Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 757287	(X3) Date Survey Completed 11/03/2025
Name of Provider or Supplier Summa Home Health Care, Inc.	Street Address, City, State 2500 E Foothill Blvd Unit 417, Pasadena, CA
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.

(X4) ID Prefix Tag	Summary Statement of Deficiencies (Each deficiency should be preceded by full regulatory or LSC identifying information)
G0000	The following reflects the findings of the California Department of Public Health (CDPH) during a complaint validation survey conducted from 10/30/2025 to 11/3/2025, at 2500 East Foothill Blvd. Unit 417, Pasadena, CA 91107. Complaint Intake # 2591188 Total Unduplicated Census: 94 Census: 14 Sample Size: 7 Home Visits: 3 Deficiencies were issued related to complaint number 2591188. IJ G580  On 11/3/2025, at 11:40 a.m., while onsite at the agency, the department called an Immediate Jeopardy (IJ, a situation in which the provider’s noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident), in the presence of the Director of Patient Care Services (DPCS) and the Administrator Designee (ADMD), related to the Home Health Agency's (HHA, medically focused care provided by skilled professionals like nurses and therapists in a patient home) failure to ensure that Registered Nurse (RN 1) administered Ertapenem (medication used to treat bacterial infections) 1 gram IV on 8/5/2025 as ordered by the physician from General Acute Care Hospital (GACH) to treat Patient 1’s intra-abdominal abscess due to lack of staffing. This failure put Patient 1 at increased risk to have infection and develop sepsis (a life-threatening condition that occurs when the body’s immune system overreacts to an infection that could lead to widespread inflammation and organ damage) that could lead to hospitalization and death. On 11/3/2025, the HHA was unable to submit an IJ removal Plan (IJRP, a plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation). On 11/3/2025 at 4 p.m., the Department completed the survey tasks and conducted an exit conference while onsite in the presence of the Director of Patient Care Services (DPCS) and the Administrator Designee (ADMD) with the IJ situation not removed.  On 11/12/2025, the HHA submitted an IJ removal plan which was reviewed and was accepted. The acceptable IJ removal plan included the following: Corrective Action Implemented / Immediate Jeopardy Removal Plan: 1. Patient 1 Status (Discharge): Patient 1 was discharged 08/11/2025 following hospitalization at the hospital and transferred to another home-health agency for post-discharge services. Patient 1 is no longer on Summa Home Health Care’s active census. 2. Leadership Oversight (11/7/2025) Completed Retraining Verification (11/8/2025): The Governing Body appointed a Registered Nurse Consultant / Compliance Officer to provide independent clinical oversight and verify staff competency in physician-order execution and reporting. The Administrator/DPCS continues in her role under mentoring and competency validation by the Compliance Officer. 3. Chart Audit (11/7/2025 – 11/10 2025): All 13 active patient records (Patients 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14) were audited to confirm that medication and treatment orders were implemented and documented accurately. No harm, injury, or adverse event was found in any record. Any documentation deficiencies were corrected and verified with ordering physicians. Audit logs and QA verification are maintained in the QA binder. 4. Policy Implementation (11/10 / 2025): Policy #2025-11B Clinical Documentation Review and QA Verification were updated to require: -All OASIS to be completed within 48 hours for all payers (Medicare, Medicaid, Medi-Cal, HMO, Private). -Medication administration within 1 hour before or after the ordered time. Documentation must occur in real time, and the physician must be notified of any variance. -Any missed or delayed visit must be rescheduled immediately completed within 24 hours—when current staff are unavailable or late. -Nurse must notify the patient and office of changes and record this communication in the Communication Log. -Weekly chart audits for all patients from 11/01/2025 to 1/30/2026 (90 days) to verify OASIS timeliness, medication administration, and communication compliance. Results are logged and trended in Quality Assurance Performance Improvement (QAPI) Documentation Accuracy and Timeliness Initiative (DATI). -After January 30, 2026, audits transition to monthly based on sustained performance. -Two RNs and three LVNs are now on staff; new hire RN #2 is available for coverage as needed. The agency also has a contract with a staffing agency to provide per-diem nurses for restaffing. 5. Administrator/DPCS Retraining (11/10 2025): The Administrator/DPCS completed one-on-one education with the RN Consultant on physician-order compliance and documentation protocols. Competency was confirmed by return demonstration and written acknowledgement of the deficiency. 6. Staff Education (11/10 2025): A facility-wide in-service led by the RN Consultant addressed: -Physician-order execution and documentation timeliness. -Missed-visit escalation and chain of command. -Implementation of Policy #2025-11A. All staff attended, signed attendance roster, and completed competency validation. 7. Monitoring and QAPI Integration: The RN Consultant will audit Verbal Communication and Missed Visit Logs weekly for 12 weeks then monthly, reporting findings to the Administrator and Governing Body through the Documentation Accuracy and Timeliness Initiative (DATI) QAPI project. 