Vns of NY Home Care Chha

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on clinical record review and staff interview the agency failed to ensure that all patients receive services as documented in their individualized plan of care. This was evident for one (1) of three (3) clinical records reviewed (Patient: #1). Failure to ensure that all patients receive services as documented in their individualized plan of care has the potential for negative patient outcomes. The Findings Are: 1. Patient #1 has a Start of Care 02/21/2026 with diagnoses including Umbilical Hernia, Hypertension, Depression documented on the Home Health Certification and Plan of Care for the Certification Period from 02/21/2026 to 04/21/2026. The Home Health Certification and Plan of Care (medical orders) with a Certification Period from 02/21/2026 to 04/21/2026 documents the following orders for home health aide services: Home Health Aide effective 02/22/2026 4WK1, 5 WK1 (4 times a week for 1 week, then 5 times a week for 1 week). This equals a total of nine (9) days of Home Health Aide visits. The home health aide duty sheet documents the agency provided services to the patient on 03/07/2026, and 03/08/2026 for a total of two (2) home health aide visits. There is no documented evidence of the home health aide services being provided as documented in patient’s individualized plan of care. On 07/09/2026 at 3:30 PM, The Administrator was interviewed and stated the insurance initially denied authorization for home health aide services and the agency only received authorization for Registered Nurse Services. On 03/02/2026 the agency received authorization for home health services.”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to ensure that all orders are revised and recorded in the patient’s Plan of Care. This was evident for one (1) of three (3) clinical records reviewed (Patient: #1). Failure to review, revise and record all orders in the patient’s Plan of Care has the potential for negative patient outcome. The Findings Are: 1. Patient #1 has a Start of Care 02/21/2026 with diagnoses including Umbilical Hernia, Hypertension, Depression documented on the Home Health Certification and Plan of Care for the Certification Period from 02/21/2026 to 04/21/2026. The Home Health Certification and Plan of Care (medical orders) with a Certification Period from 02/21/2026 to 04/21/2026 documents the following orders for Home Health Aide services: Home Health Aide effective 02/22/2026 4WK1, 5 WK1 (4 times a week for 1 week, then 5 times a week for 1 week). The Home Health Aide (HHA) duty sheet documents the home health aide providing services to the patient on 03/08/2026. There is no documented evidence of an order to provide home health aide service on 03/08/2026. On 07/09/2026 at 01:30 PM, The Patient Safety Program Manager was interviewed and did not provide an explanation for the findings.”

“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 clinical record reviews, and staff interviews, the agency failed to ensure the patient’s physician is promptly alerted to any changes in the patient’s condition or needs. This was evident in two (2) of three (3) clinical records reviewed (Patients: #1, and #2). Failure to ensure the patient’s physician is promptly alerted to any changes in the patient’s condition or needs has the potential for negative patient outcomes. The Findings Are: 1. Patient #1 has a Start of Care 02/21/2026 with diagnoses including Umbilical Hernia, Hypertension, Depression documented on the Home Health Certification and Plan of Care for the Certification Period from 02/21/2026 to 04/21/2026. The Home Health Certification and Plan of Care (medical orders) with a Certification Period from 02/21/2026 to 04/21/2026 documents the following orders for home health aide services: Home Health Aide effective 02/22/2026 4WK1, 5 WK1 (4 times a week for 1 week, then 5 times a week for 1 week). This equals a total of nine (9) days of home health aide visits. The home health aide duty sheet documents the agency providing aide services to the patient on 03/07/2026, and 03/08/2026 for a total of two (2) Home Health Aide visits. There is no documented evidence of the patient’s physician being notified that the patient did not receive home health aide service as ordered in the Plan of Care. On 07/09/2026 at 03:30 PM, the Administrator and the Patient Safety Program Manager were interviewed and did not provide an explanation for the findings. 2. Patient #2 has a Start of Care 01/15/2026 with diagnoses including Cerebrospinal Fluid Leak, Migraine, Cirrhosis of Liver documented on the Home Health Certification and Plan of Care for the Certification Period from 01/15/2026 to 03/15/2026. The Home Health Certification and Plan of Care (medical orders) with a Certification Period from 01/15/2026 to 03/15/2026 documents the following orders for Home Health Aide services: Home Health Aide effective 01/18/2026 2WK1, 3WK1, 1WK1 (2 times a week for 1 week, then 3 times a week for 1 week, then 1 time a week for 1 week). The home health aide duty sheet documents the agency providing aide services to the patient on 01/21/2026. The case coordination notes dated 01/26/2026 documents that patient coordinator speaking with the patient’s daughter, who stated that they do not want home health aide services as the patient has ongoing follow up appointments. There is no documented evidence of the patient’s physician being notified that patient did not receive home health aide service as ordered in the Plan of Care. On 07/09/2026 at 03:30 PM, the Administrator and the Patient Safety Program Manager were interviewed and did not provide an explanation for the findings.