Tender Loving Care, An Amedisys Company

“Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This Condition is not met as evidenced by: Based on record reviews and staff interviews the agency failed to ensure that Skilled professionals (nursing ) that provide services to Home Health Agency (HHA) patients communicate and are supervised to ensure coordination of care. This was evident for eleven (11) of eleven (11) patients receiving Skilled services from Licensed Practical Nurses (Patients #1, #2, #3, #4, #6, #7, #8, #9, #10, #13, #14). The Home Health Agency failed specifically to: Ensure Skilled Nursing Professionals services are delivered and supervised only by health care professionals who meet the qualifications and practice according to the agency’s established policies and procedures, with regards to assessments. (Refer to H-702) Ensure ongoing interdisciplinary assessments and communication between skilled professionals (Refer to H-706) Ensure clinicians prepare and document complete and accurate clinical and progress notes accurately to reflect the current patient’s status. (Refer to H-716) Ensure adequate supervision of the Licensed Practical Nurse (LPN) staff. (Refer to H-726) See above.”

“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 compliance reports and staff interviews, it was determined that the Governing Authority failed to submit all required Emergency Response Drill Reports to the New York State Department of Health. Failure to submit emergency reports on Health Commerce System (HCS) as required by the Department has the potential risk for negative outcomes. Findings: The Dear Administrator Letter (DAL) DHCBS 19-05 “Emergency Response Drill” dated 5/10/2019, notified all Licensed Home Care Service Agencies (LHCSAs) of the need for participation in an emergency drill. The letter states: “All LHCSA are required to participate in this drill” and specified “failure to participate will result in a deficiency citation and possible enforcement.” On 11/13/2023 request sent to the Division of Home and Community Based Services regarding agency submission of drills on 11/13/2023 as part of the survey prep. The agency submitted 4 of 5 drills. The Emergency Disaster Coordinator during interview on 12/1/2023 at 12: 00.PM, informed surveyor that agency submitted all five (5) drills. The coordinator attempts to reach HERDS and retrieve all reports on HCS was unsuccessful.”

“Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This Standard is not met as evidenced by: Based on home visit observations, clinical records review and staff interviews, the Agency failed to ensure that pertinent services and treatments are performed in accordance to the Physician’s Order. This was evident in nine (9) of seventeen (17) records reviewed. (Patients #1, #2, #3, #4, #6, #7, #9, #13 and #14). Failure to ensure that pertinent patient services and treatments are performed, has the potential for negative patient outcome. The findings include: 6) Patient #1 has a start of care date of 07/15/2023 with diagnoses of Pressure Ulcer of Right Ankle Stage 2, Type 2 Diabetes Mellitus without complications, Essential Hypertension, Alzheimer’s Disease, and Hypothyroidism as documented on the “Home Health Certification and Plan of Care” dated 11/12/2023 to 01/10/2024. The “Home Health Certification and Plan of Care” dated 11/12/2023 to 01/10/2024 documents orders for “Skilled Nurse (SN) 3wk4, 2every5wk5 (3 times per week for 4 weeks, 2 times per 5 weeks for 5 weeks); Skilled nurse to perform/teach patient/caregiver wound care to the pressure injury stage 2 to the right lateral malleolus as follows: Cleanse would with normal saline, pat to dry, may apply skin barrier to periwound as needed (prn) to prevent maceration, apply puracol to the wound, cover with gauze dressing, followed by kling, tape and net”. Interim orders dated 11/22/2023 documents: “Patient’s right lateral malleolar wound remains closed. Patient will need 1 Skilled Nurse visit/week for 2 more weeks for assessment and observation for early signs and symptoms of wound reopening. Skilled Nurse effective 11/26/2023 1wk2, 2every5wk5 (1 time per week for 2 weeks, 2 times per 5 weeks for 5 weeks)”. The “Visit Note Report” completed by the Licensed Practical Nurse on 11/13/2023 lacks documented evidence the skilled nurse performed/taught patient/caregiver wound care to the pressure injury stage 2 in accordance with the physician orders. The “Visit Note Report” documents “scab present, protective dressing applied”. The “Visit Note Report” completed by the Registered Nurse on 11/22/2023 lacks documented evidence the skilled nurse performed/taught patient/caregiver wound care to the pressure injury stage 2 in accordance with the physician orders. During a Home Visit with the Registered Nurse on 11/29/2023, the surveyor observed a scab on the patient’s right lateral malleolar wound. The surveyor observed the Registered Nurse assess the wound and did not observe a dressing being applied. The “Visit Note Report” completed by the Registered Nurse on 11/29/2023 lacks documented evidence of wound care being completed as ordered. The Agency failed to ensure that the Skilled Nurse performed the care and services as per the Plan of Care. The survey findings were reviewed with the Administrator and Director of Patient Services on 11/29/2023 at 3:55PM. No explanation was provided. 7) Patient #4 has a start of care date of 11/17/2023 with diagnoses of Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Acute on Chronic Congestive Heart Failure, Type 2 Diabetes Mellitus, Atherosclerotic Heart Disease of native Coronary Artery, Hypothyroidism, and Hyperlipidemia as documented on the “Home Health Certification and Plan of Care” dated 11/17/2023 to 01/15/2024. The “Home Health Certification and Plan of Care” dated 11/17/2023 to 01/15/2024 documents orders for “Skilled Nurse (SN) 1wk1, 2wk2, 1wk1 (1 time per week for 1 week, 2 times per week for 2 weeks, then 1 time per week for 1 week); Physical Therapy (PT) effective 11/19/2023 2wk3, 1wk3 (2 times per week for 3 weeks, 1 time per week for 3 weeks; Occupational Therapy (OT) effective 11/19/2023 1wk1 (1 time per week for 1 week). Registered Nurse (RN) to assess/teach, Licensed Practical Nurse (LPN) to observe/teach cardiopulmonary system to identify signs of decompensation and intervene to minimize the severity of fluid overload. Observe patient ability to monitor and record daily weights and vital signs, including pulse ox and Blood Pressure; record patient reported weight, or weigh patient as needed. Report increased edema or weight gain of >2 lbs (pounds) in 1 day or >5 lbs (pounds) in 1 week or 5 lbs (pounds) or more over target weight. May measure abdominal girth if unable to weigh. Scales and Blood Preesure monitor to be provided as needed.” The “Registered Nurse OASIS Admission” note dated 11/17/2023 documents a patient weight of 152 lbs. The “Visit Note Report” completed by the Registered Nurse on 11/20/2023 lacks documented evidence of a current patient weight or documentation of the self-monitored vital signs. The “Visit Note Report” completed by the Licensed Practical Nurse on 11/24/2023 lacks documented evidence of a current patient weight or documentation of the self-monitored vital signs. The record lacks documented evidence the skilled nurse educated the patient about the cardiovascular system to identify decompensation. The Agency failed to ensure that the Skilled Nurse performed the care and services as per the Plan of Care. The survey findings were reviewed with the Administrator and Director of Patient Services on 11/30/2023 at 3:50PM. No explanation was provided. 8) Patient #6 has a start of care date of 01/26/2023 with diagnoses of Pressure Ulcer of Left Ankle- Stage 2, Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, Benign Neoplasm of Cerebral Meninges, Essential Hypertension, Epilepsy and Hyperlipidemia documented on the “Home Health Certification and Plan of Care” dated 09/23/2023 to 11/21/2023 and 11/22/2023 to 01/20/2024. The “Home Health Certification and Plan of Care” dated 09/23/2023 to 11/21/2023 documents an order for “Skilled Nurse (SN) effective 09/24/2023 2wk5 (2 times per week for 5 weeks). Registered Nurse to observe and assess, Licensed Practical Nurse to observe for risk for falls and instruct in fall prevention, home safety, medication management, infection prevention, and nutrition management”. The “Home Health Certification and Plan of Care” dated 11/22/2023 to 01/20/2024 documents an order for “Skilled Nurse (SN) 1wk1, 2wk4, 3PRN (1 time per week for 1 week, 2 times per week for 4 weeks, and 3 as needed). Registered Nurse (RN) to observe and assess, Licensed Practical Nurse (LPN) to observe for risk for falls and instruct in fall prevention, home safety, medication management, infection prevention, and nutrition management”. The “Visit Note Report” completed by the Registered Nurse on 10/23/2023 lacks documented evidence the skilled nurse provided instruction on fall prevention, home safety, medication management, infection prevention, and nutrition management. The “Visit Note Report” completed by the Registered Nurse on 10/27/2023 lacks documented evidence the skilled nurse provided instruction on fall prevention, home safety and nutrition management. The “Visit Note Report” completed by the Registered Nurse on 11/09/2023 lacks documented evidence the skilled nurse provided instruction on fall prevention, home safety, medication management, infection prevention, and nutrition management. The “Visit Note Report” completed by the Licensed Practical Nurse on 11/16/2023 lacks documented evidence the skilled nurse provided instruction on fall prevention, home safety, medication management, and infection prevention. The “Visit Note Report” completed by the Licensed Practical Nurse on 11/23/2023 lacks documented evidence the skilled nurse provided instruction on fall prevention, home safety, medication management, and nutrition management. The “Visit Note Report” completed by the Licensed Practical Nurse on 11/27/2023 lacks documented evidence the skilled nurse provided instruction on medication management, infection prevention, and nutrition management. The Agency failed to ensure that the Skilled Nurse performed the care and services as per the Plan of Care. The survey findings were reviewed with the Administrator and Director of Patient Services on 11/30/2023 at 4:30PM. No explanation was provided. 9) Patient #13 has a start of care date of 08/08/2023 with diagnoses of Orthopedic Aftercare, Type 2 Diabetes Mellitus with diabetic neuropathy arthropathy, Hypertensive Heart Disease with Heart Failure, Systolic Heart Failure, and Atrial Fibrillation as documented on the “Home Health Certification and Plan of Care” dated 08/08/2023 to 10/06/2023. The “Home Health Certification and Plan of Care” dated 08/08/2023 to 10/06/2023 documents an order for “Skilled Nurse (SN) 1wk4 (1 time per week for 4 weeks), Physical Therapy (PT) 1wk2 (1 time per week for 2 weeks), 2wk3 (2 times per week for 3 weeks), 1wk2 (1 time per week for 2 weeks); Occupational Therapy (OT) 1wk1 (1 time per week for 1 week), 2wk4 (2 times per week for 4 weeks), 3PRN (as needed). Skilled nurse for instructions of diabetic care to include: diet, skin care, signs and symptoms of hypo/hyperglycemia; proper administration of diabetic medication. Skilled nurse to instruct on diabetic foot care and monitor for skin lesions on lower extremities. Blood glucose testing perform by pt. Skilled nurse to assess patient/caregiver ability to perform and record blood glucose testing as ordered and to report to physician glucose readings greater than 285 or less than 85. Skilled nursing to instruct patient on importance of HGBA1C (Hemoglobin A1C) monitoring, kidney function test, eye and foot exams.” The “Visit Note Report” completed by the Licensed Practical Nurse on 08/16/2023 lacks documented evidence that the Licensed Practical Nurse instructed Diabetic Care to include blood glucose monitoring, diet, skin care, signs and symptoms of hypo/hyperglycemia, proper administration of diabetic medication, diabetic foot care and importance HgBA1C (Hemoglobin A1C) monitoring, kidney function test, eye and foot exams”. The “Visit Note Report” completed by the Licensed Practical Nurse on 09/08/2023 lacks documented evidence that the Licensed Practical Nurse instructed Diabetic Care to include blood glucose monitoring, diet, skin care, signs and symptoms of hypo/hyperglycemia, proper administration of diabetic medication, diabetic foot care and importance HgBA1C (Hemoglobin A1C) monitoring, kidney function test, eye and foot exams”. The “Visit Note Report” completed by the Licensed Practical Nurse on 09/21/2023 lacks documented evidence that the Licensed Practical Nurse instructed Diabetic Care to include blood glucose monitoring, diet, skin care, signs and symptoms of hypo/hyperglycemia, proper administration of diabetic medication, diabetic foot care and importance HgBA1C (Hemoglobin A1C) monitoring, kidney function test, eye and foot exams”. The “Visit Note Report” completed by the Licensed Practical Nurse on 09/28/2023 lacks documented evidence that the Licensed Practical Nurse instructed Diabetic Care to include blood glucose monitoring, diet, skin care, signs and symptoms of hypo/hyperglycemia, proper administration of diabetic medication, diabetic foot care and importance HgBA1C (Hemoglobin A1C) monitoring, kidney function test, eye and foot exams”. The Agency failed to ensure that the Skilled Nurse performed the care and services as per the Plan of Care. The survey findings were reviewed with the Director of Patient Services on 12/01/2023 at 3:45PM. No explanation was provided. 3) Patient #2 with a start of care 10/26/2023 diagnoses of Scoliosis, Raynaud’s Syndrome, Indwelling Catheter, Foot drop, Atrial Fibrillation, Hypertension, Polyneuropathy, Asthma and Spinal Stenosis as documented on the “Home Health Certification and Plan of Care” for certification period 10/26/2023-12/24/2023. The “Home Health Certification and Plan of Care” for certification period 10/26/2023-12/24/2023 documents an order for “Skilled Nurse 1wk1, 2wk4 (1 time per week for 1 week, 2 times per week for 4weeks); Physical Therapy (effective 10/29/2023 1wk1, 2wk2, 1wk3 (1 times per week for week, 2 time per week for 2 weeks, 1 time per week for 3 weeks; Occupational Therapy effective 10/29/2023 1wk1 (1 time per week for 1 week). “Register Nurse to observe, assess, evaluate, and develop an individualized plan of care. Registered Nurse to “observe and assess, License Practical Nurse) to observe for risk for falls and instruct in falls prevention, home safety, medication management infection prevention and nutrition management”. Skilled Nurse for “Management of Indwelling Urinary catheter including insertion of 16 French, instill 10cc of solution into balloon every month and PRN (as needed) for leakage, blockage, dislodgement or malfunction”. The “Visit Note Report” Assessment note dated 11/08/23 were conducted by an Licensed Practical Nurse and documents in narrative note “Skilled Nurse observed patient private Aide showed competency in flushing catheter with zero difficulty and verbalized understanding in catheter care in the importance of keeping tubing entrance sterile”. The Plan of Care lacks an order for the Licensed Practical Nurse visit frequency and specific treatments for the Licesned Practical Nurse to perform. There is no documented evidence that the Plan of Care is complete. The Agency did not establish an individualized Plan of Care that includes specific treatments for Licesned Practical Nurse services. 