Home Health La Monserrate Inc.

“Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA’s governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA’s performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This Condition is not met as evidenced by: Based on documents reviewed on 11/13/2024 and 11/14/2024 from 8:30 AM until 5:00 PM, it was determined that the facility failed to evidence the development, implementation, evaluation, and maintenance of an effective, ongoing, Home Health Agency (HHA)-wide, data-driven QAPI program. The HHA’s governing body did not ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA’s performance across the spectrum of care, which makes this Condition of Participation: §484.65 Quality Assessment and Performance Improvement ( QAPI) Not Met. (Cross Reference Tags: G642, G644, G646, G656 and G658). 6. No evidence was found that the facility has a quality indicator for infection control since 08/30/2022. During an interview with the supervisor employee #1, on 11/14/2024 at 10:00 AM she stated that she had been in this position as supervisor since 10/08/2024. During an interview with the Administrator employee #7, on 11/14/2024 at 11:50 AM she states that all manuals were found in revision with quality and infection control coordinator, that previously was on charge of other personnel. Findings Include: 1. The facility failed to design and implement QAPI that must at least be capable of showing measurable improvement on indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. 2. The facility failed to include in the QAPI program quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. 3. The facility failed to maintain performance improvement activities that are focused on indicators related with patient outcomes and all Home Health Agency (HHA) services. 4. The facility failed to have a mechanism in place to ensure that actions aimed at performance improvement, are implemented and that those actions, are measured its success to ensure that improvements are sustained. 5. The facility failed to ensure that one or more specific quality improvement projects are undertaken each year.”

“Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This Standard is not met as evidenced by: Based upon an Emergency Preparedness Program (EPP) survey performed on 11/14/2024 from 9:00 AM to 11:30 AM, to evaluate emergency preparedness requirements, it was determined that the facility failed to ensure policies and procedures to facilitate the support of volunteers and other healthcare professionals in an emergency. Findings include: During the review of the facilities Emergency Preparedness Program with the Administrator (employee #7) on 11/14/2024 it was noted that the facility failed to stablished policies and procedures to ensure and facilitate the support of volunteers and other healthcare professionals in an emergency as required under §484.102(b)(5).”

“Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.542(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. This Standard is not met as evidenced by: Based upon an Emergency Preparedness Program (EPP) survey performed on 11/14/2024 from 9:00 AM to 11:30 AM, to evaluate emergency preparedness requirements, it was determined that the facility failed to maintain an emergency preparedness communication plan that complies with Federal, State and local laws. Findings include: During the review of the facilities Emergency Preparedness Program with the Administrator (employee #7) on 11/14/2024 it was noted that the facility failed to have in place a written communication plan of how the facility coordinates patient care and how the facility interacts and coordinate with emergency management systems to protect health and safety of patients as required under §484.102(c).”

“Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: Based upon an Emergency Preparedness Program (EPP) survey performed on 11/14/2024 from 9:00 AM to 11:30 AM, to evaluate emergency preparedness requirements, it was determined that the facility failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws. Findings include: During the review of the facilities Emergency Preparedness Program with the Administrator (employee #7) on 11/14/2024 it was noted that the facility failed to provide up dated contact information for the Staff, Entities providing services under arrangements, patients physicians and other facilities as required under §484.102(c)(1) of the Emergency Preparedness.”

“Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This Standard is not met as evidenced by: Based upon an Emergency Preparedness Program (EPP) survey performed on 11/14/2024 from 9:00 AM to 11:30 AM, to evaluate emergency preparedness requirements, it was determined that the facility failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws. Findings include: During the review of the facilities Emergency Preparedness Program with the Administrator (employee #7) on 11/14/2024 it was noted that the facility failed to provide evidence of the Emergency Preparedness Communication Plan that included updated contact information for Federal, State, tribal, regional or local emergency preparedness staff and other sources of assistance”

“Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID’s staff, Federal, State, tribal, regional, and local emergency management agencies. This Standard is not met as evidenced by: Based upon an Emergency Preparedness Program (EPP) survey performed on 11/14/2024 from 9:00 AM to 11:30 AM, to evaluate emergency preparedness requirements, it was determined that the facility failed to develop primary / alternate means for communication with staff, Federal, State regional and local emergency management agencies in compliance with Federal, State and local laws. Findings include: During the review of the facilities Emergency Preparedness Program with the Administrator (employee #7) on 11/14/2024 it was noted that the facility failed to provide evidence of the Emergency Preparedness Communication Plan that included primary and alternate means for communicating with the facility staff, Federal, State, regional and local emergency management agencies under §484.102(c)(3).”

