County Home Health

“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 record review and interview the agency failed to electronically transmit each completed OASIS (a comprehensive assessment tool used by CMS to collect certain patient information) to the CMS system within 30 days of completing the assessments for 6 of 6 assessments transmitted from 07/22/2022 to 07/24/2024. Failure of the agency to transmit OASIS data within the required time frame prevented the agency’s patient data from being made available to CMS for analysis to evaluate the agency performance levels in the provision of patient care. The surveyor reviewed the OASIS Error Detail Report for the agency in the IQIES portal on 07/23/2024, as part of the preparation for the survey. The report documented 6 late assessments transmitted from 09/16/2022 to 05/09/2024 were submitted more than 30 days after the M0090 (the date of completion of the assessment.) During the entrance conference on 07/23/24, the surveyor noted the late submissions found during survey preparation and asked for OASIS final validation reports for the last two years. The surveyor reviewed the OASIS Agency Final Validation reports provided by the Office Manager on 07/26/2024. The records revealed 6 oasis validation reports with the error message “Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” An interview was conducted with Alternate Administrator on 07/23/24 at 11:00 AM. The surveyor reviewed the late transmissions of OASIS assessments with the Alternate Administrator. The surveyor asked who was responsible for transmitting the assessments. The Alternate Administrator stated he did the transmissions, and he transmitted every two weeks. The Alternate Administrator stated they had delays in completing and reviewing the documentation by the clinicians that caused the delays. Additional information regarding the delays in transmission were not provided by the end of the survey. Agency policy titled: “IM.10 Timeliness revised date: 112910” read in part: POLICY -Agency will ensure timely provision of care and services to meet the patient’s needs in compliance with all federal and state laws and regulations. PROCEDURE - A. All Agency staff, and physician/physician office staff as appropriate, will be oriented to the following parameters: 1. Evaluation visit for admission to Agency is within 48 hours of referral, discharge from hospital or on physician specific start of care order date. 2. Admission paperwork is completed within 2 days of admission to Agency. 3.Plan of care is established within 3-5 days of admission to Agency. 4. A Registered Nurse will complete the Initial Comprehensive Assessment no later than five (5) calendar days after the start of care (SOC) date for all patients in a licensed and certified agency… Encoding and submission of OASIS data to the state at least monthly and prior to billing…. “”

“Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient’s condition warrants due to a major decline or improvement in the patient’s health status, but not less frequently than- This Standard is not met as evidenced by: Based on observation, record review and interview the agency failed to ensure an update of the comprehensive assessment for 1(Patient 2) of 2 active patients after Patient 2 fell, fractured her wrist, and required surgery to repair the fracture. The agency subjected the patient to poor quality care and potential harm when the care was not revised based on the worsening patient’s condition. The patient did not obtain assistance with bathing after her fracture left her unable to use to walker. Review of Patient 2’s clinical record revealed a Comprehensive assessment completed 05/21/2024 at the start of care, and a recertification comprehensive assessment completed on 07/15/2024 and signed by the DON. A review of the entire record revealed no update to the comprehensive assessment or plan of care between 05/21/2024 and 07/15/2024. The comprehensive assessment dated 07/15/2024 did not include any information about the fractured arm. Review of Patient 2’s therapy note by PTA A documented a missed visit on 07/06/2024 due to the patient falling and breaking her left wrist. Review of Patient 2’s nurses note dated 07/11/2024 by LVN B documented the nurse conferenced with the DON regarding the client’s recent fall. Review of Patient 2’s nurses note dated 07/17/2024 by LVN B documented the nurse conferenced with the DON regarding the patient’s request for home health aide services. An interview was conducted with the DON on 07/23/2024 at 2 PM. The surveyor asked who was responsible for the update to the comprehensive assessment when the patient’s