4) Patient #3 start of care 10/20/2023 with diagnoses of Laceration to right elbow, Hypertension Heart Disease with Heart Failure, Chronic Obstructive Pulmonary Disease, Acute Respiratory with Hypoxia and Hypercapnia, Anemia, Dependence on Supplemental Oxygen, Anxiety and Major Depression as documented on the “Home Health Certification and Plan of Care” for certification period 10/20/2023-12/18/2023. The Home Health Certification and Plan of Care for certification period 10/20/2023-12/18/2023 documents an order for Register Nurse to “observe, assess, evaluate, and develop an individualized plan of care. Registered Nurse to observe and assess, Licesed Practical Nurse to “observe for risk for falls and instruct in falls prevention, home safety, medication management infection prevention and nutrition management”. Skilled Nurse to “monitor co-morbid conditions as listed on Plan of Care and any new conditions that present themselves during this episode to identify changes and intervene to minimize complications”. The “Registered Nurse OASIS Admission” dated 10/20/2023 documents abnormal findings in hearing assessment, indicating “hearing difficulty and location of hearing is right and left”. Under respiratory findings indicates” no abnormal findings”. During a Home Visit on 11/28/2023 at 11:00AM, when surveyor was speaking to patient and asked to sign the consent for the visit, the patient stated, “I don’t hear what you’re saying, lost my left hearing aid device”. Patient noted using Oxygen(O2) via nasal cannula by Oxygen Concentrator on home visit and uses Bipap 02 therapy as documented on patient current medication list at the Assisted Living Facility (ALF). The “Visit Note Reports” dated 10/24/23, 10/27/23, 10/31/23, 11/02/23 and 11/07/23, the Licensed Practical Nurse documents “no supplemental oxygen” with vital signs and under Respiratory assessment indicates “no abnormal findings”. The Plan of Care lacks an order for the Oxygen dosage, route/frequency, and patient’s Functional Limitation - Hearing Impaiment. The Agency did not establish an individualized POC that includes specific treatments for LPN services. 5) Patient #7 with start of care 10/12/2023 with diagnoses of Malignant Neoplasm of left Female Breast, Abscess of the Breast and Nipple, Urinary Tract Infection, Alzheimer’s Disease, Essential Hypertension, Anemia and Type 2 Diabetes as documented on the “Home Health Certification and Plan of Care” for certification period 10/12/2023-12/10/2023. The Home Health Certification and Plan of Care certification period 10/12/2023 - 12/10/2023 documents an order for “RN (Register Nurse) to observe, assess, evaluate, and develop an individualized plan of care. Registered Nursse to observe and assess, Licensed Practical Nurse to observe for risk for falls and instruct in falls prevention, home safety, medication management infection prevention and nutrition management”. The “Home Health Certification and Plan of Care” dated 10/12/23 to 12/10/2023 documents an order for “Skilled Nurse to perform wound care to open wound to left breast twice a week and PRN (as needed) for dislodged and soiled dressing”. The ‘Visit Note Reports’ dated 10/17/23, 10/27/23, 10/31/23, 11/07/23 and 11/14/2023 were conducted by an Licensed Practical Nurse documenting preforming “wound assessment”. Record reviewed noted missed Skilled Nurse visits on 10/20/23, one Skilled Nurse visit for the week of 11/12/23, no Skilled Nurse visits for week of 11/19/23 and one Skilled Nurse visit for the week of 11/26/23. The ‘Visit Note Reports’ dated 10/27/23, 11/03/23, 11/07/23, 11/10/23, 11/29/23 documents open wound to left breast was not measured in “wound assessment”. The Agency Policy “Wound Care-001” last revised 03/08/23documents under measurements “ln accordance with best practice and standard of care, wound will be measured a minimum of one time a week, preferably on the first visit of the week, by the same nurse, utilizing the same tool and measurement terminology. Inconsistencies noted in nursing care during home visit and documentation in record review: interim Medical Doctor order dated 11/21/23 indicated “nursing discharged scheduled week of 11/26/23, patient’s wound closed”. Wound assessment notes dated 11/03/23, 11/07/23 and 11/14/23 noted “Exudate of small amount of serosanguinous drainage”. Wound assessment notes dated 11/07/23 and 11/29/23 documents “none” for any exudate noted. During a Home Visit with the Registered Nurse on 11/29/2023 at 1:00 PM, the Registered Nurse assessed the wound and perform wound care, moderate amount of Serosanguinous drainage noted by Surveyor, but the Registered Nurse documented in her notes “none” for any exudate noted and Registered Nurse did not measure wound. The Agency did not establish an individualized Plan of Care that includes specific treatments for Licensed Practical Nurse services. The Agency failed to ensure that the Skilled Nurse perform the care and services as per the Plan of Care. The survey findings were reviewed with the Administrator and Director of Patient Services on 11/30/2023 at 3:00PM. No explanation was provided. 1) Patient #9 has a start of care date of 08/06/2023 with diagnoses including Hypertension Heart and Chronic Kidney Disease with Heart Failure stage 1, Chronic Diastolic Heart Failure, and Type 2 Diabetes Mellitus as documented on the “Home Health Certification and Plan of Care” for certification period 08/06/2023 to 10/04/2023. The patient has a discharge date of 10/04/2023. The “Home Health Certification and Plan of Care” for certification period 08/06/2023 to 10/04/2023 documents an order for “Skilled Nurse 2wk1, 1wk5, 1 every 2wk2, 1wk1 (two visits a week for one week, one visit a week for five weeks, one visit every two weeks for two weeks), Physical Therapy 1 wk1 (one visit a week for one week), Home Health Aide 1 wk5 (one visit a week for five weeks)”. “Skilled Nurse for instructions of Diabetic Care to include diet, skin care, signs and symptoms of hypo/hyperglycemia, proper administration of diabetic medication, Skilled Nurse to instruct on diabetic foot care and importance HGBA1C (Hemoglobin A1C) monitoring, kidney function test, eye and foot exams”. Blood Sugar testing 4x daily. Medications includes “Insulin Lispro (U-100) 100 units/ml (milliliter) subcutaneous pen sliding scale for blood glucose (BG) 200-250 = 2 units (give two units Insulin), 251 – 300 = 3 units, 301 – 350 = 4 units, 351 – 400 + 5 units. Lantus Solostar (U-100) 100 units/ ml subcutaneous dose 15 units at bedtime”. The “Registered Nurse Oasis Admission” visit note date 08/06/2023, the Registered Nurse documents the patient’s and Blood Sugar range of 110 - 175 and the patient’s “son checks Blood Sugar 3 x daily and administers Insulin”. There is no documented evidence that the Registered Nurse instructed Diabetic Care to include diet, skin care, signs and symptoms of hypo/hyperglycemia, proper administration of diabetic medication, diabetic foot care and importance HGBA1C (Hemoglobin A1C) monitoring, kidney function test, eye and foot exams”. The “Visit Note Report” dated 08/08/2023, the Registered Nurse documents the patient’s Blood Sugar is 168. The clinical record lacks documented evidence that the Registered Nurse instructed Diabetic Care to include diet, skin care, signs and symptoms of hypo/hyperglycemia, proper administration of diabetic medication, diabetic foot care and importance HGBA1C (Hemoglobin A1C) monitoring, kidney function test, eye and foot exams”. The “Visit Note Report” dated 08/14/2023, the Registered Nurse documents the patient’s Blood Sugar is 156. The clinical record lacks documented evidence that the Registered Nurse instructed Diabetic Care to include diet, skin care, signs and symptoms of hypo/hyperglycemia, proper administration of diabetic medication, diabetic foot care and importance HGBA1C (Hemoglobin A1C) monitoring, kidney function test, eye and foot exams”. The “Visit Note Report” dated 08/22/2023, the Registered Nurse documents the patient’s Blood Sugar is 122. The clinical record lacks documented evidence that the Registered Nurse instructed Diabetic Care to include diet, skin care, signs and symptoms of hypo/hyperglycemia, proper administration of diabetic medication, diabetic foot care and importance HGBA1C (Hemoglobin A1C) monitoring, kidney function test, eye and foot exams”. The “Visit Note Report” dated 08/29/2023, the Registered Nurse lacks documented evidence of the patient’s Blood Sugar level. The clinical record lacks documented evidence that the Registered Nurse instructed Diabetic Care to include diet, skin care, signs and symptoms of hypo/hyperglycemia, proper administration of diabetic medication, diabetic foot care and importance HGBA1C (Hemoglobin A1C) monitoring, kidney function test, eye and foot exams”. The “Visit Note Report” dated 09/07/2023, the Registered Nurse documents the patient’s Blood Sugar is 95. The clinical record lacks documented evidence that the Registered Nurse instructed Diabetic Care to include diet, skin care, signs and symptoms of hypo/hyperglycemia, proper administration of diabetic medication, diabetic foot care and importance HGBA1C (Hemoglobin A1C) monitoring, kidney function test, eye and foot exams”. The “Visit Note Report” dated 09/13/2023, the Licensed Practical Nurse documents the patient’s Blood Sugar is 187. The clinical record lacks documented evidence that the Licesned Practical Nurse nstructed Diabetic Care to include diet, skin care, signs and symptoms of hypo/hyperglycemia, proper administration of diabetic medication, diabetic foot care and importance HGBA1C (Hemoglobin A1C) monitoring, kidney function test, eye and foot exams”. The “Visit Note Report” dated 09/25/2023, the Licensed Practical Nurse lacks documented evidence of the patient’s Blood Sugar. The clinical record lacks documented evidence that the Licensed Practical Nurse instructed Diabetic Care to include diet, skin care, signs and symptoms of hypo/hyperglycemia, proper administration of diabetic medication, diabetic foot care and importance HGBA1C (Hemoglobin A1C) monitoring, kidney function test, eye and foot exams”. The Agency failed to ensure that the Skilled Nurse perform the care and services as per the Plan of Care. The survey findings were reviewed with the Administrator, Director of Patient Services on 11/28/2023 at 03:40PM. No explanation was provided. 2) Patient #14 has a start of care 09/25/23 with diagnoses of Hypertensive Heart and Chronic Kidney Disease, Acute Chronic Systolic Congestive Heart Failure, and Type 2 Diabetes Mellitus as documented on the “Home Health Certification and Plan of Care” for certification period 09/25/2023 to 11/23/2023. The “Home Health Certification and Plan of Care” for certification period 09/25/2023 to 11/23/2023 documents an order for “Skilled Nurse 3 wk 3 (three visits a week for three weeks), Physical Therapy 1 wk1 (one visit a week for one week), Occupational Therapy 1 wk 1, 2 wk 4, 1 wk4 (one visit a week for one week, two visits a week for four weeks, one visit a week for four weeks). Registered Nurse to “observe, assess and evaluate and develop an individualized Plan of Care, Registered Nurse to observe and assess”. License Practical Nurse to observe for risk for falls and instruct on fall prevention, home safety, medication management, infection prevention, and nutrition management”. “Skilled Nurse to perform wound care to #1 LLE (Left Lower Leg) cleanse with Normal Saline, apply Adaptic, Calcium Alginate and cover with Stratasorb 3w3 (three times a week)”. “Skilled Nurse for instructions of Diabetic Care to include diet, skin care, signs and symptoms of hypo/hyperglycemia, proper administration of Diabetic medication”. “Blood Glucose testing QID (four times a day), Skilled Nurse to assess patient/caregiver ability to perform and record blood glucose testing and report abnormal findings to Physician. Skilled Nurse to “report to Physician blood glucose readings greater than 350 or less than 70”. “Indwelling Urinary Catheter 18 FR (French) with 30 cc (cubic centimeter) balloon. Skilled Nurse to “assess and teach related to altered Genitourinary status to minimize complications and hospitalization”. The Skilled Nurse “Visit Note Report” dated 09/27/2023, 09/29/2023, and 10/02/2023 lack documentation of the patient’s Blood Glucose levels, Diabetic care instructions including diet, signs and symptoms of hypo/hyperglycemia, and Diabetic medications. There is no documentation of the patient’s Indwelling Urinary Catheter urine output. The Skilled Nurse “Visit Note Report” dated 10/05/2023, the License Practical Nurse documents “blood in urine persist, went to Emergency Room yesterday for evaluation, patient seems to be tugging on tubing”. The Licensed Practical Nurse documents “Inactive wound - Healed”. There is no documentation of the patien’ts blod glucose level. There is no documented evidence that the Licensed Practical Nurse notified the Registered Nurse and the Physician of the change in patient’s urinary output, Diabetic care status, and wound healing status. The Skilled Nurse “Visit Note Report” dated 10/09/2023, the License Practical Nurse lack documentation of the patient’s Blood Glucose level. The Licensed Practical Nurse documents “Foley draing clear yellow urine”. The Skilled Nurse “Visit Note Report” dated 10/16/2023 lack documented evidence of the patient’s Blood Glucose level. The Registered Nurse documents “Skilled Nurse was not able to change foley catheter. Patient went to Emergency Room and Foley Catheter was changed”. The Registered Nurse documents patient’s “Indwelling Foley size 10 cc (cubic centimeter)”. There is no documented evidence that the Physician was notified of the Emergency Room visits and change of Indwelling Foley size. The Skilled Nurse “Visit Note Report” dated 10/31/2023, lacks documtation of the patient’s Blood Glucose level, Diabetic care instructions including diet, signs and symptoms of hypo/hyperglycemia, and Diabetic medications. The Skilled Nurse “Visit Note Report” date 11/08/2023, the Licensed Practical Nurse lack documentation of the patient’s Blood Glucose level, Diabetic care instructions including diet, signs and symptoms of hypo/hyperglycemia, and Diabetic medications. There is no documentation of the patient’s Indwelling Urinary Catheter urine output The Agency failed to ensure that the Registered Nurse and Licensed Practical Nurse provide patient care services and treatments in conformance to the Plan of Care. The survey findings and interview were conducted with the Administrator and Director of Patient Services on 11/30/2023 at 04:36 PM. No explanantion was provided.”