8. Admissions Control, Suspension of Payment for New Admissions (SPNA): Per CDPH/CMS directive (11/7/2025), Summa Home Health Care remains under SPNA and will not accept new patients until substantial compliance is verified. Verification and Outcome: All 13 active patients (Patients 2–14) were audited daily; no harm or recurrence identified. Medication administration times and real-time documentation verified compliant through daily audit logs. Completion Date: 11/10/2025 Responsible Persons: Administrator/DPCS \| RN Consultant – Compliance Officer \| CEO-Chair On 11/12/2025 at 3:10 p.m., the survey team verified the implementation of the IJ removal plan during an on-site visit and the IJ was removed in the presence of the Administrator (ADM)/DPCS. IJ G-1012 On 11/3/2025, at 11:450 a.m., while onsite at the agency, the Department called an IJ, in the presence of the Director of Patient Care Services (DPCS) and the Administrator Designee (ADMD), related to the HHA’s failure to maintain a clinical record containing past and current information of patient receiving home health services for one of seven sampled patient (Patient 1) by failing to: 1. Ensure Patient 1 GACH Discharge order to administer Ertapenem (medication used to treat bacterial infections) Intravenous (IV- a way of giving a drug or other substance through a needle or tube inserted to a vein) every 24 hours was included to Patient 1’s plan of care. 2. Ensure Patient 1 medication and treatment orders were included on Patient’s 1 plan of care. 3. Ensure License staff document all interventions, including medication administration, treatments and services and responses to the interventions for Patient 1. 4. Ensure license staff completed an initial evaluation using the Outcome and Assessment Information Set (OASIS)on 8/3/2025 for Patient 1. 5. Ensure Patient 1 had a plan of care developed to outline the specific plan for medical, rehabilitation, and supportive services a patient needs at home. 6. Ensure Patient 1 had nursing notes completed for nursing visit conducted on 8/3/2025 and 8/4/2025. 7. Ensure to complete Oasis discharge comprehensive assessment for Patient 1. These failures had a potential to result with miscommunication within the interdisciplinary team (a group of professionals from different fields who collaborate to address complex issues, such as patient care), medication error, inappropriate treatment and services that could cause patient suffering severe harm, hospitalization and death. On 11/3/2025, the HHA was unable to submit an IJ removal Plan (IJRP, a plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation). On 11/3/2025 at 4 pm, the Department completed the survey tasks and conducted an exit conference while onsite in the presence of the Director of Patient Care Services (DPCS) and the Administrator Designee (ADMD) with the IJ situation not removed.  On 11/12/2025, the HHA submitted an IJ removal plan which was reviewed and was accepted. The acceptable IJ removal plan included the following: Corrective Action Implemented / Immediate Jeopardy Removal Plan: 1. Patient 1 Status (Discharge): Patient 1 was discharged 08/11/2025 from Summa Home Health Care following hospitalization and was redirected to another home-health agency for continuing care. No further services are being provided to this patient by Summa Home Health Care. 2. Leadership Oversight (11/7 2025): A Registered Nurse Consultant/ Compliance Officer assumed responsibility for auditing clinical records and mentoring the Administrator/DPCS on documentation standards and QA procedures. 3. Comprehensive Record Audit (11/7 -11/10 2025): All 13 active patient records (Patients 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14) were audited to ensure required elements (OASIS, POC, orders, notes, discharge summaries) were complete and accurate. Any missing entries were corrected and verified with the ordering physician. No harm or injury was identified in any record. 4. Policy Implementation (11/10 2025): Policy #2025-11B- "Clinical Documentation Review and QA Verification" was implemented, requiring review of each record within 48 hours of completion for accuracy and completeness, with dual sign-off by clinician and QA reviewer. 5. Administrator/DPCS Retraining (11/10 2025): The Administrator/DPCS completed targeted training conducted by the RN Consultant on proper record maintenance, OASIS submission timeliness, and QA tracking. Competency was demonstrated by return demonstration and signed acknowledgement of the deficiency. 6. Staff Education (11/10 2025): A facility-wide in-service training was conducted by the RN Consultant covering documentation accuracy, timeliness, and CMS record standards under §484.60(b) and §484.110. All staff attended and completed competency validation and attendance sign-in. On 11/12/2025 at 3:10 p.m., the survey team verified the implementation of the IJ removal plan during an on-site visit and the IJ was removed in the presence of the Administrator ADM)/DPCS. The following Conditions of Participation (COP) were not met: §484.55 Comprehensive Assessment of patients §484.60 Care planning, coordination of services, quality of care §484.110 Clinical Records
G0510	Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to meet the Condition of Participation (refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) for Comprehensive Assessment of Patients as follows: a. The Home Health Agency (HHA) failed to ensure the comprehensive assessment (the required in-person clinical assessment of the patient's physical, functional, mental, psychosocial, and cognitive status to identify the needs of the patient and caregiver that will be addressed by the home health agency's services) was completed within 5 days from the start of care for one of 7 sampled patients (Patient 1). This deficient practice had the potential to result in the patient’s needs not being identified and assessed, leading to poor quality nursing care needed to maintain the patient’s quality of life and well-being. (Refer to G520). b. The HHA failed to assess the patients' continuing need for home care services for two of 7 sampled patients (Patient 2, and Patient 3). This deficient practice resulted in the continued skilled nurse services to these patients lacking the comprehensive assessments to clearly demonstrate the continuing provision of the home health benefits. (Refer to G532). c. The HHA failed to maintain an accurate current medication profile for one of 7 sampled patients (Patient 2). This deficient practice has the potential to place the patient at risk for medication errors and adverse drug reactions. (Refer to G536). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver mandated compliance (in a way that is decided and controlled by law) with Federal regulations for Comprehensive Assessment of Patients to ensure the provision of health care services in a safe manner are provided to certified home health patients.