“Information on Occupancy/Needs CFR(s): 484.102(c)(6) §403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.542(c)(7), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (7) [(5) or (6)] A means of providing information about the [facility’s] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC’s needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice’s inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. This Standard is not met as evidenced by: Based upon an Emergency Preparedness Program (EPP) survey performed on 11/14/2024 from 9:00 AM to 11:30 AM, to evaluate emergency preparedness requirements, it was determined that the facility failed to maintain an emergency preparedness communication plan that complies with Federal, State and local laws. Findings include: During the review of the facilities Emergency Preparedness Program with the Administrator (employee #7) on 11/14/2024 it was noted that the facility failed to have written procedures of providing information about the facility’s occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.”

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on three (3) home visits (H.V) with records review, four (4) records review (R.R), administrative documents review, policies and procedures (P&P’s) review, interview with the Supervisor (employee #1), during a survey process performed from 11/13/2024 through 11/14/2024, from 8:30 AM till 5:00 PM, it was determined that the facility failed to encode and electronically transmit each completed OASIS assessment to CMS within 30 days of completing of the assessment of the beneficiary on 6 out of 7 records reviewed (RR-H.V #1, #3 and, R.R #1, #2, #3 and #4) . Findings include: During interview with the supervisor employee #1, during the record review on 11/13/2024 at 3:00 PM state that the OASIS of the R.R #2 was not completed per the Registered nurse that performed the OASIS and was not transmitted to CMS. During the review of facility encoding and transmission of the comprehensive assessment OASIS with the administrative Assistance supervisor (employee #2), on 11/14/2024 at 3:00 PM, she explain that many of the OASIS was not transmitted due to the personnel did not complete the OASIS and the following was found during the review: 1. H.V. #1 has a Start of Care (S.O.C) of 01/04/2024 and was discharge on 03/01/2024, the Date Assessment Completed (M0090) of 03/01/204, the OASIS was encoded and locked on 05/09/2024 and then transmitted on 05/10/2024, 70 days after completing the assessment. The SOC (M0030) of 03/20/2024 Date Assessment Completed (M0090) of 03/20/204, for a re admission, the OASIS was encoded and locked on 05/27/2024 and then transmitted on 05/28/2024, 68 days after completing the assessment. The Date Assessment Completed (M0090) of 05/13/2024, for a recertification the OASIS was encoded and locked and then transmitted on 06/24/2024, 42 days after completing the assessment. 2. H.V. #3 has a Start of Care (S.O.C) of 07/10/2024,the Date Assessment Completed (M0090) of 07/10/204, the OASIS was encoded and locked on 08/12/2024 and then transmitted on 08/15/2024, 43 days after completing the assessment. The date Assessment Completed (M0090) of 09/06/204, for a recertification, the OASIS was encoded and locked on 11/08/2024 and then transmitted on 11/08/2024, 63 days after completing the assessment. The Date Assessment Completed (M0090) of 09/23/2024, for a Resumption of care (ROC) the OASIS was encoded and locked on 11/13/2024 and then transmitted on 11/14/2024, 51 days after completing the assessment. 3. R.R #1 has a Start of Care (S.O.C) of 10/11/2024, the Date Assessment Completed (M0090) of 10/11/2024, the OASIS was not encoded and locked and transmitted 35 days after completing the assessment. 4. R.R #2 has a Start of Care (S.O.C) of 06/26/2024, the Date Assessment Completed (M0090) of 07/10/204, the OASIS was encoded and locked on 08/12/2024 and then transmitted on 08/15/2024, 43 days after completing the assessment. The SOC of 10/12/2024, The date Assessment Completed (M0090) of 10/12/204, for a re-admission, the OASIS was not encoded and locked and transmitted 34 days after completing the assessment. 5. R.R #3 has a Start of Care (S.O.C) of 05/14/2024, the Date Assessment Completed (M0090) of 05/14/204, the OASIS was encoded and locked on 07/09/2024 and then transmitted on 07/09/2024, 56 days after completing the assessment. The date Assessment Completed (M0090) of 06/04/2024, for a discharge , the OASIS was encoded and locked on 07/09/2024 and then transmitted on 07/09/2024, 36 days after completing the assessment. 6. R.R #4 has a Start of Care (S.O.C) of 02/27/2024, the Date Assessment Completed (M0090) of 02/27/204, the OASIS was encoded and locked on 05/27/2024 and then transmitted on 05/28/2024, 99 days after completing the assessment. The date Assessment Completed (M0090) of 04/25/2024, for a recertification, the OASIS was encoded and locked on 06/07/2024 and then transmitted on 06/11/2024, 47 days after completing the assessment. The date Assessment Completed (M0090) of 06/25/2024/2024, for a recertification, the OASIS was encoded and locked on 07/30/2024 and then transmitted on 07/321/2024, 36 days after completing the assessment. The Start of Care (S.O.C) of 07/02/2024, the Date Assessment Completed (M0090) of 07/02/204, the OASIS was encoded and locked on 11/04/2024 and then transmitted on 11/05/2024, 126 days after completing the assessment.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on three (3) Home Visits (H.V) and four (4) Records Reviewed (R.R) and interview with facility Nursing Supervisor (employee #1), performed from 11/13/2024 through 11/14/2024, from 8:30 AM till 5:00 PM, it was determined that the facility failed to ensure that for each patient that receive home health services an individualized plan of care that identifies patient-specific measurable outcomes and goals is developed and implemented, for 2 out of 7 records reviewed (R.R. #1 and #2). 2. R.R #2 is a 62-year-old male admitted to the facility on 10/11/2024 with a diagnosis of Muscle Weakness, Physical Deconditioning, Diabetes Mellitus (DM), Cerebrovascular accident (CVA), High Blood Pressure (HBP), Acquired Immunodeficiency (HVI). During the record review on 11/13/2024 at 1:05 PM it was found that the patient was referred to Home Care for Registered Nurse (RN) Services, Home Health Aide Services (HHA), and Physical Therapy Services on 10/09/2024. The Initial Outcome and Assessment Information Set Version (OASIS) Start of Care was on 10/11/2024, the Date assessment completed (M0090) was on 10/12/2024, however the OASIS was not completed in 5 days and the following was found: a. No evidence was found that the nurse that performed the OASIS, had written an individualized plan of care that identifies patient-specific measurable outcomes and goals, established in accordance with the comprehensive assessment and patient input. Finding Include: R.R #1 was reviewed with Nursing Supervisor (employee #1) on 11/13/2024 at 1:05 PM. This is a 81-year-old female patient was admitted on 10/11/2024 with a diagnosis of Osteoarthritis, mobility problem, High Blood Pressure (HBP), Diabetes Mellitus (DM), Sacral Ulcer stage III. Recertification period of services for this case begin 10/11/2024 through 12/09/2024, with in Oasis plan of care: RN services (RN) treatment with intravenous antibiotic therapy for 12 days, then 2 visits per week, Hospice Aid (HHA) 3 visits per week and Physical Therapy (PT) 2 visits per week, it was found the following: (a) During the review of the home care plan of this case, it was identified that this case does not have a care plan.”