“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: Based on a review of the agency’s Quality Assessment Performance Improvement (QAPI) Program, Policy and Procedure, interviews with the Administrator, Director of Patient Services (DPS) it was determined that the scope of the program was inadequate to identify, analyze and track quality indicators necessary to assess the agency processes’ of care, services and operations. This was evident based on review of the Quality Assessment Performance Improvement meeting minutes for the 2022 and 2023. Failure to ensure the QAPI program adequately identify and analyze pquality indicators, has the potential for negative outcome. -The iQIES Potentially Avoidable Events (PAE’s) 10 categories listed indicated the agency observable cases with percentage of negative outcome are close or higher than the National average. The report indicates that in 8/21/ to 8/22, the agency had 46 total PAE’s that are possibly preventable. The report attributes the Potentially Avoidable Events: pressure ulcers, urinary tract infections, discharged to community with unhealed stage 2 pressure ulcers were not included in the areas requiring tracking as quality indicators. - The iQIES Potentially Avoidable Event Patient Listing Report (PAEPL) period of 8/1/2022 to 7/31/2023, data for agency documented incidence of pressure ulcer higher than the National Average; National obs: 0.36% to agency’s 0.54%. The Potentially Avoidable Event Patient Listing Report contained the names of 14 patients with increase in pressure ulcer. Patient # 11 also appeared on this report twice for discharged to community needing toileting assistance. The agency quality program did not include quality indicator derived from the iQIES Potentially Avoidable Event Patient Listing and failed to focus on high risk, high volume, or problem- prone areas (G648). - The agency’s Quality Assessment Performance Improvement Quarterly Form” for the 3rd and 4th quarter 2022, and 1st to 3rd Quarter 2023 meeting minutes documented areas of focus are: -Hospitalization. -QI (quality improvement) Events and Potentially Avoidable Events: - Falls -Complaints. The survey identified areas with significant issues that included: - Medical Doctor not notified of changes in patient condition. - Coordination of care between disciplines is limited. - Blood glucose not assessed and undocumented identified in patient # 13. - Weight not being assessed as ordered identified in patient #4. The agency’s “Quality Assessment Performance Improvement Quarterly Forms “does not contain a plan of action for the areas not in compliance and, reflects minimal input from the Professional Advisory Committee. The Patient Care Conference Committee (PCC) Meeting Minutes of 3rd, 4th quarter 2022, and 1st to 3rd quarter 2023 did not include a summary of Comprehensive Clinical Record Audits on hospitalization, avoidable events, falls and complaints. On 11/30/23 at 11am, the Administrator/DPS who is in charge of the Quality Assessment Performance Improvement process was interviewed and did not provide answers to areas of concern. The findings were reviewed with the agency during the exit conference on 12/1/2023 at 4:30PM.”

“Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This Standard is not met as evidenced by: Based on staff interviews, the agency failed to provide documented evidence that Performance Improvement Projects (PIP) were conducted. Failure to conduct performance improvement projects that reflect the scope, complexity, past performance of the agency’s services, quality improvements with documented measurable progress achieved has the potential for negative patient outcomes. The Findings Are: On 11/30/2023 at 11:00 AM, the Performance Improvement Projects were requested, no information was provided. There is no documented evidence of the agency conducting Performance Improvement Projects. On 11/30/2023 at 04:00 PM, the Chief Operating Officer/ Administrator was interviewed, and said agency did not have performance improvement project at this time.”

“Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA’s governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This Standard is not met as evidenced by: Based on record review, review of the agency’s Quality Assessment Performance Improvement (QAPI) Program, interviews with the Chief Operating Officer, Director of Patient Services (DPS), and Clinical Manager, it was determined that the scope of the program was inadequate to identify, analyze and track quality indicators necessary to assess the agency processes’ of care, services and operations. This was evident based on review of the Quality Assessment Performance Improvement meeting minutes. Failure to address priorities for improved quality of care, and patient safety has the potential for negative patient outcome. Findings: Agency’s Quality Assessment Performance Improvement quarterly forms documented increase in falls both attended and unattended as primary occurrence focus areas. Quarter 1 had 29 falls, Q2- 25, Q3-27, Q4- 43 with 26 unattended. The Quality Assessment Performance Improvement did not include analysis, intervention, and action plan for the areas of focus. The agency quality assessment and improvement program did not include expectations addressing patient safety as priority and failed to evaluate the effectiveness of the program. The Chair-person /Administrator was interviewed on 11/30/2023 at 3: 50.PM, and did not provide an explanation. The survey findings were reviewed with agency leadership at the exit conference on 12/1/2023.”

“Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA’s policies and procedures. This Standard is not met as evidenced by: Based on review of clinical records, state regulations, policy/procedure, job description, and staff interviews, the agency failed to ensure Skilled Nursing Professionals services delivery are supervised by qualified health care professionals, in accordance with State regulations; agency’s established policy and procedures. This was evident in eleven (11) of eleven (11) patient receiving License Practical Nurse services. (Patients #1, #2, #3, #4, #6, #7, #8, #9, #10, #13 and #14). Failure to ensure skilled professional services are delivered in accordance with agency policies has the potential to result in poor quality of care and possible negative outcome. The findings are: The agency’s policy “#AA-007(a) Services Provided/Supervision of Disciplines- RN/LPN” dated “10/05/23” documents: “Interpretive Guidelines §484.75(c)(1) The HHA should identify a registered nurse (RN) to supervise the care provided by licensed practical/vocational nurses (LPN/LVNs). The identified RN must in turn monitor and evaluate LPN/LVN performance in the provision of services, provision of treatments, patient education, communication with the RN, and data collection regarding the patient’s status and health needs (as delegated by the RN). Only a registered nurse may perform comprehensive assessment, evaluations, care planning and discharge planning.” 4) Patient #2 with a start of care 10/26/2023 diagnoses of Scoliosis, Raynaud’s Syndrome, Indwelling Catheter, Foot Drop, Atrial Fibrillation Hypertension, Polyneuropathy, Asthma and Spinal Stenosis as documented on the “Home Health Certification and Plan of Care cert period 10/26/2023-12/24/2023. The Home Health Certification and Plan of Care cert period 10/26/2023-12/24/2023 documents an order for “Skilled Nurse 1wk1, 2wk4 (1 time per week for 1 week, 2 times per week for 4weeks); Physical Therapy (PT) effective 10/29/2023 1wk1, 2wk2, 1wk3 (1 times per week for week, 2 time per week for 2 weeks, 1 time per week for 3 weeks; Occupational Therapy (OT) effective 10/29/2023 1wk1 (1 time per week for 1 week). RN (Register Nurse) to observe, assess, evaluate, and develop an individualized plan of care. Register Nurse to observe and assess, License Practical Nurse to observe for risk for falls and instruct in falls prevention, home safety, medication management infection prevention and nutrition management”. The “Visit Note Report” Assessment note dated 11/08/23 were conducted by an License Practical Nurse documenting preforming patient assessment. The “Visit Note Report” Assessment note dated 11/08/23 documents “indicate if you communicate with other disciplines involved in the case”. “No”. There is no documented evidence of communication between the Register Nurse and the License Practical Nurse. The License Practical Nurses are completing patient assessments. The record lacks documentation the Register Nurse reviewed the License Practical Nurse visit notes to ensure the supervision of appropriate care. The Agency failed to implement their written policy and procedures. The Director of Patient Services/Administrator was interviewed 12/01/2023 at 2.00 pm, no explanation offered. 5) Patient #3 start of care 10/20/2023 with diagnoses of Laceration to right elbow, Hypertension Heart Disease with Heart Failure, Chronic Obstructive Pulmonary Disease, Acute Respiratory with Hypoxia and Hypercapnia, Anemia, Dependence on Supplemental Oxygen, Anxiety and Major Depression as documented on the “Home Health Certification and Plan of Care” for certification period 10/20/2023-12/18/2023 The Home Health Certification and Plan of Care cert period 10/20/2023-12/18/2023 documents an order for “Skilled Nurse (SN) 1wk1, 2wk4 (1 time per week for 1 week, 2 times per week for 4weeks); Physical Therapy (PT) effective 10/29/2023 1wk1, 2wk2, 1wk3 (1 times per week for week, 2 time per week for 2 weeks, 1 time per week for 3 weeks; Occupational Therapy (OT) effective 10/29/2023 1wk1 (1 time per week for 1 week). RN (Register Nurse) to observe, assess, evaluate, and develop an individualized plan of care. Register Nurse to observe and assess, License Practical Nurse to observe for risk for falls and instruct in falls prevention, home safety, medication management infection prevention and nutrition management”. The “Visit Notes Reports” Assessment notes dated 10/24/23, 10/27/23, 10/31/23, 11/02/23, 11/07/23 were conducted by an License Practical Nurse documenting preforming patient assessments. The “Visit Note Reports” dated 10/24/23, 10/27/23, 10/31/23, 11/02/23, 11/07/23 documents “indicate if you communicate with other disciplines involved in the case”. “No”. There is no documented evidence of communication between the Register Nurse and the License Practical Nurse. The License Practical Nurses are completing patient assessments. The clinical record lacks documented evidence of Register Nurse reviewing License Practical Nurse visit note report to ensure the supervision of appropriate care. The Agency failed to implement their written policy and procedures. The Director of Patient Services/Administrator was interviewed 12/01/2023 at 2.00 pm, no explanation offered. 6) Patient #7 with start of care 10/12/2023 with diagnoses of Malignant Neoplasm of left Female Breast, Abscess of the Breast and Nipple, Urinary Tract Infection, Alzheimer’s Disease, Essential Hypertension, Anemia and Type 2 Diabetes as documented on the “Home Health Certification and Plan of Care” for certification period 10/12/2023-09/24/2023. The Home Health Certification and Plan of Care cert period 10/12/2023-09/24/2023 documents an order for “Skilled Nurse (SN) 1WK2, 2WK3 (1 time per week for 2 week, 2 times per week for 3 weeks; Physical Therapy (PT) effective 10/15/2023 2wk3, 1wk1, 2WK3,1WK4 (1 time per week for 1 week, 2 times per week for 3 weeks, 1 time per week for 4 weeks). RN (Register Nurse) to observe, assess, evaluate, and develop an individualized plan of care. Register Nurse to observe and assess, License Practical Nurse to observe for risk for falls and instruct in falls prevention, home safety, medication management infection prevention and nutrition management”. The ‘Visit Note Reports’ dated 10/17/23, 10/27/23, 10/31/23, 11/0723 and 11/14/2023 were conducted by an License Practical Nurse documenting preforming patient assessments. The ‘Visit Note Reports’ dated 10/17/23, 10/27/23, 10/31/23, 11/0723 and 11/14/2023 were conducted by License Practical Nurse an documenting preforming “wound assessment”. The License Practical Nurses “Visit Note Reports” dated 10/17/23, 10/27/23, 10/31/23, 11/0723 and 11/14/2023 documents “indicate if you communicate with other disciplines involved in the case”. “No”. There is no documented evidence of communication between the Register Nurse and the License Practical Nurse. The License Practical Nurses are completing patient assessments. The record lacks documentation the Register Nurse reviewed the License Practical Nurse visit notes to ensure the supervision of appropriate care. The Agency failed to implement their written policy and procedures. The Director of Patient Services/Administrator was interviewed 12/01/2023 at 2.00 pm, no explanation offered. 