G0520	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 interview and record review, the Home Health Agency (HHA) failed to ensure the comprehensive assessment (the required in-person clinical assessment of the patient's physical, functional, mental, psychosocial, and cognitive status to identify the needs of the patient and caregiver that will be addressed by the home health agency's services) was completed within 5 days from the start of care for one of 7 sampled patients (Patient 1). This deficient practice had the potential to result in the patient’s needs not being identified and assessed, leading to poor quality nursing care needed to maintain the patient’s quality of life and well-being. During a review of Patient 1’s GACH (hospital) discharge order dated 8/2/2025, indicated to a physician’s order to infuse Ertapenem 1 gram in Normal Saline 100 milliliters over 30 minutes via IV access every 24 hours via rate-flow/mini-bag every 24 hours until 8/24/2025 for intra-abdominal abscess. During a review of Patient 1’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care (SOC) date of 8/3/2025, with diagnosis that included acute appendicitis with perforation (a condition where the appendix , a small finger-shaped organ attached to the large intestine, becomes inflamed and ruptured. During a phone interview with Family Member (FM 1) 10/29/2025, at 12 p.m., FM 1 stated she was very upset that Registered Nurse (RN 1) did not show up on her scheduled visit day (FM 1 unable to remember the date) to infuse the IV antibiotic because RN 1 had to go to a court hearing. FM 1 stated the HHA did not send a replacement nurse that resulted to Patient 1 not getting her IV antibiotic to treat her abscess. FM 1 also stated she called the HHA the following day and the staff told her the HHA could not send a replacement nurse because there were a lot of patients needing help. During a review of Patient 1’s electronic medical record (EMR) indicated that HHA did not complete the initial evaluation using the Outcome and Assessment Information Set (OASIS) dated 8/3/2025. During an interview with RN 1 on 10/29/2025, at 1:30 p.m., she stated she did not complete the OASIS assessment because the HHA’s biller told them there was a problem with the patient’s insurance and the HHA would not get paid for services rendered. RN 1 also stated the comprehensive assessment must be completed no later than 5 calendar days after the start of care. During a review of the agency’s policy and procedure (P&P) titled, Initial and Comprehensive Assessment, dated April 2020, the P&P indicated a comprehensive patient assessment will be completed within five (5) calendar days of the patient start of care. The assessment will be patient-specific and comprehensive to include the patient’s need for home care, rehabilitative care, social, and discharge planning needs.
G0532	Continuing need for home care CFR(s): 484.55(c)(3) The patient's continuing need for home care; This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to assess the patients' continuing need for home care services for two of 7 sampled patients (Patient 2, and Patient 3). This deficient practice resulted in the continued skilled nurse services to these patients lacking the comprehensive assessments to clearly demonstrate the continuing provision of the home health benefits. a. During a review of Patient 2's Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care date (SOC) date of 8/26/2025, with a diagnosis of diabetes mellitus type II ( high blood sugar levels due to the body’s inability to use insulin effectively). During a review of Patient 2’s Home Health Certification and Plan of Care (POC) for the re-certification period from 8/25/2025 to 10/24/2025, the POC included an order for the skilled nurse (SN) to visit the patient once a week for 9 weeks. The SN was to conduct skilled assessment and observation, management of patient’s overall health status, assess vital signs (measure the basic functions of your body that includes body temperature, blood pressure, pulse and respiratory [breathing] rate), and instruct patient and/or patient caregiver regarding medication compliance and dietary regimen. The goals and outcomes included patient/caregiver will have adequate understanding of teachings on the disease conditions, will demonstrate medication compliance and diet regimen, and there will be no exacerbation or complications of disease, hospitalization or emergent care within the 9 weeks of certification period and patient will remain safe in the home, free from falls/injury/skin breakdown. Discharge planning indicated to discharge patient safely to current residence with caregiver assistance when all goals are met and skilled services are no longer needed, under MD (physician) supervision and regular follow up. During a joint home visit, on 10/31/2025, at 1 p.m., at Patient 2’s residence with the director of patient care services (DPCS), Patient 2 was observed awake, alert, oriented x 3 (to person, place, and time), and ambulatory with stable gait without using any assisted device. During an interview, Patient 2 she goes visit her physician regularly as scheduled, had no falls, no wounds, had no hospitalization, and can managed her medication and diet regimen independently. During a concurrent interview and record review, on 11/2/2025, at 11 a.m., with the Director of Patient Care Services (DPCS), the DPCS reviewed Patient 2’s clinical nursing visit notes, nursing assessment and the POC. The DPCS stated that for the month starting 8/25/2025 to 10/24/2025, Patient 2’s vital signs were within normal range, that he had no recent admissions to the hospital, no episodes of falls, no new medications, nor any evidence of the need for skilled nursing services to continue. However, the DPCS stated Patient 2 was re-certified for another 60 days for continuous skilled nursing services. The DPCS further stated Patient 1 should have been discharged because her goals have been met and there was no need for skilled nursing services. b. During a review of Patient 3's Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care date (SOC) date of 8/3/2025, with a diagnosis of hypertensive heart disease (a heart problem that develop from long term high blood pressure). During a review of Patient 3’s Home Health Certification and Plan of Care (POC) for the certification period from 8/3/2025 to 10/1/2025, the POC included an order for the skilled nurse (SN) to visit the patient once a week for 9 weeks. The SN was to conduct skilled assessment and observation, management of patient’s overall health status, assess vital signs (measure the basic functions of your body that includes body temperature, blood pressure, pulse and respiratory [breathing] rate), and instruct patient and/or patient caregiver regarding medication compliance and dietary regimen. The goals and outcomes included patient/caregiver will have adequate understanding of teachings on the disease conditions, will demonstrate medication compliance and diet regimen, and there will be no exacerbation or complications of disease, hospitalization or emergent care within the 9 weeks of certification period and patient will remain safe in the home, free from falls/injury/skin breakdown. Discharge planning indicated to discharge patient safely to current residence with caregiver assistance when all goals are met and skilled services are no longer needed, under MD (physician) supervision and regular follow up. During a concurrent interview and record review, on 11/2/2025, at 11:30 a.m., with the Director of Patient Care Services (DPCS), the DPCS reviewed Patient 3’s clinical nursing visit notes, nursing assessment and the POC. The DPCS stated that for the month starting 8/3/2025 to 10/1/2025, Patient 3’s vital signs were within normal range, that she had no recent admissions to the hospital, no episodes of falls, no wound care, nor any evidence of the need for skilled nursing services to continue. However, the DPCS stated Patient 3 was re-certified for another 60 days for continuous skilled nursing services. The DPCS further stated Patient 3 should have been discharged because his goals have been met and there was no need for skilled nursing services. During a review of the agency’s policy and procedure (P&P) titled, Discharge Criteria and Process, dated April 2020, the P&P indicated the purpose of the policy is to outline the process for discharging a patient from service. Services will be terminated when the patient meets one of the following discharge criteria: if appropriate, the physician and the organization agree that the goals of home care have been attained or are no longer attainable.