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on clinical records review and staff interviews, the agency failed to ensure that all patients receive services as documented in their individualized plan of care. This was evident for one (1) of (9) clinical records reviewed (Patient #2). Failure to ensure that all patients receive services as documented in their individualized plan of care has the potential for negative patient outcomes. The findings are: 1. Patient #2 has a Start of Care 12/18/2025 with diagnoses of Aftercare Following Joint Replacement Surgery and Presence of Artificial Knee Joint documented on the Home Health Certification and Plan of Care for the Certification Period from 12/18/2025 to 02/15/2026. The Home Health Certification and Plan of Care (medical orders) with a Certification Period from 12/18/2025 to 02/15/2026 documents the following orders for Home Health Aide services: Home Health Aide effective 12/21/2025 3WK3, 1 WK1 (3 times a week for 3 weeks, then 1 time a week for 1 week). This equals to a total of ten (10) Home Health Aide visits. The agency contracts with a Licensed Home Care Services Agency vendor for Home Health Aide Services. The Home Health Aide (HHA) time and duty sheets document the HHA provided services to the patient on 01/06/2026, 01/07/2026, 01/08/2026, 01/09/2026 and 01/12/2026 for a total of five Home Health Aide visits. The patient did not receive Home Health Aide services as ordered on Health Certification and Plan of Care for the Certification Period from 12/18/2025 to 02/15/2026. On 03/05/2026 at 1:52 PM, the Vice President of Regional Patient Care Services stated in an interview, there was a problem with the patient’s phone number and apartment number. The patient provided two different phone numbers. The vendor did not have the patient’s apartment number. The patient’s apartment number did not get transferred to Home Health Aide Exchange. (Home Health Aide Exchange is a software program that can connect the Licensed Home Care Services Agency to the Certified Home Health Agency to allow for information to be shared). On 03/06/2026 at 12:30 PM, the Vice President of Regional Patient Care Services further stated in an interview, the Home Health Aide services should have started the week of 12/22/2025. The nurse placed the Home Health Aide services request on 12/19 and it would have made the visits start on 12/22 but because the nurse was late with her visit note documentation that did not happen. There was also the problem with the patient’s phone number and apartment number.”

“Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) The HHA must— (i) Investigate complaints made by a patient, the patient’s representative (if any), and the patient’s caregivers and family, including, but not limited to, the following topics: (A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; (B) Mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the HHA. This Element is not met as evidenced by: Based on clinical record reviews and staff interviews, the agency failed to investigate patient complaints about the dissatisfaction of the services being provided. This was evident for two (2) of nine (9) clinical records reviewed (Patients #2 and #3). Failure to investigate complaints about the dissatisfaction of the services being provided has the potential to place patients at risk for negative outcomes. The findings are: 1.Patient #3 has a Start of Care date of 01/15/2026 and discharge date of 02/26/2026 with the following diagnoses Traumatic Subdural Hemorrhage without Loss of Consciousness, Cerebrospinal Fluid Leak documented on the Home Health Certification and Plan of Care for the Certification Period 01/15/2026 to 03/15/2026. The Visit Note dated 01/21/2026 documents: Supervisory visit not performed due to VNS HHA leaving just as SN (Skilled Nurse) arrived. Spouse and daughter voiced dissatisfaction with VNS HHA (Home Health Aide) services. Family states that HHA did not receive Paraprofessional Plan of Care prior to visit. Family voiced dissatisfaction with the way VNS scheduled HHA without informing family of the time the HHA would arrive and the task the HHA would assist with. Family states that they no longer want VNS Services and they will be contacting the CFM (Clinical Field Manager) to cancel HHA services. The Patient Note (from the vendor on HHAeXchange) dated 01/17/2026 documents HHA (P.D) assigned Mon/Wed/Friday effective 1/21-02/02 2 pm to 4 pm. Detailed VM (voice message) left for the member at 1:48 pm. The Clinical Record lacks documented evidence of the agency attempting any future contact the patient after 01/17/2026. The Clinical Record lacks documented evidence of a complaint investigation regarding the patient’s spouse reporting their dissatisfaction with the HHA (Home Health Aide) services. There is no documented evidence of a complaint in the complaint log. On 03/04/2025 on 04:00 PM, the Associate Director Quality Assurance Performance Improvement was interviewed and stated that the nurse (Case Manager) thought if the patient refused HHA services, the complaint is resolved. The agency’s Patient Complaints policy and procedure, dated September 2021, documents in policy section 2a, Complaints for the purpose of this policy, are defined as reported problems concerns or dissatisfaction regarding the following: Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately. 