7) Patient #8 with start of care 12/09/22 and discharge date of 01/31/2023 with diagnoses of Surgical Aftercare, Atrioventricular Complete Heart Block, Hypertension Heart, and chronic kidney disease with Heart Failure, Chronic Diastolic Congested Heart Failure, Acute Respiratory with Hypoxia, Dependence on Supplemental Oxygen and History of Fall. The Home Health Certification and Plan of Care cert period 12/9/2022-02/06/2023 documents orders for “ SN (Skilled Nurse) 1 wk. 3, Foley change every 6 -7 weeks, 3 PRN (one visits a week for three weeks, the Foley catheter change every six to seven week, three as needed visits)”. SN (Skilled Nurse) to assess, evaluate, and develop an individualized plan of care. Register Nurse to observe and assess, License Practical Nurse to observe for risk for falls and instruct in falls prevention, home safety, medication management infection prevention and nutrition management”. The “Visit Note Reports” dated 12/14/22, 12/19/22 and 01/25/2023 were conducted by an License Practical Nurse documenting preforming patient assessments. There is no documented evidence of communication between the Register Nurse and the License Practical Nurse. The License Practical Nurse “Visit Note Reports” dated 12/14/22 documents “indicate if you communicate with other disciplines involved in the case”. “No”. There is no documented evidence of communication between the Register Nurse and the License Practical Nurse. The License Practical Nurses are completing patient assessments. The record lacks documentation the Register Nurse reviewed the License Practical Nurses visit notes to ensure the supervision of appropriate care. The Agency failed to implement their written policy and procedures. The Director of Patient Services/Administrator was interviewed 12/01/2023 at 2.00 pm, no explanation offered. 8) Patient #1 has a start of care date of 07/15/2023 with diagnoses of Pressure Ulcer of Right Ankle Stage 2, Type 2 Diabetes Mellitus without complications, Essential Hypertension, Alzheimer’s Disease, and Hypothyroidism as documented on the “Home Health Certification and Plan of Care” dated 11/12/2023 to 01/10/2024. The “Home Health Certification and Plan of Care” dated 11/12/2023 to 01/10/2024 documents orders for “Skilled Nurse (SN) 3wk4, 2every5wk5 (3 times per week for 4 weeks, 2 times per 5 weeks for 5 weeks); Registered nurse (RN) to observe, assess, evaluate, and develop an individualized plan of care. Registered Nurse to observe and assess, Licensed Practical nurse (LPN) to observe for risks for falls and instruct in fall prevention, home safety, medication management, infection preventions, and nutrition management.” The Skilled Nurse “Visit Note Report” dated 11/13/2023, 11/15/2023, 11/17/2023, 11/20/2023, and 11/23/2023 document patient assessments conducted and signed by the Licensed Practical Nurse. There is no documented evidence of communication between the Licensed Practical Nurse and the Registered Nurse. There is no documented evidence the Registered Nurse reviewed the Licensed Practical Nurse visit note to ensure the supervision of appropriate care. The Agency failed to implement their written policy and procedures. On 11/29/2023 at 3:55 PM, the Administrator and Director of Patient Services were interviewed and did not provide an explanation for the findings. 9) Patient #4 has a start of care date of 11/17/2023 with diagnoses of Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Acute on Chronic Congestive Heart Failure, Type 2 Diabetes Mellitus, Atherosclerotic Heart Disease of native Coronary Artery, Hypothyroidism, and Hyperlipidemia as documented on the “Home Health Certification and Plan of Care” dated 11/17/2023 to 01/15/2024. The “Home Health Certification and Plan of Care” dated 11/17/2023 to 01/15/2024 documents orders for “Skilled Nurse (SN) 1wk1, 2wk2, 1wk1 (1 time per week for 1 week, 2 times per week for 2 weeks, 1 time per week for 1 week); Physical Therapy (PT) effective 11/19/2023 2wk3, 1wk3 (2 times per week for 3 weeks, 1 time per week for 3 weeks); Occupational Therapy (OT) effective 11/19/2023 1wk1 (1 time per week for 1 week). Registered nurse (RN) to observe, assess, evaluate, and develop an individualized plan of care. RN to observe and assess, Licensed Practical nurse (LPN) to observe for risks for falls and instruct in fall prevention, home safety, medication management, infection preventions, and nutrition management.” The Skilled Nurse “Visit Note Report” dated 11/24/2023 documents a patient assessment conducted and signed by the Licensed Practical Nurse. There is no documented evidence of communication between the Licensed Practical Nurse and the Registered Nurse. There is no documented evidence the Registered Nurse reviewed the Licensed Practical Nurse visit note to ensure the supervision of appropriate care. The Agency failed to implement their written policy and procedures. On 11/30/2023 at 3:50 PM, the Administrator and Director of Patient Services were interviewed and did not provide an explanation for the findings. 10) Patient #6 has a start of care date of 01/26/2023 with diagnoses of Pressure Ulcer of Left Ankle- Stage 2, Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, Benign Neoplasm of Cerebral Meninges, Essential Hypertension, Epilepsy and Hyperlipidemia as documented on the “Home Health Certification and Plan of Care” dated 11/22/2023 to 01/20/2024. The “Home Health Certification and Plan of Care” dated 11/22/2023 to 01/20/2024 documents an order for “Skilled Nurse (SN) 1wk1 (1 time per week for 1 week), 2wk4 (2 times per week for 4 weeks), 3PRN (as needed). Registered Nurse (RN) to observe and assess, Licensed Practical Nurse (LPN) to observe for risk for falls and instruct in fall prevention, home safety, medication management, infection prevention, and nutrition management”. The Skilled Nurse “Visit Note Report” dated 11/23/2023 and 11/27/2023 document patient assessments conducted and signed by the Licensed Practical Nurse. There is no documented evidence of communication between the Licensed Practical Nurse and the Registered Nurse. There is no documented evidence the Registered Nurse reviewed the Licensed Practical Nurse visit note to ensure the supervision of appropriate care. The Agency failed to implement their written policy and procedures. On 11/30/2023 at 4:30 PM, the Administrator and Director of Patient Services were interviewed and did not provide an explanation for the findings. 11) Patient #13 has a start of care date of 08/08/2023 with diagnoses of Orthopedic Aftercare, Type 2 Diabetes Mellitus with diabetic neuropathy arthropathy, Hypertensive Heart Disease with Heart Failure, Systolic Heart Failure, and Atrial Fibrillation as documented on the “Home Health Certification and Plan of Care” dated 08/08/2023 to 10/06/2023. The “Home Health Certification and Plan of Care” dated 08/08/2023 to 10/06/2023 documents an order for “Skilled Nurse (SN) 1wk4 (1 time per week for 4 weeks), Physical Therapy (PT) 1wk2 (1 time per week for 2 weeks), 2wk3 (2 times per week for 3 weeks), 1wk2 (1 time per week for 2 weeks); Occupational Therapy (OT) 1wk1 (1 time per week for 1 week), 2wk4 (2 times per week for 4 weeks), 3PRN (as needed). Registered nurse (RN) to observe, assess, evaluate, and develop an individualized plan of care. RN to observe and assess, Licensed Practical nurse (LPN) to observe for risks for falls and instruct in fall prevention, home safety, medication management, infection preventions, and nutrition management.” The Skilled Nurse “Visit Note Report” dated 08/16/2023, 09/08/2023, 09/21/2023, and 09/28/2023 document patient assessments conducted and signed by the Licensed Practical Nurse. There is no documented evidence of communication between the Licensed Practical Nurse and the Registered Nurse. There is no documented evidence the Registered Nurse reviewed the Licensed Practical Nurse visit note to ensure the supervision of appropriate care. The Agency failed to implement their written policy and procedures. On 12/01/2023 at 3:45 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings. 1) Patient #9 has a start of care date of 08/06/2023 with diagnoses including Hypertension Heart and Chronic Kidney Disease with Heart Failure stage 1, Chronic Diastolic Heart Failure, and Type 2 Diabetes Mellitus as documented on the “Home Health Certification and Plan of Care” for certification period 08/06/2023 to 10/04/2023. The patient has a discharge date of 10/04/2023. The “Home Health Certification and Plan of Care” for certification period 08/06/2023 to 10/04/2023 documents an order for “SN (Skilled Nurse) 2wk1, 1wk5, 1 every 2wk2, 1wk1 (two visits a week for one week, one visit a week for five weeks, one visits every two weeks for two weeks). Cardiovascular System: Skilled Nurse to assess and teach related to altered cardiovascular status to minimize complications and reduce hospitalization. Heart Failure: Skilled Nurse to assess cardiovascular system to identify signs of decompensation and intervene to minimize the severity of fluid overload, assess patient ability to monitor and recall daily weights and vital signs. Hypertension management: SN to assess/teach warning signs and symptoms to avoid hospitalization. Atrial Fibrillation: Skilled Nurse to assess/teach warning signs and symptoms to avoid hospitalization. Respiratory system: Skilled Nurse to assess and teach related altered respiratory status to minimize complications and reduce hospitalization. Diabetic management: Skilled Nurse for instructions of Diabetic care include diet, skin care, signs and symptoms of hypo/hyperglycemia, proper administration of Diabetic medication”. The Skilled Nurse “Visit Note Report” dated 09/13/2023, the LPN (License Practical Nurse) documents assessment of the patient’s “Head and Neck, no abnormal findings in head and neck assessment. Integumentary; no abnormal findings in integumentary system. Cardiovascular; no abnormal findings in cardiovascular assessment. Respiratory; no abnormal findings in respiratory assessment. Genitourinary: no abnormal findings in genitourinary assessment. Gastrointestinal: within normal limits. Endocrine/Hematopoietic Systems (Diabetic) ; no abnormal endocrine/hematopoietic findings”. The Skilled Nurse “Visit Note Report” dated 09/25/2023, the LPN (License Practical Nurse) documents assessment of the patient’s “Head and Neck, no abnormal findings in head and neck assessment. Integumentary; no abnormal findings in integumentary system. Cardiovascular; no abnormal findings in cardiovascular assessment. Respiratory; no abnormal findings in respiratory assessment. Genitourinary: no abnormal findings in genitourinary assessment. Gastrointestinal: within normal limits. Endocrine/Hematopoietic Systems (Diabetic) ; no abnormal endocrine/hematopoietic findings”. The Skilled Nurse “Visit Note Report” dated 09/13/2023 and 09/25/2023 document patient assessments conducted and signed by the Licensed Practical Nurse There is no documented evidence of a review or documentation by the Registered Nurse. There is no documented evidence of communication between the Licensed Practical Nurse and the Registered Nurse. There is no documented evidence the Registered Nurse reviewed the Licensed Practical Nurse visit note to ensure the supervision of appropriate care. The Agency failed to implement their written policy and procedures. The survey findings and interview were conducted with the Administrator, Director of Patient Services on 11/28/2023 at 03:40PM. No explanation was provided 2) Patient #10 has a start of care date of 05/30/2023 with diagnoses of Unspecified Open Wound Left Knee, Hypertensive Chronic Kidney Disease stage 1, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease as documented on the “Home Health Certification and Plan of Care” for certification period 05/30/2023 to 07/28/2023. The patient has a discharge date of 07/28/2023. The “Home Health Certification and Plan of Care” for certification period 05/30/2023 to 07/28/2023 documents and order for: Skilled Nurse 2wk1, 1wk3 two visit a week for one week, one visit a week for three weeks), Physical Therapy 2 wk6 (two visit a week for six weeks), and Occupational Therapy 1wk1 (one visit a week for one week). Skilled Nurse to “assess evaluate and develop an individualized Plan of Care”. Skilled Nurse for instruction in “Diabetic Care to include diet Low Carb, skin care, and symptoms of hypo/hyperglycemia, proper administration of Diabetic medication”. Skilled Nurse to “perfom wound care to Left Knee skin tear: cleanse with wound cleanser , apply Xeroform, cover with Foam dressing. Dressing to be changed 2X (two times) per week and PRN (as needed) for dislodged dressing, wound deterioation”. The Skilled Nurse “Visit Note Report” dated 06/02/2023, the License Practical Nurse documents assessment of the patient’s “Cardiovascular: no abnormal findings in cardiovascular observation. Respiratory: no abnormal findings in respiratory observation. Genitourinary: no abnormal findings in genitourinary observation. Gastrointestinal: no abnormal findings in gastrointestinal observation. Intergumetary: Incision/wound/skin tear with currentlry included on the patient’s Plan of Care. Endocrine/Hematopoietic Systems (Diabetic); no abnormal endocrine/hematopoietic findings”. The Skilled Nurse “Visit Note Report” dated 06/05/2023, the License Practical Nurse documents assessment of the patient’s “Cardiovascular: no abnormal findings in cardiovascular observation. Respiratory: no abnormal findings in respiratory observation. Genitourinary: no abnormal findings in genitourinary observation. Gastrointestinal: no abnormal findings in gastrointestinal observation. Intergumetary: Incision/wound/skin tear with currentlry included on the patient’s Plan of Care. Endocrine/Hematopoietic Systems (Diabetic); no abnormal endocrine/hematopoietic findings”. There is no documented evidence of communication between the Licensed Practical Nurse and the Registered Nurse. There is no documented evidence the Registered Nurse reviewed the Licensed Practical Nurse visit note to ensure the supervision of appropriate care. The Agency failed to implement their written policy and procedures. The survey findings and interview were conducted with the Director of Patient Services on 11/29/2023 at 03:57 PM. No explanation was provided. 