G0536	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 observation, interview and record review, the home health agency (HHA) failed to maintain an accurate current medication profile for one of 7 sampled patients (Patient 2). This deficient practice has the potential to place the patient at risk for medication errors and adverse drug reactions. During a review of Patient 2's Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care date (SOC) date of 8/26/2025, with a diagnosis of diabetes mellitus type II (high blood sugar levels due to the body’s inability to use insulin effectively). During a review of Patient 2’s Home Health Certification and Plan of Care (POC) for the re-certification period from 8/25/2025 to 10/24/2025, the POC included an order for the skilled nurse (SN) to visit the patient once a week for 9 weeks. The SN was to conduct skilled assessment and observation, management of patient’s overall health status, assess vital signs (measure the basic functions of your body that includes body temperature, blood pressure, pulse and respiratory [breathing] rate), and instruct patient and/or patient caregiver regarding medication compliance and dietary regimen. During a joint home visit, on 10/31/2025, at 1 p.m., at Patient 2’s residence with the director of patient care services (DPCS), Patient 2 was observed awake, alert, oriented x 3 (to person, place, and time), and ambulatory with stable gait without using any assisted device. During a review of Patient 2’s current medication, on 10/31/2025, at 1:30 p.m., with the DPCS, it was noted there was bottle of Edarbi (used to treat high blood pressure) 80 milligram (mg, a unit of measurement) 1 tablet orally daily with a refill date of 7/16/2025 and a bottle of Felodipine (used to treat high blood pressure) 5 mg one tab daily with a refill date of 7/16/2025. Patient 2’s current medication list provided by the HHA indicated both the Edarbi and Felodipine medications were not included in the list. During a concurrent interview with Patient 2, she stated she was taking the Edarbi and Felodipine medications daily for several months. During an interview, on 10/31/2025, at 2 p.m., with the DPCS, the DPCS stated nursing staff need to review the patient’s current medication every nurse visit and update the medication profile in the patient’s clinical record. During a review of the agency’s policy and procedure (P&P) titled, Medication Profile, dated April 2020, the P&P indicated patient receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications, new, and/or discontinued medications.
G0570	Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on interview, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to meet the Condition of Participation (refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) for care planning, coordination, and quality of care of patients as follows: a. The Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to develop an individualized plan of care (POC) that included problems, goals and interventions for two of seven sampled patients (Patient 1 and Patient 5). For Patient 1, who had a diagnosis of acute appendicitis with perforation (a medical emergency where the appendix, a small worm-shaped organ attached to the large intestine, ruptures and releases bacteria into the abdominal cavity). This failure had the potential to result in Patient 1 not receiving the identified needs and services, which could lead to a decline in his health status and/or injury. For Patient 5, the HHA failed to ensure that each patient's plan of care (POC) included all disciplines involved and clearly stated the frequency and duration of visits. (Refer to G574). b. The HHA failed to ensure that Registered Nurse (RN 1) administered Ertapenem (medication used to treat bacterial infections) Intravenous (IV- refers to a way of giving drug or other substances through a needle or tube inserted into a vein) medication as ordered by the physician for one of seven (7) sampled patients (Patient 1) due to lack of staffing. This failure put Patient 1 at increased risk to have infection and develop sepsis (a life-threatening condition that occurs when the body’s immune system overreacts to an infection that could lead to widespread inflammation and organ damage) that could lead to hospitalization and death. (Refer to G580). c. The Registered Nurse (RN 1) failed to notify the physician promptly regarding a missed visit for a patient needing intravenous (IV-a way of giving a drug or other substance through a needle or tube inserted into the vein) infusion for one of seven sample patients (Patient 1). This deficient practice placed the patients at a potential risk for complications that could affect their overall health status. *Refer to G590). d. The HHA failed to ensure effective coordination of care and services for one of 5 sampled patients (Patient 5). The agency did not ensure that care provided by the Certified Nursing Assistant (CNA ) and therapy staff was coordinated, documented, or reviewed by Director of Patient Care Services (DPCS). This deficient practice had the potential to result in uncoordinated care and lack of appropriate clinical oversight for the patients. (Refer to G606).   The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver mandated compliance (in a way that is decided and controlled by law) with Federal regulations for Care planning, coordination, quality of care to ensure the provision of health care services in a safe manner is provided to patients