“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 review of Quality Assessment Performance Improvement (QAPI) program information, it was determined that the facility failed to design and implement QAPI that must at least be capable of showing measurable improvement on indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. Findings include: 1. During review of QAPI program information on 11/14/2024 at 9:15 AM, the following were identified: a. It was noted that the last revision to the policies and procedures that guide and make the structure for the QAPI program was in 08/2022. b. The Home Health Agency shows evidence of some quality indicators measured, analyzed and tracked, however the same correspond to the date of 08/30/2022, and did not include all aspects of performance that allow the HHA to evaluate care processes, HHA services and operations. c. The HHA did not provide evidence of the process for selecting the indicators it will use in its QAPI program. Each indicator selected is not worked in a way that should be measurable through data to evaluate any HHA changes in procedure, policy, or intervention. d. The HHA’s QAPI program did not include procedures for measurement and analysis of the indicators, nor did it address the frequency with which such measurement and analysis will occur. e. The HHA did not show evidence that it maintains a coordinated agency-wide program for surveillance, investigation, identification, prevention, control, and research of infectious and communicable diseases as an integral part of the QAPI program.”

“Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA’s governing body. This Standard is not met as evidenced by: Based on review of Quality Assessment Performance Improvement (QAPI) program information, it was determined that the facility failed to include in the QAPI program quality indicator data, including measures derived from OASIS, were applicable, and other relevant data, in the design of its program. Findings include: 1. During review of QAPI program information on 11/14/2024 at 9:15 AM, the following was identified: a. It was noted that The Home Health Agency (HHA) last collected data to monitor the effectiveness and safety of services and quality of care; and identify opportunities for improvement was in 08/2022.”

“Program activities CFR(s): 484.65(c) (1) The HHA’s performance improvement activities must— (i) Focus on high risk, high volume, or problem-prone areas; (ii) Consider incidence, prevalence, and severity of problems in those areas; and (iii) Lead to an immediate correction of any identified problem that directly or potentially threaten the health and safety of patients. This Standard is not met as evidenced by: Based on Quality Assessment Performance Improvement (QAPI) program information, it was determined that the facility failed to maintain performance improvement activities that are focused on indicators related with patient outcomes and all Home Health Agency (HHA) services. Findings include: 1. During review of QAPI program information on 11/14/2024 at 9:15 AM, the following were identified: a. It was noted that the last documented evidence of the facility’s QAPI program demonstrating and measuring its performance was in 08/2022. b. It was noted that the last documented evidence of the facility’s governing body overseeing the QAPI program was observed in 08/2022.”