3) Patient #14 has a start of care 09/25/23 with diagnoses of Hypertensive Heart and Chronic Kidney Disease, Acute Chronic Sytolic Congestive Heart Failure, and Type 2 Diabetes Mellitus as documented on the”Home Health Certification and Plan of Care” for certification period 09/25/2023 to 11/23/2023. The “Home Health Certification and Plan of Care” for certification period 09/25/2023 to 11/23/2023 documents an order for Skilled Nurse 3 wk 3 (three visits a week for three weeks), Physical Therapy 1 wk1 (one visit a week for one week), Occupational Therapy 1 wk 1, 2 wk 4, 1 wk4 (one visit a week for one week, two visits a week for four weeks, one visit a week for four weeks). Registered Nurse to “observe, assess and evaluate and develop an individualized Plan of Care, Registered Nurse to observe and asssess”. License Practical Nurse to “observe for risk for falls and instruct on fall prevention, home safety medication management infection prevention and nutrition management”. “Skilled Nurse to perform wound care to #1 LLE (Left Lower Leg) cleanse with NS Normal Saline), apply Adaptic, Calcium Alginate and cover with Stratasorb 3w3 (thee times a week for three)”. “Skilled Nurse for instructions of Diabetic Care to include diet, skin care, signs and symptoms of hypo/hyperglycemia, proper administration of Diabetic medication”. “Blood Glucose (BG) testing QID (four times a day), Skilled Nurse to “assess patient/caregiver ability to perform and record blood glucose testing as ordered and report abnormal findings to Physician”. Skilled Nurse to “report to Physician blood glucose readings greater than 350 or less than 70”. There is no documented evidence the Registered Nurse reviewed the Licensed Practical Nurse visit note to ensure the supervision of appropriate care. The Agency failed to implement their written policy and procedures. The survey findings and interview were conducted with the Administrator and Director of Patient Services on 11/30/2023 at 04:36 PM. No explanation was provided.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on clinical records review and staff interview, the Agency failed to ensure a comprehensive review of all medication’s patients are taking. This was evident in four (4) of seventeen (17) records reviewed. (Patients #3, #4, #7 # 10). Failure to ensure a comprehensive review of medications, has the potential for negative patient outcome. The findings include: 4) Patient #4 has a start of care date of 11/17/2023 with diagnoses of Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Acute on Chronic Congestive Heart Failure, Type 2 Diabetes Mellitus, Atherosclerotic Heart Disease of native Coronary Artery, Hypothyroidism, and Hyperlipidemia as documented on the “Home Health Certification and Plan of Care” dated 11/17/2023 to 01/15/2024. The “Home Health Certification and Plan of Care” dated 11/17/2023 to 01/15/2024 documents orders for “Skilled Nurse (SN) 1wk1, 2wk2, 1wk1 (1 time per week for 1 week, 2 times per week for 2 weeks, 1 time per week for 1 week); Physical Therapy (PT) effective 11/19/2023 2wk3, 1wk3 (2 times per week for 3 weeks, 1 time per week for 3 weeks; Occupational Therapy (OT) effective 11/19/2023 1wk1 (1 time per week for 1 week). Medications: Metformin 1,000 milligrams tablet 2 times daily.” The “Visit Note Report- Registered Nurse Oasis Admission” dated 11/17/2023 documents “Interventions provided- Skilled nurse to observe and assess medications to identify immediate needs and intervene to minimize complication to make patient safe until next visit. Details/comments: Reviewed meds”. The “Visit Note Report” dated 11/20/2023 completed by the Registered Nurse indicates “no medication discrepancies, issues or non-compliance found”. The “Visit Note Report” dated 11/27/2023 completed by the Licensed Practical Nurse indicates “no medication discrepancies, issues or non-compliance found”. During a Home Visit on 11/29/2023 at 10:00AM, when asked about her medications, the patient stated, “I take so many- pills for diabetes, insulin, aspirin and a whole bunch of other things.” The medication list provided by the Assisted Living facility dated 11/27/2023 documents the patient’s current medications include: ASA 81 milligrams Daily, Atorvastatin 40 milligrams Daily, Levothyroxine 50 micrograms Daily, Multivitamin 1 tab Daily, Lispro insulin sliding scale, Ferrous sulfate 324 milligrams Daily, Furosemide 20 milligrams Daily, and Metformin 1,000 milligrams twice daily. The clinical record does not accurately identify the medications the patient is currently taking. On 11/30/2023 at 3:50 PM, the Administrator and Director of Patient Services were interviewed and did not provide an explanation for the findings. 2) Patient #3 start of care 10/20/2023 with diagnoses of Laceration to right elbow, Hypertension Heart Disease with Heart Failure, Chronic Obstructive Pulmonary Disease, Acute Respiratory with Hypoxia and Hypercapnia, Anemia, Dependence on Supplemental Oxygen, Anxiety and Major Depression as documented on the “Home Health Certification and Plan of Care” for certification period 10/20/2023-12/18/2023. The Home Health Certification and Plan of Care certification period 10/20/2023-12/18/2023 documents an order for “Skilled Nurse 1wk1, 2wk4 (1 time per week for 1 week, 2 times per week for 4weeks); Physical Therapy effective 10/29/2023 1wk1, 2wk2, 1wk3 (1 times per week for week, 2 time per week for 2 weeks, 1 time per week for 3 weeks; Occupational Therapy effective 10/29/2023 1wk1 (1 time per week for 1 week). Medications: Albuterol inhaler 90mcg (micrograms) daily, Aspirin 81mg (milligram) I tablet daily, Atenolol 25 milligram 2 tablets daily, Breo Ellipta 100 micrograms inhalation daily, Cetirizine 10 milligram daily, Buspirone 5milligram I tablet daily, Ipratropium 0.5 milligram -Albuterol 3 milligram Nebulization every 6 hours, Symbicort 160 milligram Inhaler every 12 hours, and Trazadone 50 milligram 1tablet daily.” The “Visit Note Report- Registered Nurse Oasis Admission” dated 11/17/2023 documents “Interventions provided- Skilled Nurse to observe and assess medications to identify immediate needs and intervene to minimize complication to make patient safe until next visit. Details/comments: Reviewed meds”. The Licensed Practical Nurse “Visit Note Reports” dated 10/24/23, 10/27/23, 10/31/23, 11/02/23 and 11/07/23 indicates “no medication discrepancies, issues or non-compliance found”. “Visit Note Report” dated 11/17/2023 completed by the Registered Nurse indicates “no medication discrepancies, issues or non-compliance found”. During a Home Visit on 11/28/2023 at 11:00AM, Surveyor found discrepancies between the Agency “Client Medication Report and the Assisted Living medication “order summary report”. The medication list provided by the Assisted Living dated 11/28/23 documents the patient’s current medications include: Bipap Oxygen therapy at 3 Liters/minute at bedtime and as needed, Potassium Chloride ER tablet 20 meq (milliequivalent) daily, Saline Mist Nasal Solution 0.65%, Carvedilol 6.25 milligram tablet, Cholecalciferol 50 milligram Capsule, Docusate Sodium 100 milligram capsule and Budesonide inhalation suspension 0.5ML/2MG(milliter/milligram). The clinical record lacks documented evidence of the patient’s current and accurate medication regimen. 3) Patient #7 with start of care 10/12/2023 with diagnoses of Malignant Neoplasm of left Female Breast, Abscess of the Breast and Nipple, Urinary Tract Infection, Alzheimer’s Disease, Essential Hypertension, Anemia and Type 2 Diabetes as documented on the “Home Health Certification and Plan of Care” for certification period 10/12/2023 - 12/10/2023. The Home Health Certification and Plan of Care for certification period 10/12/2023-12/10/2023 documents orders for Skilled Nurse 1WK2, 2WK3 (1 time per week for 2 week, 2 times per week for 3 weeks; Physical Therapy effective 10/15/2023 2wk3, 1wk1, 2WK3,1WK4 (1 time per week for 1 week, 2 times per week for 3 weeks, 1 time per week for 4 weeks). Medications include: Alogliptin 12.5 milligram tablet 2 times daily, Farxiga 10 milligram 1 tablet daily, Furosemide 20 milligram 1 tablet daily, Glimepiride 4 milligram 1 tablet daily and Risperidone 0.25 milligram 1 tablet daily. The “Visit Note Report- Registered Nurse Oasis Admission” dated 10/12/2023 documents “Interventions provided- Skilled Nurse to observe and assess medications to identify immediate needs and intervene to minimize complication to make patient safe until next visit. Details/comments: Reviewed meds”. During a Home Visit on 11/29/2023 at 1.00PM, the Surveyor found discrepancies between the Agency “Client Medication Report and the Assisted Living medication “order summary report”. The medication list provided by the Assisted Living dated 11/29/23 documents the patient’s current medications to include: Anastrozole 1MG (Milligram) tablet daily, Probiotics 20MG (milligram) capsule twice daily and Vitamin D3 50MCG (microgram)1 tablet daily. The Licensed Practical Nurse ‘Visit Note Reports’ dated 10/17/23, 10/27/23, 10/31/23, 11/0723 and 11/14/2023 indicates “no medication discrepancies, issues or non-compliance found”. The “Visit Note Report” dated 10//23/23, 11/03/23, 11/10/23 and 11/29/2023 completed by the Registered Nurse indicates “no medication discrepancies, issues or non-compliance found”. The clinical record lacks documented evidence of the patient’s current medications. On 11/30/2023 at 3:00 PM, the Administrator/ Director of Patient Services was interviewed, and no explanation provided. 1) Patient #10 has a start of care date of 05/30/2023 with diagnoses of Unspecified Open Wound Left Knee, Hypertensive Chronic Kidney Disease stage 1, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease as documented on the “Home Health Certification and Plan of Care” for certification period 05/30/2023 to 07/28/2023. The patient has a discharge date of 07/28/2023. The referral dated 05/30/2023 documents requested services for “Skilled Nurse, Physical Therapy and Occupational Therapy. The patient’s medications include: “ Humulin NPH Kwickpen 100 units/ml, inject “15 units” into the skin nightly”, and “Insulin Aspar Prot-Insulin Aspart 100 units/ml (70/30) subcutaneous pen, dose inject “8 units” into the skin 3 (three) times daily before meals”. The “Registered Nurse Oasis Admission” dated 05/30/2023, the Registered Nurse documents the patient’s medications to include “Humulin 70/30 U-100 Insulin 100 units/ml subcutaneous suspension, dose “1 unit”, and “Insulin Aspar Prot-Insulin Aspart 100 units/ml (70/30) subcutaneous pen, dose “1 ml (milliliter)”. The “Home Health Certification and Plan of Care” for certification period 05/30/2023 to 07/28/2023 documents and order for “Skilled Nurse 2wk1, 1wk3 two visit a week for one week, one visit a week for three weeks), Physical Therapy 2 wk6 (two visit a week for six weeks, and Occupational Therapy 1wk1 (one visit a week for one week”. Skilled Nurse to “assess evaluate and develop an individualized Plan of Care”. Skilled Nurse for instruction in “Diabetic Care to include diet Low Carb, skin care, and symptoms of hypo/hyperglycemia, proper administration of Diabetic medication”. Medications: “Humulin 70/30 U-100 Insulin 100 units/ml subcutaneous suspension, dose “1 unit” daily”, and “Insulin Aspar Pro-Insulin Aspar 100 units/ml (70/30) subcutaneous pen, dose “1 unit” daily”. The clinical record lacks documented evidence that the Skilled Nurse perform a comprehensive review of the patient’s current Diabetic medications and accurate Insulin dosage, route and frequency, in order to identify any potential adverse effects and ineffective drug therapy. The survey findings and interview were conducted with the Director of Patient Services on 11/29/2023 at 03:57 PM. No explanation was provided.”