G0574	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 interview, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to develop an individualized plan of care (POC) that included problems, goals and interventions for two of seven sampled patients (Patient 1 and Patient 5). For Patient 1, who had a diagnosis of acute appendicitis with perforation (a medical emergency where the appendix, a small worm-shaped organ attached to the large intestine, ruptures and releases bacteria into the abdominal cavity). This failure had the potential to result in Patient 1 not receiving the identified needs and services, which could lead to a decline in his health status and/or injury. For Patient 5, the HHA failed to ensure that each patient's plan of care (POC) included all disciplines involved and clearly stated the frequency and duration of visits. This deficient practice resulted in patient's needs and services not coordinated among the staff providing the care. During a concurrent home visit on 10/30/2025, at 11:30 a.m., with the DPCS preset, an interview with patient 5 (Spanish-speaking only) and Family Member 1(FM1) in the den of Patient 5’s residence. FM 1 stated that Patient 5 had a rash on his back that had been there and itching real bad for over a month. FM 1 stated that the LVN comes twice a week and that the CNA, who visits twice weekly , asked the family what for then rashes redness and itching of his back. Observation of Patient 5’s back indicated a large multiple bumpy red rash on his entire back with redness around patients 5’s cocci and buttocks area. During the home visit, the DPCS stated that she was not aware of the rash and would have to review the records and talk to the Skilled Nurse who was providing care. During a concurrent record review of patient 5’s EMR and interview with the DPCS in the HHA’s office on 11/3/2025, at 12pm., The DPCS stated the CNA providing care to patient 5 was employed through a registry due to the agency not having an in-house CNA. The DPCS confirmed there were no CNA visit notes in patient 5’s electronic medical record. The DPCS Stated CNA documentations were stored “ in a portal” and that she eeded to download and put them in the chart. The DPCS further stated she had not reviewed the CNA notes or the complete chart. During a review of Patient 5’s Home Health Certification and Plan of Care for the certification period of 9/29/2025 to 11/27/2025, with the Adm/DPCS in the HHA, it did not indicate the disciplines providing services or the frequency of visit. During an interview with the ADM/DPCA on 11/3/2025, at 11:30, in the office, she stated se did not know the POC was to have the information and that the HHA has a standard visit which is at least once a week routine. The ADM/DPCS stated she would have to ask the Skilled Nuse (SN) for the information. The ADM/DPCS was asked how does she ensure the disciplines are visiting the patient in which the ADM/DPCS stated, “they call me”. The ADM/DPCS was unable to provide the CNA/PT visit notes or any documentation the isit were being done by the various disciplines. The ADM/DPCS was unable to provide the documents and policy and procedures requested. Review of the home health certification and plan of care for patient 5 indicated a start of care date (SOC) of 2/1/2025 ,for the certification period of 9/29/2025 to 11/27/2025, With diagnosis that include hypertensive heart failure with heart failure( refers to heart problems that occur because of high blood pressure that is present for a long time), acute kidney failure( Sudden loss of kidney function when the kidneys can't filter waste which affects fluid and electrolyte balance it can happen quickly and is often reversible with treatment Alzheimer's disease( memory loss and other cognitive abilities that interfere with daily life), and cachexia( extreme loss of weight and muscle mass), and bed confinement status, During a review of Patient 1’s GACH discharge order dated 8/2/2025, indicated to a physician’s order to infuse Ertapenem 1 gram in Normal Saline 100 milliliters over 30 minutes via IV access every 24 hours via rate-flow/mini-bag every 24 hours until 8/24/2025 for intra-abdominal abscess. During a review of Patient 1’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care (SOC) date of 8/3/2025, with diagnosis that included acute appendicitis with perforation (a condition where the appendix , a small finger-shaped organ attached to the large intestine, becomes inflamed and ruptured. During a phone interview with Family Member (FM 1) 10/29/2025, at 12 p.m., FM 1 stated she was very upset that Registered Nurse (RN 1) did not show up on her scheduled visit day ( FM 1 unable to remember the date) to infuse the IV antibiotic because RN 1 had to go to a court hearing. FM 1 stated the HHA did not send a replacement nurse that led to Patient 1 not getting her IV antibiotic to treat her abscess. FM 1 also stated she called the HHA the following day and the staff told her the HHA could not send a replacement nurse because there are a lot of patients needing help. During a review of Patient 1’s electronic medical record (EMR) indicated that HHA did not develop a plan of care for intravenous (IV-a way of giving a drug or other substance through a needle or tube inserted into the vein) infusion management to treat Patient 1’s intra-abdominal abscess ( a collection of puss located within the abdominal cavity). During an interview, on 11/2/2025, at 12 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated the HHA failed to develop a care plan for IV infusion management. During a review of the agency’s policy and procedure (P&P) titled, Home Health Certification and Plan of Care, dated 7/9/2018, the P&P indicated the Home Health Certification and Plan of Care (485) is the ordering practitioner’s order for home care services. The Plan of Care will be individualized to include, but not limited to, all treatments, procedures, medications, and services authorized to be provided by direct care staff(s). The Plan of Care shall include, but not limited to identified patient problems to include diagnoses and surgical procedures.
