/3/2023, which indicated the patient needed home health services for skilled nursing for wound care, physical therapy (PT), and occupational therapy (OT). Review failed to evidence the PT contacted the patient regarding the scheduling of the PT assessment until 11/15/2023 and failed to evidence the PT completed the initial PT assessment until 11/27/2023. Review of agency documents titled “Communication Note” indicated the PT contacted the patient regarding the PT assessment on 11/15/2023, and the patient’s caregiver reported the patient wasn’t feeling well and to reschedule the visit on 11/20/2023. Review of document dated 11/20/2023 indicated there was a death in the patient’s family and to reschedule the visit on 11/22/2023. Review of document dated 11/22/2023 indicated there was no answer when the PT called the patient. No further communication was documented by the PT after 11/22/2023 prior to the visit on 11/27/2023. During an interview on 12/6/2023, at 1:59 PM, the Clinical Manager indicated there was no documentation of any attempt for the PT to complete the comprehensive assessment until 11/15/2023 and no additional attempts after 11/22/2023. 2. A clinical record review for Patient #6, start of care 12/7/2023, evidenced a referral order dated 11/27/2023 from Person E (physician) for home health for skilled nursing, PT, and OT services. Review failed to evidence the PT and OT had completed the assessments. During an interview on 12/12/2023, at 1:33 PM, the Clinical Manager indicated PT and OT had not yet completed an initial assessment yet, because the agency was needing to get orders from Person F (physician) before the therapy assessments could be scheduled since that was the patient’s primary physician. 3. A clinical record review for Patient #9, start of care 12/3/2023, evidenced an agency document titled “Start of Care” identified as the initial assessment completed by the registered nurse and dated 12/3/2023, which indicated OT was to evaluate and treat. Review failed to evidence the OT had completed a comprehensive assessment as of 12/11/2023. During an interview on 12/11/2023, at 12:34 PM, the Clinical Manager indicated OT was scheduled for the comprehensive assessment on 12/9/2023 (greater than 5 days from the start of care) but was unsure if the visit was completed. No additional documentation or information was provided.”

“At discharge CFR(s): 484.55(d)(3) At discharge. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure a comprehensive assessment was completed for 1 of 2 closed records reviewed with a discharge for goals met (Patient #12). The findings include: 1. A review of a policy revised 11/7/2023, titled “Patient Discharge Process” stated, “… Discharge OASIS [Outcome and Assessment Information Set] will be conducted within 48 hours of (or knowledge of) discharge to the community or death at home. The discharge comprehensive assessment … is required for all situations that result in an Agency discharge except to an inpatient facility or patient death at home and should be performed in conjunction with a visit, if possible….” 2. A clinical record review for Patient #12 evidenced a document titled “PT Discharge Summary” dated 10/19/2023, which indicated Patient was discharged due to goals met. Review failed to evidence the discharge summary was sent to the physician. Review of a document titled “OT [occupational therapy] Discharge Summary” dated 10/24/2023, indicated Patient was discharged due to goals met. Review evidenced a document titled “Discharge Patients” dated 12/5/2023, indicated Patient was discharged on 10/13/2023 for goals met. Review failed to evidence the discharge summary was sent to the physician. Review failed to evidence a discharge assessment was completed. During an interview on 12/11/2023, at 1:13 PM, the Administrator / PT indicated there was not a discharge assessment for this patient because the agency did not follow the rules for this patient due to the payor source of workmen’s compensation.”

“Org. had partial/extended survey CFR(s): 484.80(f)(3) Was subjected to an extended (or partially extended) survey as a result of having been found to have furnished substandard care (or for other reasons as determined by CMS or the state); or This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the home health aide (HHA) competency evaluation program was not offered by the agency which was subjected to a fully extended survey and found to have furnished substandard care in the last 2 years in 1 of 3 personnel records reviewed of home health aides. (HHA 3) The findings include: The personnel record for HHA 3, with first patient contact date 11/19/2023, failed to evidence documentation regarding a completion of a HHA training program or completion of an aide skills competency evaluation. During an interview, on 12/11/2023 at 2:09 PM, the Administrator indicated HHA 3 went with the Alternate Clinical Manager to evaluate competency and there was not any documentation for the competency. During an interview on 12/12/2023, at 2:40 PM, the Clinical Manager indicated HHA 3 went with the Alternate Clinical Manager on 11/19/2023 to a patient’s home for evaluation of competency to include bathing and personal care of the patient.”

“Make patient and personnel assignments, CFR(s): 484.105(c)(1) Making patient and personnel assignments, This Element is not met as evidenced by: Based on record review and interview, the clinical manager failed to provide oversight of the assignment of staff in 4 of 9 active clinical records reviewed. (Patient #3, 4, 7, 9) The findings include: 1. A review of an agency document titled “Agency Schedule Tasks” dated 12/5/2023, and identified as the visit schedule for the week beginning 12/3/2023, failed to evidence visits scheduled for Patients #3, 4, 7, 9. 2. A clinical record review for Patient #3 evidenced a Plan of Care for the certification period 11/16/2023-1/14/2024, which indicated the agency was to provide home health aide services 9 hours a day, 5 days a week for 9 weeks. Review failed to evidence Patient was included in the visit schedule for week of 12/3/2023. During an interview on 12/12/2023, at 11:42 AM, the Clinical Manager indicated Patient was not included in the visit schedule because the visits were not scheduled in the electronic health record, which generated the visit schedule. 3. A clinical record review for Patient #4 evidenced a “Home Health Certification and Plan of Care” for the certification period 10/25/2023-12/23/2023, which indicated the agency was to provide a skilled nurse 1 time a week. Review failed to evidence Patient was included in the visit schedule for week of 12/3/2023. During an interview on 12/7/2023, at 12:06 PM, the Clinical Manager indicated the agency provided skilled nursing visits every week and should have been included on the visit schedule. 4. A clinical record review for Patient #7 evidenced a “Home Health Certification and Plan of Care” for the certification period 12/3/2023-1/31/2024, which indicated the agency was to provide a skilled nurse 8 hours a day, 5 days a week, for 9 weeks. Review failed to evidence Patient was included in the visit schedule for week of 12/3/2023. During an interview on 12/7/2023, at 1:03 PM, the Clinical Manager indicated Patient’s visits should have been included on the visit schedule and was unsure why they were not. 5. A clinical record review for Patient #9 evidenced a “Home Health Certification and Plan of Care” for the certification period 12/3/2023-1/31/2024, which indicated the agency was to provide physical therapy (PT) services 2 times a week for 3 weeks. Review failed to evidence the patient was included on the visit schedule for the week of 12/3/2023. During an interview on 12/11/2023, at 12:43 PM, the Clinical Manager indicated she was unsure why Patient’s PT visits were not included on the visit schedule. 410 IAC 17-14-1(a)(1)(K)”