| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 757280 | (X3) Date Survey Completed 11/04/2025 |
| Name of Provider or Supplier Rely Home Health, Inc. | Street Address, City, State 100 N Brand Blvd Suite 401, Glendale, 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) |
| G1024 | Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA, agency that provides skilled health care services to patients in their own homes) failed: 1. To ensure Licensed Vocational Nurse (LVN) 1 did not willfully falsify (knowingly make a false entry into a patient record) patient records for one of thirteen sampled patients (Patient 5) when LVN 1 copied LVN 2’s visit notes for Patient 5 on 10/15/2025 and 10/17/2025, that indicated wound care was provided to Patient 5 when wound care treatment was not actually provided by LVN 1. 2. To ensure the Outcome and Assessment Information (OASIS, an assessment tool used to collect functional and clinical status data for patients) patient assessment, was authenticated with a signature of the staff who completed the OASIS form and dated for one of thirteen sampled patients (Patient 8). 3. To ensure Occupational Therapist (OT) 1, who was a contracted employee, used a unique identifier that included OT 1’s signature when completing the “Patient Assessment: OASIS (OASIS)” form for one of thirteen sampled patients (Patient 9). These failures affect data accuracy that could result in inappropriate guidance for the development of Patient 5, Patient 8 and Patient 9’s plan of care (POC), compromise patient safety, disrupt continuity of care, poor quality of care that could lead to adverse health outcome (any negative or suboptimal result affecting a person's physical or mental well-being, stemming from various factors including medical care, disease progression, or environmental exposure). On 11/4/2025 at 12 PM, while onsite at the agency, the Department called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a patient), in the presence of the agency’s Director of Patient Care Services (DPCS), for failing to demonstrate a process and provide documented evidence that the facility ensured patient records were not willfully falsified, all entries into the patient health record were appropriately authenticated, and staff obtained unique identifiers to access and authenticate protected health information (any health information that can identify an individual that is in possession of or transmitted by a "covered entity" or its business associates that relates to a patient's past, present, or future health). On 11/4/2025, at 1:10 PM, the HAA was unable to submit an acceptable IJ removal plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely). On 11/4/2025, at 1:10 PM, The Department was unable to conduct an exit conference due to the DPCS stating the HHA would no longer cooperate with the ongoing survey. The Department concluded the survey without completing the survey tasks and the IJ situation not removed. Findings: 1. During a review of Patient 5’s “Patient Profile”, undated, the Patient Profile indicated that Patient 5’s Start of Care (SOC, the initial, in-person visit and assessment conducted by a clinician to establish a patient’s care plan) was on 10/3/2025, with diagnoses that included pressure ulcer stage 2 (Partial-thickness loss of skin, presenting as a shallow open sore or wound) of right buttock, encounter for change or removal of non-surgical wound dressing (medical appointment focused solely on changing or removing a dressing [a pad applied to a wound to promote healing] from a wound that did not originally require surgery), and hypertensive heart disease with heart failure (the heart cannot pump enough blood to the body because high blood pressure has damaged it over time). During a concurrent observation and interview on 10/28/2025 at 10:35 AM with Physical Therapist Assistant (PTA) 1, LVN 1 was observed conducting Skilled Nurse (SN) visit to Patient 5. LVN 1 stated she was assigned to do Patient 5’s home visit to help the patient with mobility, exercises, and home safety because Patient 5 had recent falls. PTA 1 stated he would provide physical therapy to Patient 5. LVN 1 stated she would stop her visit and let PTA 1 continue with the visit, LVN 1 then stepped out of Patient 5’s room. During an interview on 10/28/2025 at 10:36 AM with LVN 1, LVN 1 stated she received orders from the HHA to do home visit for Patient 5 to provide help with mobility and exercise education. LVN 1 stated she visited Patient 5 two times a week and during the visits she instructed Patient 5 to walk around the room, march in place, stretch, and sit to stand using a walker. LVN 1 stated she does not provide wound care treatment or medication management when she conducts her visit to Patient 5. LVN 1 stated she only provides exercise and exercise education to Patient 5. During a concurrent interview and record review on 10/30/2025 at 10:28 AM with LVN 1, Patient 5’s Skilled Nurse Visit Notes, dated 10/15/2025 and 10/17/2025, were reviewed. The Skilled Nurse Visit Noted indicated the following assessment and treatment for Patient 5: Under homebound status, the box for wound care was checked. Under integumentary (the set of organs that forms the external covering of the body) it indicated “right buttock stage II right thigh hematoma”. Under wound type, the boxes for decubitus (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) stage I (intact skin with a localized area of redness and/or changes in sensation, temperature, or firmness), II (Partial-thickness loss of skin, presenting as a shallow open