condition changed. The DON stated the RN was responsible to do the assessments and completed the Plan of Care, and the DON reviewed them. The surveyor asked why this didn’t happen. The DON stated they didn’t know about the change in condition. The surveyor made a home visit on 07/23/2024 at 3:20 PM to the residence of Patient 2. The surveyor observed Patient 2 had with a splint on her left wrist. The surveyor asked Patient 2 about her wrist. Patient 2 stated she had fallen and fractured her wrist on 07/03/24 and had surgery on it. Patient 2 stated she was unable to use her walker as the left arm was non-weight bearing at this time. Patient 2 opened the splint and showed the surveyor the incision on her left wrist. Patient 2 changed the soiled gauze dressing over the incision during the visit. Patient 2 stated she had been asking for help with bathing because she couldn’t use her left hand. Patient 2 stated she was afraid to get into the shower without assistance and Patient 2 stated her nurse had called the office two times during different weekly visits to ask for the additional help. The surveyor asked who came to see the patient after her surgery. Patient 2 stated her nurse LNV B. The surveyor asked if another nurse had come to see Patient 2 after her surgery on 07/14/24. Patient 2 stated she had a therapist come and the therapy boss, but no other nurse. The surveyor reviewed the log of visits with vital signs in the home folder. The only entries for nursing for July were for LVN B. In an interview with the DON, Administrator, and the Office Manager on 07/26/24 at 11:30 AM, the surveyor shared the findings from the record reviews and home visits. The surveyor asked why Patient 2 did not have an update to the comprehensive assessment after 07/03/24 fall. The DON stated: “I didn’t know” about the fall, fracture and surgery. The surveyor asked about the Comprehensive assessment documented on 07/15/2024 and signed by the DON. The DON stated: “I don’t remember this one.” The surveyor asked if the DON went to the patient’s home and completed the assessment dated 07/15/2024. The DON stated: “No I didn’t see her. I reviewed the assessment after talking with [LVN B].” The surveyor asked the Administrator to explain why the failure occurred. The Administrator did not respond to the question. The surveyor asked about the patient requests for help with bathing. The Office Manager stated the patient wanted home health aide services three times per week and insurance coverage was the problem. The surveyor asked why the agency did not request an OT evaluation after the patient injury and request for assistance with bathing. The DON shrugged and did not respond. The Office Manager stated she did not know, and they would take care of it. Agency policy titled “Patient Reassessment/Recertification/Post Hospital Assessment” dated 04/26/2011 read in part: “…Reassessment for Change in Clinical or Functional Status – 1. A RN/Therapist must perform the Follow-Up Comprehensive Assessment for a major decline or improvement in the patient’s clinical or functional status if the change is not considered an expected change or outcome in the Plan of Care. 2. A significant change in the clinical status (examples) – an exacerbation in the patient condition that would not have been expected with current diagnosis; - development or increase in the number of pressure ulcers; or – a deterioration or infection of wound. 3. A significant change in the functional status (examples) – significant decline in functional status due to a falls (sic) resulting from increasing weakness with addition of therapy to the plan of care when not expected in the original Plan or Care; or patient is initially independent and becomes either partially or completely dependent 4. The reassessment will be reported to the supervising nurse and patient’s physician as soon as possible but no later than 8 hours. Orders obtained from physician as necessary…””

“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 record review and interview the agency failed to conduct performance improvement projects for 3 (July – December 2021, 2022, 2023, and through July 26/2024.) of 3 years of the survey review period. This failure limited the agency’s ability to improve care and services to agency patients and subjected patients to substandard care due to the agency’s inability to trend patterns and to implement improved services. During the entrance conference on 07/23/2024 at 11 AM the surveyor requested the agency QAPI documents for the last 3 years. A review of the QAPI documents provided by the agency on 07/26/24 revealed no Performance Improvement projects had been documented