“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 review of quality assurance activities, it was determined that the facility failed to ensure that one or more specific quality improvement projects are undertaken each year. Findings include: 1. The facility failed to provide evidence on 11/14/2024 at 4:00 PM of performance improvements projects currently underway, as well as those completed in the prior year. 2. During the quality assessment performance improvement program activities review on 11/14/2024 at 4:00 PM, it was identified that facility did not have evidence documented of quality improvement projects.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on the infection prevention and control program activities, and interview with the Administrator (employee #7), it was determined that the facility failed to ensure that accepted standards of practice, to prevent the transmission of infections and communicable diseases are adopted related to place personal protective equipment (PPE), hand wash, disinfection of non-critical equipment. Findings include: 1. During the H.V #2 performed on 11/13/2024 from 11:23 am till 12:20 PM, for bath care with home health aide (License Practice Nurse (LPN) employee #3, it was found the following: a. Employee #3, place the PPE outside the patient’s residence, without patient having history or was screening for Covid 19 infection. b. Employee #3 did not disinfect the non-critical equipment after using it with patients and returned it to the briefcase. c. Employee #3, after washing her hand put on the non-sterile glove then close the faucet and continue with patient bath without changing her glove. d. Employee#3 after finishing with the patient perform hand wash with hand sanitizer, not with soap and water.”

“Licensing CFR(s): 484.100(b) (b) Standard: Licensing. The HHA, its branches, and all persons furnishing services to patients must be licensed, certified, or registered, as applicable, in accordance with the state licensing authority as meeting those requirements. This Standard is not met as evidenced by: Based on the review of the credential files (CF) of nursing (RN), occupational therapy (OT), physical therapy (PT), assistant physical therapy (PTA), speech pathology (SP) and Social worker (S.W), it was determined that the facility failed to ensure that all discipline credential files are in compliance with applicable federal and local law for health agencies related to personnel. The facility fails to maintain an updated record of employees and contractors for hepatitis immunization, and Influenza immunization accordance to Health Department Administrative Order # 244 of October 10, 2008, updated Register of nursing professionals, Cardiopulmonary resuscitation (CPR), and Annual evaluation, for 3 out of 4 credentials reviewed, Credential File (C.F #1, #4 and #5) Findings include: 1. During the review of employee credential files () on 11/13/2024 from 1:30 PM till 3:00 PM the following was determined: a. One out of four RN (associate degree nurse) C.Fs did not have evidence of the updated Register of nursing professionals. (RN C.F #4 11/12/2024). b. One out of four RN C.Fs did not have evidence of the updated CPR. (RN C.F #2 11/07/2024). c. One out of four RN C.Fs did not have evidence of the immunization of hepatitis. (RN C.F #2). d. Two out of four RN C.Fs did not have evidence of the updated Influenza immunization. (RN C.F #1, 04/28/2024, C.F. 4, 09/06/2024). e. One out of four RN C.Fs did not have evidence of the updated annual evaluation. (RN C.F #4). f. One out of four RN C.Fs did not have evidence of the Duties and functions was sign and dated by the personnel. (RN C.F #1). g. One out of one OT C.Fs did not have evidence of the Register of OT professionals, Hepatitis B, Influenza and Covid 19 vaccine, Health certification, criminal background check law 300 and criminal record. (OT C.F #9). h. One out of one SP C.Fs did not have evidence of the Register of SP professionals, Hepatitis B, Influenza and Covid 19 vaccine, Health certification, criminal background check law 300 and criminal record. (SP C.F #10). i. One out of eight PT C.Fs did not have evidence of Hepatitis B and Covid 19 vaccine. (PT C.F #3). j. One out of eight PTA C.Fs did not have evidence of Hepatitis B vaccine. (PTA C.F #4). k. Seven out of eight PT and PTA C.Fs did not have evidence of updated influenza vaccine. (PT C.F #2, #3, PTA C.F. 4, #5, #6, #7 and #8). l. Three out of eight PT and PTA C.Fs did not have evidence of updated Covid 19 vaccine. (PT C.F #2, #3. m. Six out of eight PT and PTA C.Fs did not have evidence of an updated annual evaluation. (PT C.F #2, #3, PTA C.F. #4, #5, #6, #7). n. One out of two SW C. Fs did not have evidence of Hepatitis B and updated influenza vaccine. (SW #2).”

“State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This Element is not met as evidenced by: Based on review of the agency’s admission information of patients’ rights/responsibilities, interviews with patients’ legal representatives and review of documents with the agency’s supervisor (employee #1), it was determined that the facility failed to inform patients of the hotline telephone number established by the State Agency for the purpose of receiving complaints. Findings include: During the review of patient admission orientation document provided to the patient during the initial visit on 11/13/2024 at 10:00 AM, it was found that the Medicare (787-273-8487) and the State Licensing (787-273-8488) Agency’s hotline telephone numbers to lodge complaints or specific grievance related to abuse, neglect and harassment were not updated.”

“Access to auxiliary aids and language service CFR(s): 484.50(c)(12) Be informed of the right to access auxiliary aids and language services as described in paragraph (f) of this section, and how to access these services. This Element is not met as evidenced by: Based on review of admission package, it was determined that the facility failed to promote patient’s right to be informed of the access to auxiliary aids and language services and how to access these services. Findings include: 1. During review of admission package and patient’s rights policies and procedures on 11/13/2024 at 11:15 AM, the following was identified: a. Information related to the availability and procedure to access auxiliary aids and language services if needed and how to access these services were not included in the patient’s admission package.”