1) Patient #2 has a Start of Care 12/18/2025 with diagnoses of aftercare following joint replacement surgery and presence of artificial knee joint documented on the Home Health Certification and Plan of Care for the Certification Period from 12/18/2025 to 02/15/2026. The Client Coordination Note Report dated 01/21/2026 documents Patient #2 called the agency on 01/21/2026 at 2:57 PM to report the following: I want to discharge from Visiting Nurse Service, there are too many issues related with my Home Health Aide services, I haven’t had a Home Health Aide visit since 01/12/26, also my insurance provided me a letter that the services should have been provided until 01/18/26, my Registered Nurse told me she is discharging me, the Physical Therapist has already discharged me but I didn’t continue receiving Home Health Aide services, I have contracted with another agency (name of agency) and just want a call from Visiting Nurse Service explaining why services were not rendered and I need this call to happen as soon as possible . . . . agent advised I will message the case manager, clinical field manager and branch for immediate call back . . . . . Follow up comment entered by (name of Registered Nurse, Clinical Field Manager) Case Manager contacted regarding patient’s request. There is no documented evidence of agency staff addressing and investigating the patient’s complaint about Home Health Aide services. On 03/05/2026 at 1:52 PM, the Vice President Regional Patient Care Services stated in an interview the complaint should have been escalated and the nurse (Case Manager) is no longer here to find out what was discussed with the patient about their complaint.”

“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 clinical records reviews and staff interviews, the agency failed to ensure each individualized plan of care includes all the required information. This was evident for two (2) of nine (9) clinical records reviewed (Patients #1 and #6). Failure to ensure each individualized plan of care includes all the required information has the potential for negative patient outcomes. The findings are: 1.Patient #6 has a Start of Care date of 02/14/2026 with the following diagnoses Aftercare Following Surgery for Neoplasm, Malignant Neoplasm of Rectum documented on the Home Health Certification and Plan of Care for the Certification Period 02/14/2026 to 04/14/2026. The RN (Registered Nurse) OASIS (Outcome and Assessment Information Set) Admission Note dated 02/14/2026 documents: Genitourinary: Indicate Genitourinary Assessment: Indwelling/Suprapubic Catheter. Indicate Indwelling/Suprapubic Catheter Findings: WNL (within normal limit). The RN (Registered Nurse) Narrative dated 02/18/2026 documents: Patient received in no distress for disease management and Ileostomy education, JP Drain education/care, Foley cath. care. Patient’s Foley Catheter is secured with 100cc of clear yellow urine bag. Patient denies abdominal pain/discomfort, or foul smelling uring when bag is emptied. The RN (Registered Nurse) Narrative dated 02/20/2026 documents: Patient reports she changed bag prior to VN arrival. VN observed removed Foley bag in trash can next to bed. VN reinforced importance of performing daily Foley Care and proper technique to secure leg bag. Patient verbalized understanding and able to perform return demonstration. The RN (Registered Nurse) Narrative dated 02/25/2026 documents: Patient reports she attended her Gynecology appointment yesterday and had Foley catheter removed. Patient denies pain or discomfort while voiding. There is no documented evidence of the Home Health Certification and Plan of Care for the Certification Period 02/14/2026 to 04/14/2026 including Foley care. On 03/06/2026 at 4:00 PM, The Vice President of Quality was interviewed and stated: “We don’t have order for Foley.” 1) Patient #1 has a Start of Care date of 02/19/2026 with diagnoses of aftercare following joint replacement surgery and presence of left artificial knee joint documented on the Home Health Certification and Plan of Care for the Certification Period from 02/19/2026 to 04/19/2026. The Visit Note Report documents the Registered Nurse conducted an initial nursing admission visit on 02/19/2026. The visit note report dated 02/19/2026 documents the patient’s surgical incision wound site was covered by a dsd (dry sterile dressing). A photograph dated 02/19/2026 included in the wound record report documents a white bandage covering the incision site. The Home Health Certification and Plan of Care (medical orders) dated 02/19/2026 to 04/19/2026 documents under treatment left knee incision, observation only at this time. The Home Health Certification and Plan of Care (medical orders) lack documented evidence of including when the bandage should be removed and what care should be provided to the incision site. On 03/05/2026 at 1:52 PM, the Vice President Regional Patient Care Services stated in an interview, they agreed that it should have been documented the coordination with the physician about what care was to be provide with the patient’s dressing and incision. 