“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 home visit observations, record review and staff interview, the Agency failed to establish individualized Plans of Care that includes License Practical Nurse services, treatments, and patient’s Rehabilitation Potential. This is evident in seven (7) of seventeen (17) clinical records reviewed. (Patients #2, #3, #5, #6, #7, #9, #10). Failure to establish comprehensive Plans of Care, has the potential for negative patient outcome. The findings include: 6) Patient #5 has a start of care date of 09/12/2023 with diagnoses of Aphasia following cerebral infarction, Apraxia following cerebral infarction, Spinal Stenosis, Essential Hypertension, and Hypothyroidism as documented on the “Home Health Certification and Plan of Care” dated 09/12/2023 to 11/10/2023. The “Visit Note Report- RN OASIS Assessment” dated 09/12/2023 documents “Client’s mental status: Alert, Other (specify); Indicate other mental status: Pt had a Cerebrovascular Accident (CVA) and has aphasia. Skilled Nurse is unable to determine patients orientation”. The “Home Health Certification and Plan of Care” dated 09/12/2023 to 11/10/2023 documents “Functional limitations: endurance, ambulation”. There is no documented evidence of the functional limitation of speech in the plan of care. The plan of care is not individualized and indicative of the patient’s functional status. The Administrator and Director of Patient Services were interviewed and findings reviewed on 11/29/2023 at 3:50PM. No explanation was provided. 7) Patient #6 has a start of care date of 01/26/2023 with diagnoses of Pressure Ulcer of Left Ankle- Stage 2, Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, Benign Neoplasm of Cerebral Meninges, Essential Hypertension, Epilepsy and Hyperlipidemia as documented on the “Home Health Certification and Plan of Care” dated 11/22/2023 to 01/20/2024. The “Visit Note Report- Registered Nurse Recert with Skill” dated 11/202/2023 documents “Abnormal Findings in Eyes Assessment- Diabetic retinopathy, bilateral”. During a Home Visit on 11/30/2023 at 12:00PM, when asked to sign the consent for the visit, the patient stated, “I am blind, I cannot see the paper”. The “Home Health Certification and Plan of Care” dated 11/22/2023 to 01/20/2024 documents “Functional limitations: incontinence, endurance, ambulation”. There is no documented evidence of the functional limitation of sight in the plan of care. The plan of care is not individualized and indicative of the patient’s functional status. On 11/30/2023 at 4:30 PM, the Administrator and Director of Patient Services were interviewed and did not provide an explanation for the findings. 3) Patient #2 with a start of care 10/26/2023 diagnoses of Scoliosis, Raynaud’s Syndrome, Indwelling Catheter, Foot drop, Atrial Fibrillation, Hypertension, Polyneuropathy, Asthma and Spinal Stenosis as documented on the “Home Health Certification and Plan of Care” for certification period 10/26/2023 -12/24/2023. The Home Health Certification and Plan of Care for certification period 10/26/2023-12/24/2023 documents an order for Register Nurse to “observe, assess, evaluate, and develop an individualized plan of care. Registered Nurse to observe and assess”. License Practical Nurse to “observe for risk for falls and instruct in falls prevention, home safety, medication management infection prevention and nutrition management”. Skilled Nurse “Management of Indwelling Urinary catheter including insertion of 16 French, instill 10cc (cubic centimeter) of solution into balloon every month and PRN (as needed) for leakage, blockage, dislodgement or malfunction”. The “Visit Note Report” Assessment note dated 11/08/23 were conducted by an Licensed Practical Nurse and documents in narrative note” Skilled Nurse observed patient private showed competency in flushing catheter with zero difficulty and verbalized understanding in catheter care in the importance of keeping tubing entrance sterile”. The Plan of Care lacks an order for the Licensed Practical Nurse visit frequency and specific treatments for the Licensed Practical Nurse to perform. There is no documented evidence that the Plan of Care is complete. The Agency did not establish an individualized Plan of Care that includes specific treatments for Licensed Practical Nurse services. 4) Patient #3 start of care 10/20/2023 with diagnoses of Laceration to right elbow, Hypertension Heart Disease with Heart Failure, Chronic Obstructive Pulmonary Disease, Acute Respiratory with Hypoxia and Hypercapnia, Anemia, Dependence on Supplemental Oxygen, Anxiety and Major Depression as documented on the “Home Health Certification and Plan of Care” for certification period 10/20/2023-12/18/2023. The Home Health Certification and Plan of Care for certification period 10/20/2023-12/18/2023 documents an order for Registered Nurse to “observe, assess, evaluate, and develop an individualized plan of care. Registered Nurse to observe and assess, Licensed Practical Nurse to “observe for risk for falls and instruct in falls prevention, home safety, medication management infection prevention and nutrition management”. Skilled Nurse to “monitor co-morbid conditions as listed on Plan of Care and any new conditions that present themselves during this episode to identify changes and intervene to minimize complications”. The “Registered Nurse OASIS Admission” dated 10/20/2023 documents abnormal findings patient in hearing assessment, indicating “hearing difficulty and location of hearing is right and left”. Under respiratory findings indicates” no abnormal findings”. During a Home Visit on 11/28/2023 at 11:00AM, when surveyor was speaking to patient and asked to sign the consent for the visit, the patient stated, “I don’t hear what you’re saying, lost my left hearing aid device”. Patient was observed with Oxygen (O2) via nasal cannula by Oxygen concentrator on home visit and uses Bipap Oxygen therapy as documented on patient current medication list at the Assisted Living Facility (ALF). The “Visit Note Reports” dated 10/24/23, 10/27/23, 10/31/23, 11/02/23 and 11/07/23, the Licensed Practical Nurse documents “no supplemental oxygen” with vital signs and under Respiratory assessment indicates “no abnormal findings”. The Plan of Care lacks an order for the Licensed Practical Nurse visit frequency, Bipap machine and Oxygen dosage, route and frequency. The Agency did not establish an individualized Plan of Care. 5) Patient #7 with start of care 10/12/2023 with diagnoses of Malignant Neoplasm of left Female Breast, Abscess of the Breast and Nipple, Urinary Tract Infection, Alzheimer’s Disease, Essential Hypertension, Anemia and Type 2 Diabetes as documented on the “Home Health Certification and Plan of Care” for certification period 10/12/2023-09/24/2023. The Home Health Certification and Plan of Care for certification period 10/12/2023-09/24/2023 documents an order for Register Nurse to “observe, assess, evaluate, and develop an individualized plan of care. Registered Nurse to observe and assess, License Practical Nurse to “observe for risk for falls and instruct in falls prevention, home safety, medication management infection prevention and nutrition management”. Skilled Nurse to “perform wound Care to open wound to left breast twice a week and PRN (as needed) for dislodged and soiled dressing”. The ‘Visit Note Reports’ dated 10/17/23, 10/27/23, 10/31/23, 11/0723 and 11/14/2023 were conducted by an Licensed Practical Nurse documenting preforming “wound assessment”. The Agency did not establish an individualized Plan of Care that includes specific treatments for Licensed Practical Nurse services. The Agency failed to ensure that the Skilled Nurse perform the care and services as per the Plan of Care. The survey findings were reviewed with the Administrator and Director of Patient Services on 11/30/2023 at 3:00PM. No explanation was provided. 1) Patient #9 has a start of care date of 08/06/2023 with diagnoses including Hypertension Heart and Chronic Kidney Disease with Heart Failure stage 1, Chronic Diastolic Heart Failure, and Type 2 Diabetes Mellitus as documented on the “Home Health Certification and Plan of Care” for certification period 08/06/2023 to 10/04/2023. The “Home Health Certification and Plan of Care” (POC) for certification period 08/06/2023 to 10/04/2023 documents an order for “SkilledNurse 2wk1, 1wk5, 1 every 2wk2, 1wk1 (two visits a week for one week, one visit a week for five weeks, one visits every two weeks for two weeks). “Registered Nurse to observe and assess, License Practical Nurse observe for risk for falls and instruct in fall prevention, home safety, medication management, infection prevention and nutrition management”. Treatments include: “Cardiovascular System: Skilled Nurse to assess and teach related to altered cardiovascular status to minimize complications and reduce hospitalization. Heart Failure: Skilled Nurse to assess cardiovascular system to identify signs of decompensation and intervene to minimize the severity of fluid overload, assess patient ability to monitor and recall daily weights and vital signs. Hypertension management: Skilled Nurse to assess/teach warning signs and symptoms to avoid hospitalization. Atrial Fibrillation: SN to assess/teach warning signs and symptoms to avoid hospitalization. Respiratory system: Skilled Nurse to assess and teach related altered respiratory status to minimize complications and reduce hospitalization. Diabetic management: Skilled Nurse for instructions of Diabetic care include diet, skin care, signs and symptoms of hypo/hyperglycemia, proper administration of Diabetic medication”. The POC lacks an order for the Licensed Practical Nurse visit frequency and specific treatments for the Licensed Practical Nurse to perform. There is no documented evidence that the Plan of Care is complete. The Agency did not establish an indiividualized Plan of Care that includes specific treatments for Licensed Practical Nurse services. The survey findings were reviewed with the Administrator, Director of Patient Services on 11/28/2023 at 03:40PM. No explanation was provided. 2) Patient #10 has a start of care date of 05/30/2023 with diagnoses of Unspecified Open Wound Left Knee, Hypertensive Chronic Kidney Disease stage 1, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease as documented on the “Home Health Certification and Plan of Care” for certification period 05/30/2023 to 07/28/2023. The patient has a discharge date of 07/28/2023. The referral dated 05/30/2023 documents requested services for Skilled Nurse, Physical Therapy and Occupational Therapy. The patient’s medications include: “ Humulin NPH Kwickpen 100 units/ml, inject “15 units” into the skin nightly”, and “Insulin Aspar Prot-Insulin Aspart 100 units/ml (70/30) subcutaneous pen, dose inject “8 units” into the skin 3 (three) times daily before meals”. The “Registered Nurse Oasis Admission” dated 05/30/2023, the Registered Nurse documents the patient’s medications to include “Humulin 70/30 U-100 Insulin 100 units/ml subcutaneous suspension, dose “1 unit”, and “Insulin Aspar Prot-Insulin Aspart 100 units/ml (70/30) subcutaneous pen, dose “1 ml (milliliter)”. The “Home Health Certification and Plan of Care” for certification period 05/30/2023 to 07/28/2023 documents and order for “Skilled Nurse 2wk1, 1wk3 two visit a week for one week, one visit a week for three weeks), Physical Therapy 2 wk6 (two visit a week for six weeks, and Occupational Therapy 1wk1 (one visit a week for one week”. Skilled Nurse to “assess evaluate and develop an individualized Plan of Care”. Skilled Nurse for instruction in “Diabetic Care to include diet Low Carb, skin care, and symptoms of hypo/hyperglycemia, proper administration of Diabetic medication”. Medications: “Humulin 70/30 U-100 Insulin 100 units/ml subcutaneous suspension, dose “1 unit” daily”, and “Insulin Aspar Pro-Insulin Aspar 100 units/ml (70/30) subcutaneous pen, dose “1 unit” daily”. The Plan of Care lacks an order of the patient’s current and accurate Insulin dosage, route and frequency. The Plan of Care is not individualized to include all medications. The survey findings and interview were conducted with the Director of Patient Services on 11/29/2023 at 03:57 PM. No explanation was provided.”