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on three (3) Home Visits (H.V) and four (4) Records Reviewed (R.R), review of policy and procedure with Nursing Supervisor (employee #1), during a survey process performed from 11/13/2024 through 11/14/2024, from 8:30 AM till 5:00 PM, it was determined that the agency failed to ensure that the comprehensive assessment must be completed within 5 days of the start of care for 2 out of 7 records reviewed (R.R. #1 and #2). Findings include: 2. R.R #2 is a 62-year-old male admitted to the facility on 10/11/2024 with a diagnosis of Muscle Weakness, Physical Deconditioning, Diabetes Mellitus (DM), Cerebrovascular accident (CVA), High Blood Pressure (HBP), Acquired Immunodeficiency (HVI). During the record review on 11/13/2024 at 1:05 PM it was found that patients were referred to Home Care for Registered Nurse (RN) Services, Home Health Aid Services (HHA), and Physical Therapy Services on 10/09/2024. The Initial Outcome and Assessment Information Set Version (OASIS) Start of Care was on 10/11/2024, the Date assessment completed (M0090) was on 10/12/2024, however the following item was left in blank the OASIS was not completed in 5 days: a. Current Payment Source for Home Care (M0150). b. Most recent immunization such as Tetanus, Tuberculosis (Tb), Hepatitis B was not assessed. c. Health status Home Bound. d. Prognosis. e. Brief Interview for Mental Status (BIMS), Repetition of three words (C0200), Temporal Orientation, Able to report correct years, month and date (C0300), Recallable to recall sock, blue, bed (C0400). f. Sign and symptom of Delirium part c) disorganized thinking and d) altered level of consciousness (C1310). g. Grooming (M1800). h. Ability to Dress (M1810, M1820). i. ability to Wash (M1830). j. Toilet transfer (M1840). j. Toilet hygiene (M1845). k. Transferring (M1850). l. Ambulatory (M1860). m. Self Care (GG0110. n. Mobility (GG0170). o. Treat for UTI(M1600). p. Urinary Incontinence (M1610). q. Ostomy (M1630) r. Primary diagnosis & Other diagnosis (M1021 &M1023). s. Risk for Hospitalization (M1033). t. Pain interference with therapy (J0520). u. Pain interference with day-to-day activities (J0530). v. When patient dyspneic (M1400). w. Nutritional Approaches (K0520). x. Height and weight (M1060) y. Feeding or Eating (M1870). z. Pressure ulcer (M1306), M1322), M1324, M1330, M1340. aa. High Drug Classes (N0415). bb. Drug Regimen Review (M2001, M2003, M2010, M2020, M2030). cc. Medication Administration Record. dd. Special Treatment, Procedure, Program (O0110). ee. Therapy Need (M2200). ff. Skilled Intervention. gg. Registered Nurse Signature. According to registered Nurse patient communication notes the patient was oriented and communicative, total ADL dependent, bed confinement, urinary foley dependent, with pressure area in the Sacro. The patient needs HHA 3 visits per week per 9 weeks. Frequency of nursing services 2 visits per week for 9 weeks. No evidence was found that the nurse asses the urinary system and pressure ulcer in the initial OASIS. On 11/04/2024 the patient was transferred to the hospital, then was admitted to Hospice care, however, the OASIS for the transfer was not documented. During the interview with the supervisor employee #1 on 11/13/2024 at 1:30 PM she states that the nurse that performed this admission resign, she took with them to complete the OASIS and yesterday send a message as reminder to complete the OASIS. Findings Include: R.R #1 was reviewed with Nursing Supervisor (employee #1) on 11/13/2024 at 1:05 PM. This is a 81-year-old female patient was admitted on 10/11/2024 with a diagnosis of Osteoarthritis, mobility problem, High Blood Pressure (HBP), Diabetes Mellitus (DM), Sacral Ulcer stage III. Recertification period of services for this case began 10/11/2024 through 12/09/2024, with in Oasis plan of care: RN services (RN) treatment with intravenous antibiotic therapy for 12 days, then 2 visits per week, Hospice Aid (HHA) 3 visits per week and Physical Therapy (PT) 2 visits per week, it was found the following: (a) The Registered Nurse (RN), perform the OASIS-E start of care on 10/11/2024 refers Date Assessment Complete (M0090) was completed on 09/11/2024, however the following parts to be mentioned are not documented: Most Recent Immunizations, Sensory Status, Mental Status part Behavioral, Psychosocial, Should Brief Interview for Mental Status (C0100), Repetition of Three Words (C0200), Temporal Orientation (C0300), Recall (C0400), Genito Urinary (GU), (patient with urinary catheter not document), Digestive System, Endocrine System, Blood Sugar (dxt), Pressure Ulcer/ Injury Risk, score for Braden Scale, Integumentary System (diagram of sacral ulcer and right hip injury, Current Number of Unhealed Pressure Ulcers/Injury at Each Stage (M1311 part B1 Stage 3), Current Number of Stage (M1322), Does this patient have a surgical wound (M1340), Status of Problematic Surgical Wound that is observable (M1342), High-Risk Drug Classes: use and indication (N0415 part 2), Medication Follow up (M2003), Medication administration record, Special Treatments, Procedures and Programs (00110) part (H1 IV Medication), and Therapy Need (M2200).”