for July - December 2021, 2022, 2023, and through July 2024. No complaints were documented in the complaint log, no incidents in the incident book, no evidence of record reviews of active and discharged records, no QAPI reports, no ongoing, focused program to measure client outcomes, and no written plan of implementation. In an interview with the DON, Administrator, and the Office Manager on 07.26.24 at 11:30 AM the surveyor asked why there was no QAPI program information or committee meeting provided to the surveyor as requested. The Administrator stated: There were only 2 patients. The Office Manager asked what the surveyor was looking for. At 12:30PM the Office Manager brought the surveyor the following documents: 1. “Annual PACK meeting report County Home Health” The document read in part “The administrator discussed the operations of 2020 and explained the changes from previous year.” The document discussed the changes from 2020 and the effects on the agency from COVID 19. 2. “01/15/2023 Professional Advisory Committee Meeting – The board of directors have held a meeting on Jan 10th, 2021 to discuss the various matter…” 3. “01/15/2022 Professional Advisory Committee Meeting – The board of directors have held a meeting on Jan 10th, 2021 to discuss the various matter…” Documents 2. And 3. Were identical except for the date listed as 01/15/2023 on Document 2. and 01/15/2022. Neither document contained evidence of an ongoing QAPI program. 4. “01/15/2022 Professional Advisory Committee Meeting – 01/01/2021 thru 12/31/2021 -The board of directors have held a meeting on Jan 10th, 2021 to discuss the various matter…” The rest of document 4 was identical to Document 2 and 3. None of the documents contained evidence of an ongoing QAPI program. 5. Document 5 listed the agency’s name and address and phone number, date 01/16/2023 and read in part “The Administrative Committee have conducted a meeting and Attended a Webinar and discussed on the matters to improve our Quality Care and Learning New Changes… Get ready for Joint Commission survey…” 6. Document 6 listed another agency’s name, and the same address and phone number. Document 6 was identical to Document 5. In an interview with the DON, Administrator, and the Office Manager on 07.26.24 at 1:00 PM the surveyor asked about documents 1-4 containing dates and information regarding January 2020. There was no response from the DON. Administrator and the Office Manager. The surveyor asked if the agency was getting ready for Joint Commission survey. The Administrator stated that was for another home health agency. The surveyor asked who was responsible for the QAPI program and the Performance Improvement Projects. The Administrator stated he was and “the agency had only 2 patients.” The agency did not provide additional documents or evidence of a Performance Improvement Projects by the end of the survey. Review of the agency policy titled: “QAPI. 1 Quality Assessment Performance Improvement Plan Revised date: 032710” read in part: PURPOSE - To develop a Quality Assessment Performance Improvement Plan (QAPI), developed by leaders and implemented by the QAPI/Utilization Review (UR) committee, which captures significant outcomes essential to safe and quality care. POLICY - Agency leaders will develop a plan that sets priorities for data collection and is reviewed and updated or revised at least once within the calendar year, or more often if needed, by the QAPI/UR Committee. Agency will strive to improve operational and patient health outcomes by implementing a performance improvement plan that incorporates the following essential processes: • Designing processes; • Monitoring performance through data collection; • Analyzing current performance; and • Improving and sustaining improved performance over time. Agency will focus primarily on its processes and/or system performances rather than an individual’s performance yet will recognize the importance of the competence of its staff. Performance improvement priorities identified by leaders will be identified through the collection of data for analysis of Agency services with a system that measures significant outcomes. Review of the agency policy titled: “QAPI.5 Performance Improvement Process: Improved Performance revised date 050407” read in part: “… Policy Agency leaders/QAPI committee will be responsible for setting the priorities for improvement activities based on Agency functions, the defined measurement factors, the resources required to facilitate the improvement …” Review of the agency policy and procedures manual found no specific policy addressing the requirements for Performance improvement projects.”

“Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This Element is not met as evidenced by: Based on observation, record review, and interview the agency failed to document both the existence of the complaint and the resolution of the complaint for 2 (Patient 2 and 3) of 7 patient records reviewed. Patients’ complaints about services were not addressed and resolved which violated the patient’s rights. This placed the patients at risk of further abuse, neglect or exploitation. Review of the complaint logs provided by the agency on 07/23/2024 revealed no complaints were documented for 2022, 2023, and 2024. The surveyor made a home visit on 07/23/2024 at 3:20 PM to the residence of Patient 2. The surveyor observed Patient 2 had with a splint on her left wrist. The surveyor asked Patient 2 about her wrist. Patient 2 stated she had fallen and fractured her wrist on 07/03/24 and had surgery on it. Patient 2 stated she was unable to use her walker as the left arm was non-weight bearing at this time. Patient 2 opened the splint and showed the surveyor the incision on her left wrist. Patient 2 changed the soiled gauze dressing over the incision during the visit. Patient 2 stated she has been asking for help with bathing because she can’t use her left hand. Patient 2 stated she was afraid to get into the shower without assistance and Patient 2 stated her nurse had called the office two times during different weekly visits to ask for the additional help. The surveyor asked if the patient had ever made a complaint to the agency. Patient 2 stated they had called the office and complained twice about not getting the Home Health Aide services requested, first in June 2024 and again in July 2024 and they had not resolved her issues. Patient 2 stated it was no use calling the office since they didn’t resolve the concerns, so Patient 2 next told the nurse who sees her weekly. The Patient stated the nurse called the office two weeks in a row in July 2024 while in Patient 2’s home to relay the Patient’s complaints and request for assistance. Review of Patient 2’s plan of care for the certification 05/21/2024 to 07/19/2024 revealed Chronic Obstructive Pulmonary Disease (a group of lung diseases that block airflow and make it difficult to breathe), Abnormalities of gait and mobility (deviations from normal walking and movement which can affect balance). Review of Patient 2’s clinical record revealed a Comprehensive assessment completed on 07/15/2024 and signed by the DON. A review of the comprehensive assessment failed to find any information about the client’s complaints to the agency regarding the need for more assistance since July 3,2024 when Patient 2 fractured her arm. Review of Patient 2’s therapy note by PTA A documented a missed visit on 07/06/2024 due to the patient falling and breaking her left wrist. Review of Patient 2’s nurses note dated 07/11/2024 by LVN B documented the nurse conferenced with the DON regarding the client’s recent fall. Review of Patient 2’s nurses note dated 07/17/2024 by LVN B documented the nurse conferenced with the DON regarding the patient’s request for home health aide services. An interview was conducted with the DON, Administrator, and the Office Manager on 07.26.24 at 11:30 AM. The surveyor shared the findings from the record reviews and home visits. The surveyor asked why Patient 2 did not have an update to the comprehensive assessment after July 3 fall. The Supervising Nurse stated: “I didn’t know” about the fall, fracture, and surgery. The surveyor asked about the Comprehensive assessment documented on 07/15/2024 and signed by the DON. The DON stated: “I don’t remember this one.” The surveyor asked if the DON went to the patient’s home and completed the assessment dated 07/15/2024. The Supervising Nurse stated: “No I didn’t see her. I reviewed the assessment after talking with LVN B.” The surveyor asked about the client’s requests for help with bathing and complaints about not being provided the home health aide services needed. The Office Manager stated the client wanted home health aide services three times per week and insurance coverage was the problem. The surveyor asked why an OT evaluation was not requested after the client’s injury and request for assistance with bathing. The Supervising Nurse shrugged and did not respond. The Office Manager stated she did not know, and they would take care of it. The surveyor asked who was responsible for documenting complaints. The Office Manager stated she was. The Administrator stated he did not have anything else to add to explain or correct the findings. Review of discharged Patient 3’s record revealed a start of care of 10/27/2022 for Ovarian Cancer (a cancer of the female organs that produce eggs [ovaries]), Adult Failure to thrive (a syndrome of wight loss, decreased appetite, inactivity, often with dehydration, depressive symptoms, and impaired immune response), and Anemia (when the blood doesn’t have enough healthy red blood cells that carry oxygen throughout the body.) that was completed by PT A. The Plan of Care contained orders for a home health aide three times per week for 8 weeks. A review of the entire record found no home health aide services were provided. The record documented the patient complained about the lack of services on 11/07/2022 and requested a discharge of services because the agency didn’t provide the home health aide services. The surveyor requested and reviewed the Complaint log for October 2022 on July 5, 2023. There were no complaints documented on the complaint log for October 2022. An interview was conducted with the DON, Administrator, and the Office Manager on 07.26.24 at 11:30 AM. The surveyor shared the findings from the record reviews and home visits. The surveyor asked about the complaint by Patient #3. The Office manager stated: ‘We couldn’t provide services and we have had an issue with understanding the program. If it was a complaint due to discharge, I didn’t think of it as a complaint.” No additional information, response, or comment was provided by the DON or the Administrator to explain or correct the findings. Agency policy titled: “RI.6 RESOLUTION OF PATIENT CONFLICTS, GRIEVANCES OR COMPLAINTS Revised date: 091011” read in part: PURPOSE - To establish a procedure and ensure the patient’s/caregiver’s and or guardian’s right to voice conflicts, file a complaint, and provide and to make recommendations for resolutions of conflicts without fear of retaliation, coercion, discrimination, reprisal