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on Clinical Record review and staff interview, the agency failed to ensure an ongoing interdisciplinary assessment between skilled professionals that include periodic discussions among the team regarding the patient’s health status and recommendations for the Plan of Care. This was evident in two (2) of seventeen (17) clinical records reviewed (Patients #1 and #9). Failure to ensure of an ongoing interdisciplinary assessments and discussion of the patient’s status, has the potential for negative patient outcomes. The findings are: 2) Patient #1 has a start of care date of 07/15/2023 with diagnoses of Pressure Ulcer of Right Ankle Stage 2, Type 2 Diabetes Mellitus without complications, Essential Hypertension, Alzheimer’s Disease, and Hypothyroidism as documented on the “Home Health Certification and Plan of Care” dated 09/13/2023 to 11/11/2023 and 11/12/2023 to 01/10/2024. The “Home Health Certification and Plan of Care” dated 11/12/2023 to 01/10/2024 documents orders for “Skilled Nurse (SN) 3wk4, 2every5wk5 (3 times per week for 4 weeks, 2 times per 5 weeks for 5 weeks); Registered nurse (RN) to observe, assess, evaluate, and develop an individualized plan of care. Registered Nurse to observe and assess, Licensed Practical nurse (LPN) to observe for risks for falls and instruct in fall prevention, home safety, medication management, infection preventions, and nutrition management.” The Skilled Nurse “Visit Note Report” dated 11/10/2023 documents a comprehensive wound assessment conducted and signed by the Licensed Practical Nurse indicating the wound has no scab present. The Skilled Nurse “Visit Note Report” dated 11/13/2023 documents a comprehensive wound assessment conducted and signed by the Licensed Practical Nurse indicating the wound has a scab present. The Skilled Nurse “Visit Note Report” dated 11/15/2023 and 11/17/2023 documents a comprehensive wound assessment conducted and signed by the Licensed Practical Nurse indicating no change in the wound status. The Skilled Nurse “Visit Note Report” dated 11/20/2023 documents a comprehensive wound assessment including wound measurements conducted and signed by the Licensed Practical Nurse. The note documents the wound is “completely epithelized; scab present”. There is no documented evidence that the Licensed Practical Nurse communicated the findings from the visit, including the change in the wound, to the Registered Nurse. The record lacks documented evidence the Registered Nurse and Licensed Practical Nurse communicated to ensure ongoing interdisciplinary assessment of the patient occurs. On 11/29/2023 at 3:55 PM, the Administrator and Director of Patient Services were interviewed and did not provide an explanation for the findings. 1) Patient #9 has a start of care date of 08/06/2023 with diagnoses including Hypertension Heart and Chronic Kidney Disease with Heart Failure stage 1, Chronic Diastolic Heart Failure, and Type 2 Diabetes Mellitus as documented on the “Home Health Certification and Plan of Care” for certification period 08/06/2023 to 10/04/2023. The patient has a discharge date of 10/04/2023. The “Home Health Certification and Plan of Care” for certification period 08/06/2023 to 10/04/2023 documents an order for Skilled Nurse 2wk1, 1wk5, 1 every 2wk2, 1wk1 (two visits a week for one week, one visit a week for five weeks, one visit every two weeks for two weeks, one visit a week for one week). “RN (Registered Nurse) to observe and assess, LPN (License Practical Nurse) observe for risk for falls and instruct in fall prevention, home safety, medication management, infection prevention and nutrition management. The “Visit Note Report” date 09/07/2023, the Registered Nurse documents “Patient had procedure 1 week ago with non-removable dressing on Left chest surgical implants site. Patient states dressing to removed in 2 weeks”. The “Patient Care Coordination” does not include communication with the LPN. The Skilled Nurse “Visit Note Report” dated 09/13/2023, the LPN documents “Surgical incision removable dressing remains clean and intact. Dressing due to be removed next week”. The “Patient Care Coordination” section of the visit report does not include communication with the RN. The Skilled Nurse “Visit Note Report” dated 09/25/2023, the License Practical Nurse does not document the patient’s surgical incision status. The “Patient Care Coordination” does not include communication with the Registered Nurse that the surgical incision was not observed. The record lacks documented evidence the Registered Nurse and Licensed Practical Nurse communicated to ensure ongoing interdisciplinary assessment of the patient occurs. The survey findings were reviewed with the Administrator, Director of Patient Services on 11/28/2023 at 03:40PM. No explanation was provided.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on record reviews and staff interview, the agency failed to ensure that clinicians prepare and document complete and accurate clinical and progress notes that reflect the current patients status. This was evident for two (2) of seventeen (17) clinical records reviewed. (Patients #3, and #7). Failure to ensure that clinicians prepare and document complete and accurate clinical and progress notes, has the potential for negative patient outcomes. The Findings are: 1) Patient #3 start of care 10/20/2023 with diagnoses of Laceration to right elbow, Hypertension Heart Disease with Heart Failure, Chronic Obstructive Pulmonary Disease, Acute Respiratory with Hypoxia and Hypercapnia, Anemia, Dependence on Supplemental Oxygen, Anxiety and Major Depression. The Home Health Certification and Plan of Care for certification period 10/20/2023-12/18/2023 documents orders for “Register Nurse 1 wk1, 2wk4 (one visit a week for one week and two visits a week for four weeks) to “observe, assess, evaluate, and develop an individualized plan of care. Register Nurse to observe and assess, License Practical Nurse to observe for risk for falls and instruct in falls prevention, home safety, medication management infection prevention and nutrition management”. Medications include “Oxygen 2 Liters continuous”. The License Practical Nurses “Visit Note Reports” dated 10/24/23,10/27/23, 10/31/23,11/02/23 and 11/07/23 documents “no supplemental oxygen” with vital signs and under Respiratory assessment indicates “no abnormal findings”. The clinical record lacks documented that the License Practical Nurse documented the patient’s use of oxygen and respiratory status as per the Plan of Care. 2) Patient #7 with start of care 10/12/2023 with diagnoses of Malignant Neoplasm of left Female Breast, Abscess of the Breast and Nipple, Urinary Tract Infection, Alzheimer’s Disease, Essential Hypertension, Anemia and Type 2 Diabetes. The Home Health Certification and Plan of Care for certification period 10/12/23 to 12/10/2023 documents orders for “ Skilled Nurse1WK2, 2WK3 (1 time per week for 2 week, 2 times per week for 3 weeks”. Skilled Nurse to perform wound Care to open wound to left breast twice a week and PRN for dislodged and soiled dressing”. Register Nurse) to observe, assess, evaluate, and develop an individualized plan of care. RN to observe and assess, License Practical Nurse to observe for risk for falls and instruct in falls prevention, home safety, medication management infection prevention and nutrition management”. During home visit on 11/29/23 at 1.00pm with the Register Nurse, the Register Nurse performed wound care and dressing changed to patient’s left breast. The Register Nurse documented “ no drainage noted” under wound assessment but the Surveyor noted dressing was soiled with moderate amount of drainage. There is no documented evidence of accurate and complete clinical note by the Register Nurse that reflects the patient’s wound status. The Director of Patient Services/Administrator was interviewed 12/01/2023 at 2.00 pm, no explanation offered.”

“Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This Element is not met as evidenced by: Based on clinical record reviews and staff interview, the agency failed to ensure that ongoing communication with each patient’s Physician was maintained. This was evident for two (2) of seventeen (17) clinical records reviewed (Patients #7 and #13). Failure to ensure that ongoing communication with each patient’s Physician, has the potential for negative patient outcomes. The Findings Are: 2) Patient #13 has a start of care date of 08/08/2023 with diagnoses of Type 2 Diabetes Mellitus with foot ulcer, Type 2 Diabetes Mellitus with diabetic neuropathy arthropathy, Hypertensive Heart Disease with Heart Failure, Systolic Heart Failure, and Atrial Fibrillation as documented on the “Home Health Certification and Plan of Care” dated 10/07/2023 to 12/05/2023. The “Home Health Certification and Plan of Care” dated 10/07/2023 to 12/05/2023 documents an order for “Skilled Nurse (SN) effective 10/08/2023 1wk5 (1 time per week for 5 weeks), 3PRN (as needed). Registered Nurse to observe, assess, evaluate, and develop an individualized plan of care. Agency may accept orders from consulting physicians (Podiatrist). Registered Nurse to observe and assess, Licensed Practical Nurse to observe for risk for falls and instruct in fall prevention, home safety, medication management, infection prevention, and nutrition management. The “Client Coordination Note Report” dated 10/19/2023 documents a missed Skilled Nurse visit on 10/19/2023. “Reason visit not made: Patient refused. Missed visit reported to Physician/Physician representative: (Podiatrist). Additional comments: Patient told Skilled Nurse that she will be going to wound care tomorrow 10/20/2023 and that (Podiatrist) didn’t want wound care to be done on Thursday 10/19/2023, since he wanted to see the wound/exudate for himself”. The “Client Coordination Note Report” dated 10/24/2023 documents a missed Skilled Nurse visit on 10/24/2023. “Reason visit not made: Patient refused. Missed visit reported to Physician/Physician representative: (Podiatrist). Additional comments: Patient stated she will be going to wound care to have dressing changed on Tuesday October 24th, 2023 and Thursday October 26th, 2023”. The “Client Coordination Note Report” dated 11/04/2023 documents a missed Skilled Nurse visit on 11/02/2023. “Reason visit not made: Patient had a physician appointment. Missed visit reported to Physician/Physician representative: (Podiatrist).” The “Client Coordination Note Report” dated 11/19/2023 documents a care coordination follow-up note by the Registered Nurse “Patient informed Skilled Nurse that (Podiatrist) does not want anyone doing the wound care as of right now. Patient requested that wound care be stopped for now”. The record lacks documented evidence that the ordering physician was made aware of several missed visits or reported change in care plan by the consulting physician. On 12/01/2023 at 3:45 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings. 1) Patient #7 with start of care 10/12/2023 with diagnoses of Malignant Neoplasm of left Female Breast, Abscess of the Breast and Nipple, Urinary Tract Infection, Alzheimer’s Disease, Essential Hypertension, Anemia and Type 2 Diabetes Mellitus. The Home Health Certification and Plan of Care for certification period 10/12/2023-12/10/2023 documents orders for “ Skilled Nurse 1WK2, 2WK3 (1 time per week for 2 week, 2 times per week for 3 weeks). Skilled Nurse to perform wound Care to open wound to left breast twice a week and PRN for dislodged and soiled dressing. Register Nurse to observe, assess, evaluate, and develop an individualized plan of care. Register N to observe and assess, License Practical Nurse to observe for risk for falls and instruct in falls prevention, home safety, medication management infection prevention and nutrition management”. Record reviewed noted missed Nurse visits on 10/20/23, one Nurse visit for the week of 11/12/23, no Nurse visits for week of 11/19/23 and one Nurse visit for the week of 11/26/23. There is no documented evidence the physician was notified of missed visits. The survey findings were reviewed with the Administrator and Director of Patient Services on 11/30/2023 at 3:00PM. No explanation was provided.”

“Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This Element is not met as evidenced by: Based on clinical records review, policy review, and staff interview, the agency failed to ensure that Licensed Practical Nurses are working within the services Licensed Practical Nurse State regulations, agency’s policy and under the supervision of a Registered Nurse. This was evident for eleven (11) of eleven (11) patients receiving Skilled services from Licensed Practical Nurses (Patients #1, #2, #3, #4, #6, #7, #8, #9, #10, #13, #14). Failure to adequately supervise Licensed Practical Nurse, has the potential to result in negative patient outcomes. The findings are: The agency’s policy “#AA-007(a) Services Provided/Supervision of Disciplines- RN/LPN” dated “10/05/23” documents: Interpretive Guidelines §484.75(c)(1) “The HHA should identify a registered nurse (RN) to supervise the care provided by licensed practical/vocational nurses (LPN/LVNs). The identified RN must in turn monitor and evaluate LPN/LVN performance in the provision of services, provision of treatments, patient education, communication with the RN, and data collection regarding the patient’s status and health needs (as delegated by the RN)”. “Qualified personnel observe and evaluate each direct care personnel performing their job duties prior to providing care independently and at frequencies required by state or federal regulations”. “Agencies must adhere to the most stringent regulations (state, federal, accreditation, professional practice, etc.)”. 8) Patient #1 has a start of care date of 07/15/2023 with diagnoses of Pressure Ulcer of Right Ankle Stage 2, Type 2 Diabetes Mellitus without complications, Essential Hypertension, Alzheimer’s Disease, and Hypothyroidism as documented on the “Home Health Certification and Plan of Care” dated 11/12/2023 to 01/10/2024. The “Home Health Certification and Plan of Care” dated 11/12/2023 to 01/10/2024 documents orders for “Skilled Nurse 3wk4, 2every5wk5 (3 times per week for 4 weeks, 2 times per 5 weeks for 5 weeks); Registered Nurse to “observe, assess, evaluate, and develop an individualized plan of care. Registered Nurse to observe and assess”, Licensed Practical Nurse to “observe for risks for falls and instruct in fall prevention, home safety, medication management, infection preventions, and nutrition management.” The Skilled Nurse “Visit Note Report” dated 11/13/2023, 11/15/2023, 11/17/2023, 11/20/20, and 11/23/2023 document patient assessments conducted and signed by the Licensed Practical Nurse. The clinical record lacks documented evidence that the Registered Nurse communicated, reviewed visit notes, supervised and evaluated the Licensed Practical Nurse performance in the provision of patient care and services. On 11/29/2023 at 3:55 PM, the Administrator and Director of Patient Services were interviewed and did not provide an explanation for the findings. 9) Patient #4 has a start of care date of 11/17/2023 with diagnoses of Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Acute on Chronic Congestive Heart Failure, Type 2 Diabetes Mellitus, Atherosclerotic Heart Disease of native Coronary Artery, Hypothyroidism, and Hyperlipidemia as documented on the “Home Health Certification and Plan of Care” dated 11/17/2023 to 01/15/2024. The “Home Health Certification and Plan of Care” dated 11/17/2023 to 01/15/2024 documents orders for Skilled Nurse 1wk1, 2wk2, 1wk1 (1 time per week for 1 week, 2 times per week for 2 weeks, 1 time per week for 1 week); Physical Therapy effective 11/19/2023 2wk3, 1wk3 (2 times per week for 3 weeks, 1 time per week for 3 weeks; Occupational Therapy effective 11/19/2023 1wk1 (1 time per week for 1 week). Registered Nurse to “observe, assess, evaluate, and develop an individualized plan of care. Registered Nurse to observe and assess”, Licensed Practical Nurse to “observe for risks for falls and instruct in fall prevention, home safety, medication management, infection preventions, and nutrition management.” The Skilled Nurse “Visit Note Report” dated 11/24/2023 documents a patient assessment conducted and signed by the Licensed Practical Nurse. The clinical record lacks documented evidence that the Registered Nurse communicated, reviewed visit notes, supervised and evaluated the Licensed Practical Nurse performance in the provision of patient care and services. On 11/30/2023 at 3:50 PM, the Administrator and Director of Patient Services were interviewed and did not provide an explanation for the findings. 10) Patient #6 has a start of care date of 01/26/2023 with diagnoses of Pressure Ulcer of Left Ankle- Stage 2, Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, Benign Neoplasm of Cerebral Meninges, Essential Hypertension, Epilepsy and Hyperlipidemia as documented on the “Home Health Certification and Plan of Care” dated 11/22/2023 to 01/20/2024. The “Home Health Certification and Plan of Care” dated 11/22/2023 to 01/20/2024 documents an order for “Skilled Nurse 1wk1 (1 time per week for 1 week), 2wk4 (2 times per week for 4 weeks), 3PRN (as needed). Registered Nurse to “observe and assess”, Licensed Practical Nurse to “observe for risk for falls and instruct in fall prevention, home safety, medication management, infection prevention, and nutrition management”. The Skilled Nurse “Visit Note Report” dated 11/23/2023 and 11/27/2023 document patient assessments conducted and signed by the Licensed Practical Nurse. The clinical record lacks documented evidence that the Registered Nurse communicated, reviewed visit notes, supervised and evaluated the Licensed Practical Nurse performance in the provision of patient care and services. On 11/30/2023 at 4:30 PM, the Administrator and Director of Patient Services were interviewed and did not provide an explanation for the findings. 11) Patient #13 has a start of care date of 08/08/2023 with diagnoses of Orthopedic Aftercare, Type 2 Diabetes Mellitus with diabetic neuropathy arthropathy, Hypertensive Heart Disease with Heart Failure, Systolic Heart Failure, and Atrial Fibrillation as documented on the “Home Health Certification and Plan of Care” dated 08/08/2023 to 10/06/2023. The “Home Health Certification and Plan of Care” dated 08/08/2023 to 10/06/2023 documents an order for “Skilled Nurse 1wk4 (1 time per week for 4 weeks), Physical Therapy 1wk2 (1 time per week for 2 weeks), 2wk3 (2 times per week for 3 weeks), 1wk2 (1 time per week for 2 weeks); Occupational Therapy 1wk1 (1 time per week for 1 week), 2wk4 (2 times per week for 4 weeks), 3PRN (as needed). Registered Nurse to “observe, assess, evaluate, and develop an individualized plan of care”. Registered Nurse to “observe and assess”. Licensed Practical Nurse to “observe for risks for falls and instruct in fall prevention, home safety, medication management, infection preventions, and nutrition management.” The Skilled Nurse “Visit Note Report” dated 08/16/2023, 09/08/2023, 09/21/2023, and 09/28/2023 document comprehensive assessments conducted and signed by the Licensed Practical Nurse. The clinical record lacks documented evidence that the Registered Nurse communicated, reviewed visit notes, supervised and evaluated the Licensed Practical Nurse performance in the provision of patient care and services. On 12/01/2023 at 3:45 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings. 4) Patient #2 with a start of care 10/26/2023 diagnoses of Scoliosis, Raynaud’s Syndrome, Indwelling Catheter, Foot drop, ATRIAL Fibrillation, Hypertension, Polyneuropathy, Asthma and Spinal Stenosis, admitted to the home care agency on 10/26/2023. The Home Health Certification and Plan of Care certification period 10/26/2023-12/24/2023 documents orders for “Registered Nurse to observe, assess, evaluate, and develop an individualized plan of care. Registered Nurse to observe and assess, Licensed Practical Nurse to observe for risk for falls and instruct in falls prevention, home safety, medication management infection prevention and nutrition management”. The “Visit Note Report” Assessment note dated 11/08/23 were conducted by an Licesne Practical Nurse documenting preforming patient assessments. The Licensed Practical Nurse documents “indicate if you communicate with other disciplines involved in the case”. “No”. The clinical record lacks documented evidence that the Registered Nurse communicated, reviewed visit notes, supervised, and evaluated the Licensed Practical Nurse performance in the provision of patient care and services. 5) Patient #3 start of care 10/20/2023 with diagnoses of Laceration to right elbow, Hypertension Heart Disease with Heart Failure, Chronic Obstructive Pulmonary Disease, Acute Respiratory with Hypoxia and Hypercapnia, Anemia, Dependence on Supplemental Oxygen, Anxiety and Major Depression. The Home Health Certification and Plan of Care for certication period 10/20/2023-12/18/2023 documents an oders for Registered Nurse to “observe, assess, evaluate, and develop an individualized plan of care. Registered Nurse to observe and assess, Licensed Practical Nurse to observe for risk for falls and instruct in falls prevention, home safety, medication management infection prevention and nutrition management”. The “Visit Notes Reports” Assessment notes dated 10/24/23, 10/27/23, 10/31/23, 11/02/23, and 11/07/23 were conducted by an Licensed Practical Nurse documenting performing patient assessments. The Licensed Practical Nurse documents “indicate if you communicate with other disciplines involved in the case”. “No”. The clinical record lacks documented evidence that the Registered Nurse communicated, reviewed visit notes, supervised and evaluated the License Practical Nurse performance in the provision of patient care and services. 6) Patient #7 with start of care 10/12/2023 with diagnoses of Malignant Neoplasm of left Female Breast, Abscess of the Breast and Nipple, Urinary Tract Infection, Alzheimer’s Disease, Essential Hypertension, Anemia and Type 2 Diabetes. The Home Health Certification and Plan of Care for certification period 10/12/2023-12/10/2023 documents orders for “ Skilled Nurse 1wk2, 2wk3 (1 time per week for 2 week, 2 times per week for 3 weeks). Skilled Nurse to “observe, assess, evaluate, and develop an individualized plan of care. Registered Nurse to observe and assess, Licensed Practical Nurse to observe for risk for falls and instruct in falls prevention, home safety, medication management infection prevention and nutrition management”. The ‘Visit Note Reports’ dated 10/17/23, 10/27/23, 10/31/23, 11/0723 and 11/14/2023 were conducted by an Licensed Practical Nurse documenting performing patient assessments. The Licensed Practical Nurse documents “indicate if you communicate with other disciplines involved in the case”. “No”. The clinical record lacks documented evidence that the Registered Nurse communicated, reviewed visit notes, supervised, and evaluated the Licensed Practical Nurse performance in the provision of patient care and services. 7) Patient #8 with start of care 12/09/22 and discharge date of 01/31/2023 with diagnoses of Surgical Aftercare, Atrioventricular Complete Heart Block, Hypertension Heart, and chronic kidney disease with Heart Failure, Chronic Diastolic Congested Heart Failure, Acute Respiratory with Hypoxia, Dependence on Supplemental Oxygen and History of Fall. The Home Health Certification and Plan of Care for certification period 12/9/2022-02/06/2023 documents orders “Skilled Nurse to “assess, evaluate, and develop an individualized plan of care. Registered Nurse to observe and assess, License Practical Nurse to “observe for risk for falls and instruct in falls prevention, home safety, medication management infection prevention and nutrition management”. The “Visit Note Reports” dated 12/14/22,12/19/22 and 01/25/2023 were conducted by an Licensed Practical Nurse documenting preforming comprehensive assessments. The “Visit Note Reports” dated 12/14/22 documents “indicate if you communicate with other disciplines involved in the case”. “No”. The record lacks documented evidence that the Registered Nurse communicated, reviewed visit notes, supervised, and evaluated the Licensed Practical Nurse performance in the provision of patient care and services. The Director of Patient Services/Administrator was interviewed 12/01/2023 at 2.00 pm and findings reviewed, no explanation was provided. 1) Patient #9 has a start of care date of 08/06/2023 with diagnoses including Hypertension Heart and Chronic Kidney Disease with Heart Failure stage 1, Chronic Diastolic Heart Failure, and Type 2 Diabetes Mellitus as documented on the “Home Health Certification and Plan of Care” for certification period 08/06/2023 to 10/04/2023. The patient has a discharge date of 10/04/2023. The “Home Health Certification and Plan of Care” for certification period 08/06/2023 to 10/04/2023 documents an order for “Skilled Nurse 2wk1, 1wk5, 1 every 2wk2, 1wk1 (two visits a week for one week, one visit a week for five weeks, one visits every two weeks for two weeks). Registered Nurse to “observe and assess”. Licensed Practical Nurse “observe for risk for falls and instruct in fall prevention, home safety, medication management, infection prevention and nutrition management”. The Skilled Nurse “Visit Note Report” dated 09/13/2023 and 09/25/2023 document patient assessments conducted and signed by the Licensed Practical Nurse. The clinical record lacks documented evidence that the Registered Nurse communicated, reviewed visit notes, supervised and evaluated the Licensed Practical Nurse performance in the provision of patient care and services. The survey findings were reviewed with the Administrator, Director of Patient Services on 11/28/2023 at 03:40 PM. No explanation was provided. 2) Patient #10 has a start of care date of 05/30/2023 with diagnoses of Unspecified Open Wound Left Knee, Hypertensive Chronic Kidney Disease stage 1, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease as documented on the “Home Health Certification and Plan of Care” for certification period 05/30/2023 to 07/28/2023. The patient has a discharge date of 07/28/2023. The “Home Health Certification and Plan of Care” for certification period 05/30/2023 to 07/28/2023 documents and order for Skilled Nurse 2wk1, 1wk3 two visit a week for one week, one visit a week for three weeks). Skilled Nurse “assess evaluate and develop an individualized Plan of Care”. Skilled Nurse for instruction in “Diabetic Care to include diet Low Carb, skin care, and symptoms of hypo/hyperglycemia, proper administration of Diabetic medication”. Skilled Nurse to “perform wound care to Left Knee skin tear: cleanse with wound cleanser, apply Xeroform, cover with Foam dressing. Dressing to be changed 2X (two times) per week and PRN (as needed) for dislodged dressing, wound deterioration”. The Skilled Nurse “Visit Note Report” dated 06/02/2023 and 06/05/2013 document patient assessments conducted and signed by the Licensed Practical Nurse. The clinical record lacks documented evidence that the Registered Nurse communicated, reviewed visit notes, supervised and evaluated the Licensed Practical Nurse performance in the provision of patient care and services. The survey findings and interview were conducted with the Director of Patient Services on 11/29/2023 at 03:57 PM. No explanation was provided. 3) Patient #14 has a start of care 09/25/23 with diagnoses of Hypertensive Heart and Chronic Kidney Disease, Acute Chronic Systolic Congestive Heart Failure, and Type 2 Diabetes Mellitus as documented on the “Home Health Certification and Plan of Care” for certification period 09/25/2023 to 11/23/2023. The “Home Health Certification and Plan of Care” for certification period 09/25/2023 to 11/23/2023 documents an order for Skilled Nurse 3 wk 3, Physical Therapy 1 wk1 (one visit a week for one week), Occupational Therapy 1 wk 1, 2 wk 4, 1 wk4 (one visit a week for one week, two visits a week for four weeks, one visit a week for four weeks). Registered Nurse to “observe, assess and evaluate and develop an individualized Plan of Care, Registed Nurse to observe and assess. License Practical Nurse to “observe for risk for falls and instruct on fall prevention, home safety, medication management, infection prevention, and nutrition management”. “Skilled Nurse to perform wound care to #1 LLE (Left Lower Leg) cleanse with Normal Saline, apply Adaptic, Calcium Alginate and cover with Stratasorb 3w3 (three times a week)”. “Skilled Nurse for instructions of Diabetic Care to include diet, skin care, signs and symptoms of hypo/hyperglycemia, proper administration of Diabetic medication”. “Blood Glucose testing QID (four times a day), Skilled Nurse to assess patient/caregiver ability to perform and record blood glucose testing and report abnormal findings to Physician. SN to “report to Physician blood glucose readings greater than 350 or less than 70”. “Indwelling Urinary Catheter 18 FR (French) with 30 cc (cubic centimeter) balloon. SN to “assess and teach related to altered Genitourinary status to minimize complications and hospitalization”. The Skilled Nurse “Visit Note Report” dated 09/27/2023, 09/29/2023, 10/02/2023, 10/05/2023, 10/09/2023, and 11/08/2023, documents patient assessments conducted and signed by the Licensed Practical Nurse. The clinical record lacks documented evidence that the Registered Nurse communicated, reviewed visit notes, and evaluated the Licensed Practical Nurse performance in the provision of patient care and services. The survey findings and interview were conducted with the Administrator and Director of Patient Services on 11/30/2023 at 04:36 PM. No explanation was provided.”