“Eligibility for Medicare home health benefit CFR(s): 484.55(b)(2) Except as provided in paragraph (b)(3) of this section, a registered nurse must complete the comprehensive assessment and for Medicare patients, determine eligibility for the Medicare home health benefit, including homebound status. This Element is not met as evidenced by: Based on survey with three (3) Home Visits (H.V) and four (4) records reviewed (R.R), with the Nursing Supervisor (employee #1), during a survey process performed from 11/13/2024 through 11/14/2024, from 8:30 AM till 5:00 PM, it was determined that the facility failed ensure the registered nurse must complete the comprehensive assessment, for 2 out of 7 records reviewed (R.R. #1, #2). Findings include: 2. R.R #2 is a 62-year-old male admitted to the facility on 10/11/2024 with a diagnosis of Muscle Weakness, Physical Deconditioning, Diabetes Mellitus (DM), Cerebrovascular accident (CVA), High Blood Pressure (HBP), Acquired Immunodeficiency (HVI). During the record review on 11/13/2024 at 1:05PM it was found that patient was referred to Home Care for Registered Nurse (RN) Services, Home Health Aid Services (HHA), and Physical Therapy Services on 10/09/2024. The Initial Outcome and Assessment Information Set Version (OASIS) Start of Care was on 10/11/2024, the Date assessment completed (M0090) was on 10/12/2024, however the following item were left in blank the OASIS was not completed in 5 days: a. Current Payment Source for Home Care (M0150). b. Most recent immunization such as Tetanus, Tuberculosis (Tb), Hepatitis B was not assessed. c. Health status Home Bound. d. Prognosis. e. Brief Interview for Mental Status (BIMS), Repetition of three words (C0200), Temporal Orientation, Able to report correct years, month and date (C0300), Recallable to recall sock, blue, bed (C0400). f. Sign and symptom of Delirium part c) disorganized thinking and d) altered level of consciousness (C1310). g. Grooming (M1800). h. Ability to Dress (M1810, M1820). i. ability to Wash (M1830). j. Toilet transfer (M1840). j. Toilet hygiene (M1845). k. Transferring (M1850). l. Ambulatory (M1860). m. Self Care (GG0110. n. Mobility (GG0170). o. Treat for UTI(M1600). p. Urinary Incontinence (M1610). q. Ostomy (M1630) r. Primary diagnosis & Other diagnosis (M1021 &M1023). s. Risk for Hospitalization (M1033). t. Pain interference with therapy (J0520). u. Pain interference with day-to-day activities (J0530). v. When patient dyspneic (M1400). w. Nutritional Approaches (K0520). x. Height and weight (M1060) y. Feeding or Eating (M1870). z. Pressure ulcer (M1306), M1322), M1324, M1330, M1340. aa. High Drug Classes (N0415). bb. Drug Regimen Review ( M2001, M2003, M2010, M2020, M2030). cc. Medication Administration Record. dd. Special Treatment, Procedure, Program (O0110). ee. Therapy Need (M2200). ff. Skilled Intervention. gg. Registered Nurse Signature. According to registered Nurse patient communication notes the patient was oriented and communicative, total ADL dependent, bed confinement, urinary Foley dependent, with pressure area in the Sacro. The patient needs HHA 3 visits per week per 9 weeks. Frequency of nursing services 2 visits per week for 9 weeks. No evidence was found that the nurse asses the urinary system and pressure ulcer in the initial OASIS. On 11/04/2024 the patient was transferred to the hospital, then was admitted to Hospice care, however, the OASIS for the transfer was not documented. During the interview with the supervisor (employee #1) on 11/13/2024 at 1:30 PM she states that the nurse that performed this admission resign, she took with them to complete the OASIS and yesterday send a message as reminder to complete the OASIS. Finding Include: R.R #1 was reviewed with Nursing Supervisor (employee #1) on 11/13/2024 at 1:05 PM. This is a 81-year-old female patient was admitted on 10/11/2024 with a diagnosis of Osteoarthritis, mobility problem, High Blood Pressure (HBP), Diabetes Mellitus (DM), Sacral Ulcer stage III. Recertification period of services for this case begin 10/11/2024 through 12/09/2024, with in Oasis plan of care: RN services (RN) treatment with intravenous antibiotic therapy for 12 days, then 2 visits per week, Hospice Aid (HHA) 3 visits per week and Physical Therapy (PT) 2 visits per week, it was found the following: (a) The registered nurse (RN), did not document on the OASIS-E Start of Care the following parts: Most Recent Immunizations, Sensory Status, Mental Status part Behavioral, Psychosocial, Must Brief Interview for Mental Status (C0100), Three Word Repetition (C0200), Temporal Orientation (C0300), Recall (C0400), Genito Urinary (GU), (patient with urinary catheter however no document), Digestive System, Endocrine System, Blood Sugar (dxt), Pressure Ulcer/Injury Risk, Braden Scale score, Integumentary System (sacral ulcer and right hip injury diagram, Current number of unhealed pressure ulcers/injuries at each stage (M1311 part B1 stage 3), Current number of stages (M1322), Does this patient have a surgical wound (M1340), Status of problematic surgical wound that is observable (M1342), High risk drug classes: Use and indication (N0415 part 2), Medication follow-up (M2003), Medication administration record, Special treatments, procedures and programs (00110) part (H1 IV medication), and Need for therapy (M2200).”