G0580	Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure that Registered Nurse (RN 1) administered Ertapenem (medication used to treat bacterial infections) Intravenous (IV- refers to a way of giving drug or other substances through a needle or tube inserted into a vein) medication as ordered by the physician for one of seven (7) sampled patients (Patient 1) due to lack of staffing. This failure put Patient 1 at increased risk to have infection and develop sepsis (a life-threatening condition that occurs when the body’s immune system overreacts to an infection that could lead to widespread inflammation and organ damage) that could lead to hospitalization and death. On 11/3/2025, at 11:40 a.m., while onsite at the agency, the Department called an Immediate Jeopardy (IJ, a situation in which the provider’s noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident), in the presence of the Director of Patient Care Services (DPCS) and the Administrator Designee (ADMD), related to the Home Health Agency's (HHA, medically focused care provided by skilled professionals like nurses and therapists in a patient home) failure to ensure that Registered Nurse (RN 1) administered Ertapenem (medication used to treat bacterial infections) 1 gram IV on 8/5/2025 as ordered by the physician from General Acute Care Hospital (GACH) to treat Patient 1’s intra-abdominal abscess due to lack of staffing. This failure put Patient 1 at increased risk to have infection and develop sepsis (a life-threatening condition that occurs when the body’s immune system overreacts to an infection that could lead to widespread inflammation and organ damage) that could lead to hospitalization and death. On 11/3/2025, the HHA was unable to submit an IJ removal Plan (IJRP, a plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation). On 11/3/2025 at 4 pm, the Department completed the survey tasks and conducted an exit conference while onsite in the presence of the Director of Patient Care Services (DPCS) and the Administrator Designee (ADMD) with the IJ situation not removed.  On 11/11/2025 the HHA was able to submit an IJ removal plan for G580 and G1012. The IJ removal plan was reviewed and accepted on 11/12/2025. On 11/12/2025 at 3:10 P.M., the survey team verified the implementation of the IJ removal while onsite and the IJ was removed in the presence of the DPCS. Findings: During a review of Patient 1’s General Acute Care Hospital (GACH) discharge order dated 8/2/2025, the discharge order indicated to infuse Ertapenem 1 gram (unit of measurement) in Normal Saline (a mixture of water and salt) 100 milliliters (ml, unit of measurement) over 30 minutes via IV access every 24 hours via rate-flow/mini-bag (a small IV bag of medication that is administered at a controlled rate using a flow rate controller) every 24 hours until 8/24/2025 for intra-abdominal abscess.   During a review of Patient 1’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care (SOC) date of 8/3/2025, with diagnosis that included acute appendicitis with perforation (a condition where the appendix [a small finger-shaped organ attached to the large intestine], becomes inflamed and ruptured).     During a phone interview with Family Member (FM 1) on 10/29/2025, at 12 p.m., FM 1 stated she was very upset that Registered Nurse (RN 1) did not show up on her scheduled visit day (FM 1 unable to remember the date) to infuse the IV antibiotic because RN 1 had to go to a court hearing. FM 1 stated the HHA did not send a replacement nurse that led to Patient 1 not getting her IV antibiotic to treat her abscess. FM 1 also stated she called the HHA the following day and the staff told her the HHA could not send a replacement nurse because there were a lot of patients needing help.   During an interview with RN 1 on 10/29/2025, at 1 p.m., she stated she had a scheduled visit on 8/5/2025, to infuse the IV Ertapenem medication but she was unable to do the visit because she had to go to a court hearing on that day. RN 1 stated she tried looking for a replacement nurse, but they refused to do the visit because the patient lives far.   During a review of Patient 1’s electronic medical record (EMR) (from 8/3/2025 to 8/10/2025), Patient 1’s EM indicated that HHA did not complete the initial evaluation using the Outcome and Assessment Information Set (OASIS) for evaluation conducted on 8/3/2025, there was no plan of care developed, no physician’s order for all patient’s medications being administered to the patient, no nursing notes completed for nursing visit scheduled dates of 8/3/2025 and 8/4/2025.   A review of the HHA's policy dated 11/2023 entitled" Administration and Documentation of Medications", indicated that the license nurse will administer medications as ordered by the physician that can be safely administered and monitored during a home visit.  License nursing personnel will administer and document medications which have been ordered as part of the plan of care and have been approved for safe administration and monitoring during a home visit.
G0590	Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on interview, and record review, the Registered Nurse (RN 1) failed to notify the physician promptly regarding the intravenous (IV-a way of giving a drug or other substance through a needle or tube inserted into the vein) infusion not administered due to the RN's missed visit for one of seven sample patients (Patient 1). This deficient practice placed the patients at a potential risk for complications that could affect the patient's health status and well being. During a review of Patient 1’s GACH (hospital) discharge order dated 8/2/2025, indicated to a physician’s order to infuse Ertapenem 1 gram in Normal Saline 100 milliliters over 30 minutes via IV access every 24 hours via rate-flow/mini-bag every 24 hours until 8/24/2025 for intra-abdominal abscess. During a review of Patient 1’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care (SOC) date of 8/3/2025, with diagnosis that included acute appendicitis with perforation (a condition where the appendix , a small finger-shaped organ attached to the large intestine, becomes inflamed and ruptured). During a phone interview with Family Member (FM 1) 10/29/2025, at 12 p.m., FM 1 stated she was very upset the Registered Nurse (RN 1) did not show up on her scheduled visit day ( FM 1 unable to remember the date) to infuse the IV antibiotic because RN 1 had to go to a court hearing. FM 1 stated the HHA did not send a replacement nurse that led to Patient 1 not getting her IV antibiotic to treat her abscess. FM 1 also stated she called the HHA the following day and the staff told her the HHA could not send a replacement nurse because there were a lot of patients needing help. During an interview with RN 1 on 10/29/2025, at 1 p.m., she stated she had a scheduled visit on 8/5/2025, to infuse the IV Ertapenem medication but she was unable to do the visit because she had to go to a court hearing on that day. RN 1 stated she tried looking for a replacement nurse, but they refused to do the visit because the patient lives far. RN 1 also stated she did not notify the physician regarding the missed visit. During a review of Patient 1’s electronic medical record (EMR) indicated there was no documented evidence the physician was notified regarding a missed visit for an IV antibiotic infusion to treat Patient 1’s intra-abdominal abscess (a collection of pus located within the abdominal cavity). During a review of the agency’s undated policy and procedure titled, “Care Planning Process”, indicated the purpose of this policy is to provide clinical direction to the clinicians providing direct patient care. The plan of care will be based upon the physician’s (or other authorized licensed independent practitioner’s) orders and will encompass the equipment, supplies, and services required to meet the patient’s needs. Clinicians will inform the patient’s physician (or other authorized licensed independent practitioner) of any changes that suggest a need to alter the plan of care. Changes must be written, dated, and signed by the professional making the changes.