2) Patient #6 has a Start of Care date of 02/14/2026 with the following diagnoses Aftercare Following Surgery for Neoplasm, Malignant Neoplasm of Rectum documented on the Home Health Certification and Plan of Care for the Certification Period 02/14/2026 to 04/14/2026. The RN (Registered Nurse) OASIS (Outcome and Assessment Information Set) Admission Note dated 02/14/2026 documents: Genitourinary: Indicate Genitourinary Assessment: Indwelling/Suprapubic Catheter. Indicate Indwelling/Suprapubic Catheter Findings: WNL (within normal limit). The RN (Registered Nurse) Narrative dated 02/18/2026 documents: Patient received in no distress for disease management and Ileostomy education, JP Drain education/care, Foley cath. care. Patient’s Foley Catheter is secured with 100cc of clear yellow urine bag. Patient denies abdominal pain/discomfort, or foul smelling uring when bag is emptied. The RN (Registered Nurse) Narrative dated 02/20/2026 documents: Patient reports she changed bag prior to VN (Visiting Nurse) arrival. VN observed removed Foley bag in trash can next to bed. VN reinforced importance of performing daily Foley Care and proper technique to secure leg bag. Patient verbalized understanding and able to perform return demonstration. The RN (Registered Nurse) Narrative dated 02/25/2026 documents: Patient reports she attended her Gynecology appointment yesterday and had Foley catheter removed. Patient denies pain or discomfort while voiding. There is no documented evidence of the Home Health Certification and Plan of Care for the Certification Period 02/14/2026 to 04/14/2026 including Foley care. On 03/06/2026 at 4:00 PM, The Vice President of Quality was interviewed and stated: “We don’t have order for Foley.””

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on clinical records reviews and staff interviews, the agency failed to coordinate care delivery to meet the patient’s needs and involve the patient. This was evident for one (1) of nine (9) clinical records reviewed (Patient #1) Failure to coordinate care delivery to meet the patient’s needs and involve the patient has the potential for negative patient outcomes. The findings are: 1. Patient #1 has a Start of Care date of 02/19/2026 with diagnoses of Aftercare Following Joint Replacement Surgery and Presence of Left Artificial Knee Joint documented on the Home Health Certification and Plan of Care for the Certification Period from 02/19/2026 to 04/19/2026. The patient was discharged from the hospital on 02/18/2026. The Registered Nurse Visit Note Report documents the Registered Nurse conducted an initial nursing admission visit on 02/19/2026. The Visit Note Report dated 02/19/2026 documents the patient’s surgical incision wound site was covered by a dsd (dry sterile dressing). A photograph dated 02/19/2026 included in the wound record report documents a white bandage was covering the incision site. There is no documented evidence of the Registered Nurse coordinating with the patient about the patient’s discharge instructions from the hospital about when to remove the bandage and care of the incision site. On 03/05/2026 at 1:52 PM, the Vice President Regional Patient Care Services stated in an interview, they did not see any discharge instructions from the hospital in the clinical record. The nurse should have documented asking the patient about the discharge summary and going over it with the patient. The clinical record documents on 02/19/2026 at 10:29 AM, the patient signed the agency consent form, Facts About Your Home Care Services and Payment, informing the patient the initial plan of care for nursing visits was three (3) visits a week for 8 weeks. The Home Health Certification and Plan of Care (medical orders) dated 02/19/2026 to 04/19/2026 documents the frequency of nursing visits changed to Skilled Nurse, 1 WK1, 2 WK 1, 1 WK 2 (1 visit for 1 week, then 2 visits a week for 1 week, and then 1 visit a week for 2 weeks). The agency work week is from Sunday to Saturday. The initial nursing visit was on Thursday, 02/19/2026 during the work week starting on Sunday, 02/15/2026 and ending on Saturday 02/21/2026. The next work week began on Sunday, 2/22/2026 and ended on Saturday 02/28/2026. After the initial nursing visit on 02/19/2026, the next documented contact with the patient was a Coordination Notes Report dated 02/26/2026. The Coordination Notes Report dated 02/26/2026 documents the Registered Nurse entered a note for a missed visit, reason for missed visit: patient requesting no further nursing visits. From the time of the initial nursing visit on 02/19/2026 until the patient requested no further nursing visits on 02/26/2026, the clinical record lacks documented evidence of the patient being informed of the change of nursing visits from 3 times a week to 2 visits a week for 1 week, and then 1 visit a week for 2 weeks. On 03/06/2026 at 12:30 PM, the Vice President Regional Patient Care Services stated in an interview, they understood the findings but did not provide any further explanation.”