sore or wound) and see wound sheet assessment and treatment were checked. During an interview on 10/30/2025 at 10:28 AM with LVN 1, LVN 1 stated she could not recall if wound care was provided to Patient 5 during the home visit and if the wound care treatment was not documented, the treatment was not done. LVN 1 stated the contents of the 10/15/2025 and 10/17/2025 Skilled Nurse Visit Notes were copied from the previous nurse’s (LVN 2) visit notes. LVN 1 stated she intended to go back and uncheck anything she did not do during her home visits with Patient 5. During an interview on 10/30/2025 at 10:28 AM with LVN 1, LVN 1 stated she should not copy Patient 5’s assessment information from the documentation of the previous nurse to put on her Skilled Nurse Visit Note. LVN 1 stated she should only document data from her own assessment during her visit with Patient 5. LVN 1 stated not having accurate documentation (copying the Skilled Nurse Visit Notes of LVN 2) could lead to inaccurate assessment. LVN 1 stated accurate documentation was important to ensure Patient 5’s care and wound care treatment were provided. During an interview on 11/3/2025 at 3:16 PM with the DPCS, the DPCS stated that “if a nurse accepts the fact that they copied another nurse’s notes then it is a falsification of records”. During an interview on 11/3/2025 at 3:20 PM with Quality Assurance (QA), the QA stated that “nurses need to make their own assessments, and oversight can happen in a pattern of copying and can fall into patient neglect (failure of a caretaker to supply the patient with the necessary food, clothing, shelter, health care, or supervision; or the absence or likelihood of an absence of the necessary food, clothing, shelter, health care, or supervision for a patient)”. The QA stated, “there could be an opportunity to miss a change of condition” and there was a potential risk for missed adverse medication reactions, change in medication regimen, or changes from a patient’s baseline (an initial measurement of a condition that is taken at an early time point and used for comparison over time to look for changes). During a review of the facility’s policy and procedure (P&P) titled, “Contents of Clinical Record”, dated 11/2024, the P&P indicated: “The clinical record will contain sufficient information to identify the patient, describe the patient’s problems and needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among organization and contract personnel”. “The following information will be available in the clinical record for patients receiving skilled care: [...] procedures and/or treatments rendered [...] documentation of the assessment data collected, actions and interventions performed, and patient response to care provided.” During a review of the facility’s P&P titled, “Wound Care Policy and Procedure,” dated 4/10/2024, the Wound Care Policy and Procedure indicated the following: “The agency shall ensure that wound care is performed by licensed professionals or trained staff under supervision, documented properly, and aligned with physician directives.” “Wound Monitoring and Assessment: Conduct wound reassessment at intervals directed by the physician, record all assessments, interventions, and wound progress in the client’s medical record, identify and report signs of infection or delayed healing promptly” “Documentation: Maintain detailed, accurate records of all wound care activities, assessments, and evaluations, including date/time, interventions, wound status, and patient responses.” During a review of the facility’s P&P titled, “Ongoing Assessments,” dated November 2024, the P&P indicated, “During each home visit the appropriate clinician will re-evaluate the patient according to the problems identified during the initial visit and thereafter.” 2. During a review of Patient 8’s “Patient Profile”, undated, the Patient Profile indicated that Patient 8’s SOC was on 10/8/2025, with a diagnosis of hypertension (HTN, pressure in the blood vessels is high). During a review of Patient 8’s “Patient Assessment: OASIS”, for the certification period of 10/8/2025 to 12/6/2025, it indicated, Patient 8’s primary diagnosis as spondylosis without myelopathy or radiculopathy, lumbar region (a condition where the intervertebral discs in the lower back degenerate, without damage to the spinal cord or nerve roots) and other diagnoses including presence of right artificial shoulder joint, generalized muscle weakness, muscle wasting and atrophy (wasting or shrinkage of a body part or tissue), joint stiffness, and low back pain. During a review of Patient 8’s “Patient Assessment: OASIS”, for the certification period of 10/8/2025 to 12/6/2025, further indicated the following: Discipline of Person Completing the Assessment: PT (Physical Therapy) Care Staff Name: the record indicated the company name (Contracted Company [CC] 2) instead of the name of the clinician who completed the form. Date Assessment Completed: 10/8/2025 This assessment is currently being completed for the following reason: start of care-further visits planned. The signature and date lines were blank under the section “I have personally reviewed all of the above information and hereby, certify, affirm, and declare that the above information is complete, true, accurate, and correct.” During an interview on 11/3/2025 at 2:01 PM with the CC2 Intake Coordinator, the CC 2 Intake Coordinator stated CC2’s staff had access to the form “Patient Assessment: OASIS” through the HHA’s EMR. The CC2 Intake Coordinator stated the form “Patient Assessment: OASIS” must be completed by the