“Improvements are sustained CFR(s): 484.65(c)(3) The HHA must take actions aimed at performance improvement, and, after implementing those actions, the HHA must measure its success and track performance to ensure that improvements are sustained. This Element is not met as evidenced by: Based on review of Quality Assessment Performance Improvement (QAPI) program information, it was determined that the facility failed to have a mechanism in place to ensure that actions aimed at performance improvement, are implemented and that those actions, are measured its success to ensure that improvements are sustained. Findings include: 1. During the review of QAPI program information on 11/14/2024 at 9:15 AM, the following were identified: a. It was found that the last documented evidence of the procedure used to ensure that actions aimed at performance improvement, are implemented and that those actions, are measured for success to ensure that improvements are sustained was in 08/2022.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on three (3) Home Visits (H.V) and four (4) Records Reviewed (R.R) and interview with facility Nursing Supervisor (employee #1), it was determined that the facility failed to ensure that the Skilled professionals must assume responsibility for, but not to be restricted to preparing clinical notes for 1 out of 7 records reviewed (R.R. #1). Findings include: R.R #1 was reviewed with Nursing Supervisor (employee #1) on 11/13/2024 at 1:05 PM. This is a 81-year-old female patient was admitted on 10/11/2024 with a diagnosis of Osteoarthritis, mobility problem, High Blood Pressure (HBP), Diabetes Mellitus (DM), Sacral Ulcer stage III. Recertification period of services for this case begin 10/11/2024 through 12/09/2024, with in Oasis plan of care: RN services (RN) treatment with intravenous antibiotic therapy for 12 days, then 2 visits per week, Hospice Aid (HHA) 3 visits per week and Physical Therapy (PT) 2 visits per week, it was found the following: a) The nurse performs visits on 10/31/2024, on 11/04/2024, on 11/08/2024 and 11/11/2024, however no evidence was found related to the visits notes. b) It was observed that the notes of the registered nurse on 10/12/2024, on 10/13/2024, on 10/14/2024, on 10/15/2024, on 10/16/2024, on 10/17/2024, on 10/18/2024, on 10/19/2024, on 10/20/2024, on 10/21/2024, on 10/22/2024, on 10/23/2024, on 10/25/2024 and 10/28/2024 are incomplete. c) During review of the records, it was noted that the physical therapy (PT) staff visit note, from 10/21/2024 documents that the patient has pain, however, in the pain assessment section, it does not estimate pain based on the numerical scale. d) During review of the records on 10/25/2024, on 10/28/2024, on 10/28/2024, on 11/01/2024, on 11/04/2024, on 11/04/2024, on 11/04/2024, on 11/07/2024, on 11/11/2024 and 11/13/2024 it was noted that the physical therapy (PT) staff does not estimate pain in the pain assessment section.”

“Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This Element is not met as evidenced by: Based on review of organization and administration services, it was determined that the facility failed to appoint a qualified pre-designated person, authorized in writing by the administrator and the governing body, to assume the same responsibilities and obligations as the administrator, when the administrator is not available. Findings include: 1. During review of organization and administration services policies and procedures on 11/14/2024 at 10:19 AM, the following was identified: a. The facility did not have to appoint an individual who is responsible for fulfilling the role of the administrator in his/her absence. b. Governing body did not approve and established in advance a pre-designated individual who is responsible for fulfilling the role of the administrator in his/her absence. During interview with governing body president employee #6, on 11/14/2024 at 2:00 PM state that in case that the administrator employee #7 or he was outside of the facility, all personnel contact them by cell phone.”