“HH aide supervision elements CFR(s): 484.80(h)(4)(i-vi) Home health aide supervision must ensure that aides furnish care in a safe and effective manner, including, but not limited to, the following elements: (i) Following the patient’s plan of care for completion of tasks assigned to a home health aide by the registered nurse or other appropriate skilled professional; (ii) Maintaining an open communication process with the patient, representative (if any), caregivers, and family; (iii) Demonstrating competency with assigned tasks; (iv) Complying with infection prevention and control policies and procedures; (v) Reporting changes in the patient’s condition; and (vi) Honoring patient rights. This Element is not met as evidenced by: Based on clinical record reviews and staff interviews, the agency failed to ensure that supervisory visits were conducted to evaluate whether home health aide services were furnished in a safe and effective manner. This was evident for one (1) of nine (9) clinical records reviewed (Patient #2). Failure to ensure that supervisory visits were conducted to evaluate whether home health aide services were furnished in a safe and effective manner has the potential for negative patient outcomes. The findings are: 1. Patient #2 has a Start of Care 12/18/2025 with diagnoses of Aftercare Following Joint Replacement Surgery and Presence of Artificial Knee Joint documented on the Home Health Certification and Plan of Care for the Certification Period from 12/18/2025 to 02/15/2026. The Home Health Aide (HHA) time and duty sheets document the Home Health Aide provided services to the patient on 01/06/2026, 01/07/2026, 01/08/2026, 01/09/2026 and 01/12/2026. From the start of Home Health Aide services on 01/06/206 until the end of Home Health Aide services on 01/12/2026 there was one skilled visit by the Registered Nurse. The Registered Nurse Visit Note Report dated 01/07/2026 documents, Visit Type: Registered Nurse plus supervision and under supervisory functions, was a supervisory visit performed? The answer was N/A (not applicable). There is no documented evidence of the Registered Nurse supervising the Home Health Aide to ensure the Home Health Aide is following the patient’s plan of care for completion of tasks; maintaining an open communication process with the patient, representative (if any), caregivers, and family; demonstrating competency with assigned tasks; complying with infection prevention and control policies and procedures; reporting changes in the patient’s condition; and honoring patient rights. On 03/06/2026 at 3:30 PM, the Vice President Regional Patient Care Services stated in an interview, they did not have any documentation of aide supervision.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information: (1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on clinical record review, policies and procedures, and staff interview, the agency failed to ensure the registered nurse conducts a comprehensive assessment of the patient’s wound(s) to reflect the patient’s current status. This was evident for one (1) of three (3) clinical records reviewed (Patients #1). Failure to ensure the registered nurse conducts a comprehensive assessment of the patient’s wound(s) to reflect the patient’s current status has the potential for negative patient outcomes. The findings are: Patient #1 has a Start of Care date of 09/11/2024 with the diagnoses Pressure Ulcer of Right Heel, Stage 4; Hypertensive Heart Disease with Heart Failure, Peripheral Vascular Disease, Unspecified. Vascular Dementia, Anxiety Disorder documented in the Home Health Certification and Plan of Care for the Certification Period 03/10/2025 to 05/08/2025. The “Assessments: Initial Comprehensive and Update to Comprehensive Assessment:” Policy (Revised 03/2025) documents: “Patient specific comprehensive assessment must accurately reflect the patient’s current health status and include:” a comprehensive physical assessment. The “Wound Evaluation and Management” Policy (Revised 6/2023) documents the following procedures: evaluate patient’s health status - perform complete physical assessment; perform basic wound evaluation; and document wound evaluation