G0606	Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure there was an effective coordination among staffs providing care and services for one of 5 sampled patients (Patient 5). This deficient practice had the potential to result in the care and services identified in the plan of care will not be implemented among staff that could affect the patient's health and safety. During a concurrent home visit on 10/30/2025, at 11:30 a.m., with the DPCS, an interview with Patient 5 (Spanish-speaking only) and Family Member 1(FM1) in the den of Patient 5’s residence. FM 1 stated that Patient 5 had a rash on his back that had been there and itching really bad for over a month. FM 1 stated that the LVN comes twice a week and that the CNA visits twice weekly. During the home visit it was observed Patient 5’s back had a large multiple bumpy red rashes on his entire back with redness around Patients 5’s coccyx (tailbone) and buttocks area. DPCS stated that she was not aware of the rashes and would have to review the records and would talk to the Skilled Nurse who was providing care. During a concurrent record review of Patient 5’s EMR and interview with the DPCS in the HHA’s office on 11/3/2025, at 12pm., The DPCS stated the CNA providing care to Patient 5 was employed through a registry due to the agency not having an in-house CNA. The DPCS confirmed there were no CNA visit notes in the Patient 5’s electronic medical record. The DPCS stated CNA documentations were stored “in a portal” and that she needed to download and put them in the chart. The DPCS further stated she had not reviewed the CNA notes or the complete chart. Review of Patient 5’s Home Health Certification and Plan of Care form, indicated Patient 5 was admitted to the HHA, with a start of care date of 2/1/2025, with diagnosis of Hypertensive heart disease with heart failure, acute kidney failure, cachexia, Alzheimer’s for the certification period of 9/29/2025 to 11/27/2025. The ADM/DPCS was unable to provide the HHA's policy and procedure as requested.
G1008	Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This CONDITION is not met as evidenced by: Based on interview, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to meet the Condition of Participation (refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) for Clinical records as follows: The HHA failed to maintain a clinical record containing past and current information of patient receiving home health services for one of seven sampled patients (Patient 1) by failing to:   1. Ensure Patient 1 General Acute Care Hospital (GACH) Discharge order to administer Ertapenem (medication used to treat bacterial infections) Intravenous (IV- a way of giving a drug or other substance through a needle or tube inserted to a vein) every 24 hours was included in Patient 1’s plan of care.   2. Ensure Patient 1 medication and treatment orders were included on Patient’s 1 plan of care.   3. Ensure License staff document all interventions, including medication administration, treatments and services and responses to the interventions for Patient 1.   4. Ensure license staff completed an initial evaluation using the Outcome and Assessment Information Set (OASIS initial evaluation, a comprehensive evaluation of a patient's health and needs conducted at the beginning of home health care services) on 8/3/2025 for Patient 1.   5. Ensure Patient 1 had a plan of care developed to outline the specific plan for medical, rehabilitation, and supportive services a patient needs at home   6. Ensure Patient 1 had nursing notes completed for nursing visit conducted on 8/3/2025 and 8/4/2025.   7. Ensure to complete Oasis discharge comprehensive assessment (a required evaluation of a home health patient's clinical and functional status upon leaving the agency's care) for Patient 1.   These failures had a potential to result with miscommunication within the interdisciplinary team (a group of professionals from different fields who collaborate to address complex issues, such as patient care), medication error, inappropriate treatment and services that could cause patient suffering severe harm, hospitalization and death. (Refer to G1012).   The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver mandated compliance (in a way that is decided and controlled by law) with Federal regulations for Clinical Records to ensure the provision of health care services in a safe manner is provided to patients.
G1012	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 interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to maintain a clinical record containing past and current information of patient receiving home health services for one of seven sampled patients (Patient 1) by failing to:  1. Ensure Patient 1 (General Acute Care Hospital) GACH Discharge order dated 8/2/2025 to administer Ertapenem (medication used to treat bacterial infections) Intravenous (IV- a way of giving a drug or other substance through a needle or tube inserted to a vein) every 24 hours was included to Patient 1’s plan of care.   2. Ensure Patient 1 medication and treatment orders were included on Patient’s 1 plan of care.   3. Ensure License staff document all interventions, including medication administration, treatments and services and responses to the interventions for Patient 1.   4. Ensure license staff completed an initial evaluation using the Outcome and Assessment Information Set (OASIS) on 8/3/2025 for Patient 1.   5. Ensure Patient 1 had a plan of care developed to outline the specific plan for medical, rehabilitation, and supportive services a patient needs at home.   6. Ensure Patient 1 had nursing notes completed for nursing visit conducted on 8/3/2025 and 8/4/2025.   7. Ensure to complete Oasis discharge comprehensive assessment for Patient 1.   These failures had a potential to result with miscommunication within the interdisciplinary team (a group of professionals from different fields who collaborate to address complex issues, such as patient care), medication error, inappropriate treatment and services that could cause patient suffering severe harm, hospitalization and death. On 11/3/2025, at 11:450 a.m., while onsite at the agency, the Department called an IJ, in the presence of the Director of Patient Care Services (DPCS) and the Administrator Designee (ADMD), related to the HHA’s failure to maintain a clinical record containing past and current information of patient receiving home health services for one of seven sampled patient (Patient 1) by failing to: 1. Ensure Patient 1 GACH Discharge order to administer Ertapenem (medication used to treat bacterial infections) Intravenous (IV- a way of giving a drug or other substance through a needle or tube inserted to a vein) every 24 hours was included to Patient 1’s plan of care. 2. Ensure Patient 1 medication and treatment orders were included on Patient’s 1 plan of care.3. Ensure License staff document all interventions, including medication administration, treatments and services and responses to the interventions for Patient 1. 