clinician performing the initial evaluation and the clinician must sign the assessment.” During a review of the facility’s P&P titled, “Person or Entity Authentication Policy,” undated, the P&P indicated: “The purpose of this policy is to ensure that (name of the HHA) verifies the identity of any person or entity seeking access to electronic protected health information (ePHI). This helps protect patient confidentiality and maintain compliance with the Health Insurance Portability and Accountability Act (HIPAA) Security Rule.” “Each user is assigned a unique user ID to access system containing ePHI” “Shared accounts are strictly prohibited.” During a review of the facility’s P&P titled, “OASIS Data Transmission,” dated November 2025, the P&P indicated: “OASIS data is collected and completed by the qualified clinician as part of the comprehensive assessment at the required time points” “All encoded OASIS data shall accurately reflect the patient’s status at the time the assessment was completed” “Discrepancies identified will be corrected following organization approved processes” “The organization must electronically transmit accurate, complete and encoded OASIS data for each patient...” 3. During a review of Patient 9’s “Patient Profile”, undated, the Patient Profile indicated that Patient 9’s SOC was on 10/11/2025, with a diagnosis of essential primary hypertension (pressure in the blood vessels is high without an identifiable medical cause) and primary osteoarthritis (a joint disease that causes the breakdown of protective tissue that cushions the ends of bones, without an identifiable medical cause) of the left shoulder. During a review of Patient 9’s “Patient Assessment: OASIS”, for the certification period of 10/11/2025 to 12/9/2025, the record indicated, name of the care staff assigned to the patient was documented as the contracted company name (CC1) instead of the actual name of the clinician who performed the initial patient assessment.. The OASIS was not signed by the actual person who performed the initial assessment. During an interview on 10/31/2025 at 3:39 PM with the Director of Patient Care Services (DPCS), the DPCS stated that Occupational Therapy (OT, a therapy service that helps people improve their ability to perform everyday tasks such as dressing, bathing and cooking) can complete an SOC if that is the only service ordered for the patient and that OT had access to complete the OASIS form. The DPCS stated when the OASIS form is completed, it should be signed and dated and when a contracted employee completes the OASIS, the name and signature that appears on the OASIS form would be under the employee’s contracted company and not the individual staff who completed the OASIS. During an interview on 10/31/2025 at 3:51 PM with the DPCS, the DPCS stated the only way to determine who completed the “Patient Assessment: OASIS” was to compare the report against visit notes, and determine which clinician performed a home visit on the same day the “Patient Assessment: OASIS” was dated. During an interview on 11/3/2025 at 12:08 PM with OT 1, OT 1 stated the process when a new patient was assigned to her was that she would receive an intake form and if it were for an SOC, she would complete the “Occupational Therapy-OT OASIS-SOC (the OT SOC notes)” that she would submit to the HHA. During a concurrent interview and record review on 11/3/2025 at 1:50 PM with OT 1, Patient 9’s “OT OASIS-SOC”, dated 10/11/2025, was reviewed. Patient 9’s “OT OASIS-SOC” indicated it was signed by OT 1. OT 1 stated that for SOC’s, she only completes the “OT OASIS-SOC form”. OT 1 stated she was not familiar with the “OASIS” form and that she did not fill out the “OASIS”, form for Patient 9. OT 1 stated when she needed to access HHA’s electronic medical record (EMR, a digital collection of patient’s health information), she signs in using the User ID under (CC 1 of OT 1) and not under her own name. During a concurrent interview and record review on 11/3/2025 at 3:02 PM with Customer Support Representative 2 (CSR 2) of the HHA’s EMR, the “EMR User Activity” report, dated 9/30/2024 to 10/31/2025, for Patient 9 was reviewed. The “EMR User Activity” report indicated Patient 9’s OASIS was accessed on 10/30/2025 at 3:04 PM by “User ID: CC 1”. CSR 2 stated “cannot specify which person signed the OASIS and if it was from the contracted company or the home health agency and that it was the same account because the same credentials were used”. During a review of the facility’s P&P titled, “Person or Entity Authentication Policy,” undated, indicated: “The purpose of this policy is to ensure that (name of the HHA) verifies the identity of any person or entity seeking access to electronic protected health information (ePHI). This helps protect patient confidentiality and maintain compliance with the Health Insurance Portability and Accountability Act (HIPAA) Security Rule.” “Each user is assigned a unique user ID to access system containing ePHI” “Shared accounts are strictly prohibited.” During a review of the facility’s P&P titled, “OASIS Data Transmission,” dated November 2025, the P&P indicated: “OASIS data is collected and completed by the qualified clinician as part of the comprehensive assessment at the required time points” “All encoded OASIS data shall accurately reflect the patient’s status at the time the assessment was completed” “Discrepancies identified will be corrected following organization approved processes” “The organization must electronically transmit accurate, complete and encoded OASIS data for each patient...” |