“In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This Element is not met as evidenced by: Based on review of the infection prevention and control program activities, and interview with the Administrator (employee #1), it was determined that the facility failed to ensure that skill professional services follow accepted standards of practice to prevent the transmission of infections and communicable diseases for 1 out of 3 home visits (H.V #2). Findings include: 1. During the H.V #2 performed on 11/13/2024 from 11:23 AM till 12:20 PM, for bath care with home health aide (License Practice Nurse (LPN) employee #3, it was found the following: a. Employee #3, place the PPE outside the patient’s residence, without patient having history or was screening for Covid 19 infection. b. Employee #3 did not disinfect the non- critical equipment after using it with patients and returned it to the briefcase. c. Employee #3, after washing her hand put on the non-sterile glove then close the faucet and continue with patient bath without changing her glove. d. Employee#3 after finishing with the patient perform hand wash with hand sanitizer, not with soap and water.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on three (3) Home Visits (H.V) and four (4) Records Reviewed (R.R) and interview with facility Nursing Supervisor (employee #1),performed from 11/13/2024 through 11/14/2024, from 8:30 AM till 5:00 PM, it was determined that the facility failed to have the patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes and plan of care for 2 out of 7 records reviewed (R.R. #1, #2). Findings include: 2. R.R #2 is a 62-year-old male admitted to the facility on 10/11/2024 with a diagnosis of Muscle Weakness, Physical Deconditioning, Diabetes Mellitus (DM), Cerebrovascular accident (CVA), High Blood Pressure (HBP), Acquired Immunodeficiency (HVI). During the record review on 11/13/2024 at 1:05 PM it was found that patients were referred to Home Care for Registered Nurse (RN) Services, Home Health Aid Services (HHA), and Physical Therapy Services on 10/09/2024. The Initial Outcome and Assessment Information Set Version (OASIS) Start of Care was on 10/11/2024, the Date assessment completed (M0090) was on 10/12/2024, however the OASIS was incomplete and not completed in 5 days and failed to ensure that medical record documentation includes accurate information related to patient assessment During the interview with the supervisor employee #1 on 11/13/2024 at 1:30 PM she states that the nurse that performed this admission resign, she took with them to complete the OASIS and yesterday send a message as reminder to complete the OASIS. Finding Include: R.R #1 was reviewed with Nursing Supervisor (employee #1) on 11/13/2024 at 1:05 PM. This is a 81-year-old female patient was admitted on 10/11/2024 with a diagnosis of Osteoarthritis, mobility problem, High Blood Pressure (HBP), Diabetes Mellitus (DM), Sacral Ulcer stage III. Recertification period of services for this case began 10/11/2024 through 12/09/2024, with in Oasis plan of care: RN services (RN) treatment with intravenous antibiotic therapy for 12 days, then 2 visits per week, Hospice Aid (HHA) 3 visits per week and Physical Therapy (PT) 2 visits per week, it was found the following: (a) The Registered Nurse (RN), perform the OASIS-E start of care on 10/11/2024 refers Date Assessment Complete (M0090) was completed on 09/11/2024. (b) The registered nurse (RN), did not document on the OASIS-E Start of Care the following parts: Most Recent Immunizations, Sensory Status, Mental Status part Behavioral, Psychosocial, Must Brief Interview for Mental Status (C0100), Three Word Repetition (C0200), Temporal Orientation (C0300), Recall (C0400), Genito Urinary (GU), (patient with urinary catheter however no document), Digestive System, Endocrine System, Blood Sugar (dxt), Pressure Ulcer/Injury Risk, Braden Scale score, Integumentary System (sacral ulcer and right hip injury diagram), Current number of unhealed pressure ulcers/injuries at each stage (M1311 part B1 stage 3), Current number of stages (M1322), Does this patient have a surgical wound (M1340), Status of problematic surgical wound that is observable (M1342), High risk drug classes: Use and indication (N0415 part 2), Medication follow-up (M2003), Medication administration record, Special treatments, procedures and programs (00110) part (H1 IV medication), and Need for therapy (M2200). (c) During the review of the home care plan of this case, it was identified that it does not have a care plan. d) The nurse performed week visits the periods (11/10/2024 through 11/11/2024), however no evidence was found related to the patient’s glucose level (Dxt) during the visit. e) The nurse performed week visits the periods (11/10/2024 through 11/11/2024), however no evidence was found related to the estimate of stage III sacral ulcer and ulcer measurements. f) The nurse performs visits on 10/31/2024, on 11/04/2024, on 11/08/2024 and 11/11/2024, however no evidence was found related to the visits notes. g) It was observed that the notes of the registered nurse on 10/12/2024, on 10/13/2024, on 10/14/2024, on 10/15/2024, on 10/16/2024, on 10/17/2024, on 10/18/2024, on 10/19/2024, on 10/20/2024, on 10/21/2024, on 10/22/2024, on 10/23/2024, on 10/25/2024 and 10/28/2024 are incomplete. h) During review of the records, it was noted that the physical therapy (PT) staff visit note, from 10/21/2024 document that the patient has pain, however, in the pain assessment section, it does not estimate pain based on the numerical scale. i) During review of the records on 10/25/2024, on 10/28/2024, on 10/28/2024, on 11/01/2024, on 11/04/2024, on 11/04/2024, on 11/04/2024, on 11/07/2024, on 11/11/2024 and 11/13/2024 it was noted that the physical therapy (PT) staff does not estimate pain in the pain assessment section.”