4. Ensure license staff completed an initial evaluation using the Outcome and Assessment Information Set (OASIS)on 8/3/2025 for Patient 1. 5. Ensure Patient 1 had a plan of care developed to outline the specific plan for medical, rehabilitation, and supportive services a patient needs at home 6. Ensure Patient 1 had nursing notes completed for nursing visit conducted on 8/3/2025 and 8/4/2025. 7. Ensure to complete Oasis discharge comprehensive assessment for Patient 1. These failures had a potential to result with miscommunication within the interdisciplinary team (a group of professionals from different fields who collaborate to address complex issues, such as patient care), medication error, inappropriate treatment and services that could cause patient suffering severe harm, hospitalization and death.   On 11/3/2025, the HHA was unable to submit an IJ removal Plan (IJRP, a plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation). On 11/3/2025 at 4 pm, the Department completed the survey tasks and conducted an exit conference while onsite in the presence of the Director of Patient Care Services (DPCS) and the Administrator Designee (ADMD) with the IJ situation not removed.  On 11/11/2025 the HHA was able to submit an IJ removal plan. The IJ removal plan was reviewed and accepted on 11/12/2025. On 11/12/2025 at 3:10 P.M., the survey team verified the implementation of the IJ removal while onsite and the IJ was removed in the presence of the DPCS. Review of Patient 5’s Home Health Certification and Plan Of Care form, indicated Patient 5 was admitted to the HHA, with a start of care date of 2/1/2025, with diagnosis of Hypertensive heart disease with heart failure, acute kidney failure, Cachexia ,Alzheimer’s for the certification period of 9/29/2025 to 11/27/2025. There were no CNA visit notes in patients EMR for the certification period During a concurrent home visit on 10/30/2025, at 11:30 a.m., with the DPCS preset, an interview with patient 5 (Spanish-speaking only) and Family Member 1(FM1) in the den of Patient 5’s residence. FM 1 stated that Patient 5 had a rash on his back that had been there and itching real bad for over a month. FM 1 stated that the LVN comes twice a week and that the CNA, who visits twice weekly , asked the family what for then rashes redness and itching of his back. Observation of Patient 5’s back indicated a large multiple bumpy red rash on his entire back with redness around patients 5’s cocci and buttocks area. During the home visit, the DPCS stated that she was not aware of the rash and would have to review the records and talk to the Skilled Nurse who was providing care. During a concurrent record review of patient 5’s EMR and interview with the DPCS in the HHA’s office on 11/3/2025, at 12pm., The DPCS stated the CNA providing care to patient 5 was employed through a registry due to the agency not having an in-house CNA. The DPCS confirmed there were no CNA visit notes in patient 5’s electronic medical record. The DPCS Stated CNA documentations were stored “ in a portal” and that she eeded to download and put them in the chart. The DPCS further stated she had not reviewed the CNA notes or the complete chart. During a review of Patient 5’s Home Health Certification and Plan of Care for the certification period of 9/29/2025 to 11/27/2025, with the Adm/DPCS in the HHA, it did not indicate the disciplines providing services or the frequency of visit. During an interview with the ADM/DPCA on 11/3/2025, at 11:30, in the office, she stated se did not know the POC was to have the information and that the HHA has a standard visit which is at least once a week routine. The ADM/DPCS stated she would have to ask the Skilled Nuse (SN) for the information. The ADM/DPCS was asked how does she ensure the disciplines are visiting the patient in which the ADM/DPCS stated, “they call me”. The ADM/DPCS was unable to provide the CNA/PT visit notes or any documentation the isit were being done by the various disciplines. The ADM/DPCS was unable to provide the documents and policy and procedures requested. Findings: During a review of Patient 1’s GACH discharge order dated 8/2/2025, indicated to a physician’s order to infuse Ertapenem 1 gram in Normal Saline 100 milliliters over 30 minutes via IV access every 24 hours via rate-flow/mini-bag every 24 hours until 8/24/2025 for intra-abdominal abscess. During a review of Patient 1’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated a start of care (SOC) date of 8/3/2025, with diagnosis that included acute appendicitis with perforation (a condition where the appendix , a small finger-shaped organ attached to the large intestine, becomes inflamed and ruptured. During a phone interview with Family Member (FM 1) 10/29/2025, at 12 p.m., FM 1 stated she was very upset that Registered Nurse (RN 1) did not show up on her scheduled visit day ( FM 1 unable to remember the date) to infuse the IV antibiotic because RN 1 had to go to a court hearing. FM 1 stated the HHA did not send a replacement nurse that led to Patient 1 not getting her IV antibiotic to treat her abscess. FM 1 also stated she called the HHA the following day and the staff told her the HHA could not send a replacement nurse because there are a lot of patients needing help. During a review of Patient 1’s electronic medical record (EMR) indicated that HHA did not complete the initial evaluation using the Outcome and Assessment Information Set (OASIS) dated 8/3/2025, there was no plan of care developed, no physician’s order for all patient’s medications being administered to the patient, no nursing notes completed for nursing visit scheduled dates of 8/3/2025 and 8/4/2025, and no discharge OASIS done. During an interview with RN 1 on 10/29/2025, at 1:30 p.m., she stated she did not complete the OASIS assessment, her nursing notes, the discharge OASIS and discharge summary and she did not transfer the hospital’s discharge physician’s order to their agency’s physician’s order form because the HHA’s biller told them there was a problem with the patient’s insurance and the HHA would not get paid for services rendered. A review of the HHA's policy and procedure dated 11/2023, entitled "Contents Of The Clinical Records", indicated a clinical record will be maintained for each patient receiving care. The clinical record will contain sufficient information to identify the patient, describe the patient's problem and needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among organization and contact personnel. The following information will be available in the clinical record for patients receiving skilled care as follows: a. Plan of treatment, plan of care b. signed and dated progress notes for each discipline rendering service c. Record and Findings of initial and ongoing assessments d. Procedures and treatments rendered e. Care planning activity based on the patient's problem, needs, and expected outcomes f. Transfer/discharge summaries and other summary reports sent to the physician as required by law and regulation and organization policy.