or unreasonable interruption of care. POLICY Agency will receive, document, address and resolve conflicts that involve complaints made by a patient, a patient’s family or guardian, or a patient’s health care provider. Agency will provide a written statement that informs the patient/caregiver of the complaint procedure at time of admission. Agency will not retaliate against a person for filing a complaint, presenting a grievance, or providing, in good faith, information relating to services provided by Agency…Procedure A. Agency will investigate complaints made by a patient, a patient’s family or guardian, or a patient’s health care provider regarding: 1. Treatment or care that was furnished by Agency 2. Treatment or care that Agency failed to furnish 3. Lack of respect for the patient’s property by anyone furnishing services on behalf of the Agency…E. Agency will complete the investigation and document all components of the investigation within 30 days after the receipt of the complaint, unless Agency has and documents reasonable cause for the delay. F. Agency will involve the patient/caregiver and/or the patient’s physician as appropriate to reach a resolution. G. Agency will consider all patient/caregiver recommendations to reach a resolution… All actions taken and follow-up performed will be documented on the complaint form, as well as reported to the management staff. J. Resolution/outcome information is communicated to the complainant… I. All actions taken and follow-up performed will be documented on the complaint form, as well as reported to the management staff J. Resolution/outcome information is communicated to the complainant.”

“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 observation, record review and interview the plan of care for the 2 (Patient 1 and 2) of 2 active patients of the agency, the plans of care failed to include 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. The agency subjected patients to potential harm and poor-quality care. Review of Patient 1’s plan of care for the certification 06/14/24 to 08/12/24 revealed diagnoses of Type 2 Diabetes Mellitus (A condition in which the body has trouble controlling blood sugar and using it for energy), Chronic Obstructive Pulmonary Disease (a group of lung diseases that block airflow and make it difficult to breathe), Generalized Anxiety Disorder (worrying constantly and can’t control it), Hypertension (high blood pressure without an identifiable cause). Review of the entire plan of care revealed no description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. In an interview with LVN A on 07/23/2024 at 1:30PM, LVN A stated she saw Patient 1 weekly on Thursdays or Fridays. LVN A stated she was working on blood sugar management with Patient 1 as her blood sugars had been high and Patient 1 didn’t have a glucometer to check her blood sugars. LVN A stated she was trying to help the patient find transportation for appointments, and Patient 1 needed to find another room to rent and would run out of minutes on her cell phone toward the end of each month. LVN A stated she had helped Patient 1 with refills of her medications and getting a glucometer. LVN A stated she was at risk of hospitalization if she didn’t control her blood sugar, and she had not had a recent hospitalization or emergency room visit that the nurse was aware of. The surveyor made a home visit on 07/23/2024 at 4:10 PM to the residence of Patient 1. The surveyor asked Patient 1 about her concerns about her health. Patient 1 stated she needed help with transportation to appointments, finding a new room to rent, and help reconnecting her cell phone. Patient 1 stated she had not been to the hospital or emergency room lately. Patient 1 stated LVN A visited her weekly and checked on her and took her blood sugar. Review of Patient 2’s plan of care for the certification 05/21/2024 to 07/19/2024 revealed Chronic Obstructive Pulmonary Disease (a group of lung diseases that block airflow and make it difficult to breathe), Abnormalities of gait and mobility (deviations from normal walking and movement which can affect balance). Review of the entire plan of care revealed no description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. In an interview with the DON on 07/23/2024 at 2 PM the surveyor asked who was responsible for development of the plans of care. The DON stated the RN who did the assessments completed the Plan of Care and the DON reviewed them. The DON stated she did not check for a statement of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors because she didn’t know to. The surveyor made a home visit on 07/23/2024 at 3:20 PM to the residence of Patient 2. The surveyor observed Patient 2 had with a splint on her left wrist. The surveyor asked Patient 2 about her wrist. Patient 2 stated she had fallen and fractured her wrist on July 3 and had surgery on it. Patient 2 stated she was unable to use her walker as the left arm was non-weight bearing at this time. Patient 2 opened the splint and showed the surveyor the incision on her left wrist. Patient 2 changed the soiled gauze covering over the incision during the visit. Patient 2 stated she had been asking for help with bathing because she couldn’t use her left hand. Patient 2 stated she was afraid to get into the shower without assistance and her nurse had called the office two times during her weekly visits to ask for the additional help. In an interview with the DON, Administrator, and the Office Manager on 07.26.24 at 11:30 AM the surveyor shared the findings from the record reviews and home visits. The surveyor asked why the plans of care did not contain the required description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. The DON stated they didn’t know they needed this. The Office Manager stated they didn’t know where this information would go in the electronic medical record. The surveyor asked the Administrator if they had anything else to add to explain why the failure occurred. The Administrator stated they didn’t know they needed to do this and would correct it. Agency policy titled: Plan of Care TX.6 dated 04/04/2011 read in part: Purpose-To develop an individualized Plan of Care to ensure patient specific needs are net appropriately according to state and federal regulations…. Review of the agency policy found the policy failed to include the federal regulatory requirement for the Plan of care to include 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.”

“Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on record review and interview, the agency failed to provide each patient a visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA for 2 (Patient 1 and 2) of 2 active patients who received home visits from the surveyor. This failure placed the patients at risk of missed visits due to conflicts in scheduling other medical appointments. Review of the sample patient admission folder provided by the Office Manager on 07/23/2024 at 4 PM revealed no blank schedule forms in the packet. Review of Patient 2’s plan of care for the certification 05/21/2024 to 07/19/2024 revealed Chronic Obstructive Pulmonary Disease (a group of lung diseases that block airflow and make it difficult to breathe), Abnormalities of gait and mobility (deviations from normal walking and movement which can affect balance). The surveyor made a home visit on 07/23/2024 at 3:20 PM to the residence of Patient 2. The surveyor reviewed the home folder provided by the agency and found no written schedule of services by the HHA staff. The surveyor asked Patient 2 who came to see her from the agency. Patient 2 stated LVN B and PTA A came to see her. The surveyor asked if the patient had a schedule of the frequency and disciplines coming to see her. Patient 2 stated she did not have a schedule and she would like to have a schedule so she could coordinate her and her husbands’ doctor appointments around the visits. The surveyor asked when LVN B and PTA A came to see her. The patient stated different days each week and stated they would call and say they were on the way. Review of Patient 1’s plan of care for the certification 06/14/24 to 08/12/24 revealed diagnoses of Type 2 Diabetes Mellitus (A condition in which the body has trouble controlling blood sugar and using it for energy), Chronic Obstructive Pulmonary Disease (a group of lung diseases that block airflow and make it difficult to breathe), Generalized Anxiety Disorder (worrying constantly and can’t control it), Hypertension (high blood pressure without an identifiable cause). The surveyor made a home visit on 07/23/2024 at 4:10 PM to the residence of Patient 1. The surveyor reviewed the home folder provided by the agency and found no written schedule of services by the HHA staff. The surveyor asked Patient 1 who came to see her from the agency. Patient 1 stated LVN A came to see her. The surveyor asked if the patient had a schedule of the services with the frequency and disciplines coming to see her. Patient 2 stated she did not have a schedule and she could not call the nurse because her phone was out of minutes. The surveyor asked when LVN A came to see her. Patient 1 stated she came most weeks on different days. An interview was conducted with the DON, Administrator, and the Office Manager on 07/26/24 at 11:30 AM. The surveyor shared the findings from the review of the sample home admission packet and the ones found in Patient 1 and 2’s homes. The surveyor asked whose responsibility it was to provide the schedule of services to the patients. The DON stated it was the nurses and therapists seeing the patients. The surveyor asked why there wasn’t a schedule in the sample packet. The Office Manager said she would take care of it. The surveyor asked the Administrator why this requirement was not met. The Administrator stated they were not aware of it and would correct it. Review of the agency’s policy and procedures manual failed to find a policy with the requirements for a written schedule of service for the patients.”