in patient’s record. The Registered Nurse Start of Care comprehensive assessment note dated 09/11/2024 documents: “Patient has unstageable pressure ulcer to right heel. No signs or symptoms of infection noted to wound site.” The Registered Nurse Coordination Note – Wound Consult Request dated 09/12/2024 documents: “Visit Date/Photo Date 9/11;” the “Indicate additional wound details” section of the Wound Consult Request is blank. The Start of Care comprehensive assessment lacks documented evidence of the registered nurse documenting a wound assessment in accordance with agency policies. . The recertification assessment dated 11/06/2024, the resumption of care assessment dated 11/29/2024, and the recertification assessment dated 01/06/2025, document: “Stage 4 Pressure Ulcer Right Heel; “no signs or symptoms of infection noted” to wound site, with no additional wound description/evaluation noted in the assessments. The recertification assessments and the resumption of care assessment lack documented evidence of the registered nurse documenting the wound evaluation and progress, in accordance with agency policies. The comprehensive assessment and updates to comprehensive assessment lack documented evidence of an accurate reflection of the patient’s current wound status. On 05/06/2025 at 1:43PM, the Vice President of Quality, the Vice President of Regional Patient Care Service, and the Associate Director of Quality were interviewed about the findings. On 05/06/2025 at 3:45PM, Vice President of Quality stated the agency has “no” additional documentation to provide for the findings.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on clinical record review, policy and procedures, and staff interview, the agency failed to ensure the skilled nurse provide services as ordered by the physician as indicated in the plan of care. This was evident for one (1) of three (3) clinical records reviewed (Patient #1). Failure to provide services that are ordered by the physician as indicated in the plan of care, has the potential for negative patient outcomes. The findings are: 1. Patient #1 has a Start of Care date of 09/11/2024 with the diagnoses Pressure Ulcer of Right Heel, Stage 4; Hypertensive Heart Disease with Heart Failure, Peripheral Vascular Disease, Unspecified. Vascular Dementia, Anxiety Disorder documented in the Home Health Certification and Plan of Care for the Certification Period 03/10/2025 to 05/08/2025. The Home Health Certification and Plan of Care for the Certification Period 09/11/2024 to 11/09/2024 documents the following wound care order: “Unstageable Pressure Ulcer Right Heel: Cleanse with Normal Saline, paint with Betadine, apply Betadine soaked gauze to wound bed, cover with gauze dressing, wrap with Kling, secure with tape 3xWeekly.” The skilled nurse “subsequent visit” note dated 09/25/2024 documents: “right heel now Stage 4 Pressure Ulcer. VN (Visiting Nurse) obtained verbal order from MD (Medical Doctor) for change in wound care treatment.” The Physician Order dated 09/25/2024 documents the following verbal wound care order: “Stage 4 Pressure Ulcer Right Heel: Cleanse with Normal Saline, apply Calcium Alginate with Silver to wound bed, apply Betadine to eschar, cover with ABD (Abdominal) pad, wrap with Kling, secure with tape 3xWeekly.” The skilled nurse “subsequent visit” notes dated 10/04/2024, 10/07/2024, 10/23/2024, and 10/30/2024 document: “Wound care provided Unstageable Pressure Ulcer Right Heel Cleanse with Normal Saline, paint with Betadine, apply Betadine soaked gauze to wound bed, cover with gauze dressing, wrap with Kling, secure with tape 3xWeekly (three times a week);” and rendered wound care as ordered. The skilled nurse visit notes lack documented evidence of the nurse providing wound care as ordered by the physician during the visits on 10/04/2024, 10/07/2024, 10/23/2024, and 10/30/2024. The Resumption of Care Physician Order dated 11/29/2024 for documents the following wound care order: “Stage 4 Pressure Ulcer Right Heel. Cleanse with Normal Saline, apply Calcium Alginate with Silver to wound bed then paint eschar with Betadine, cover with Abdominal pad, wrap with Kling, secure with tape 3xWeekly.” The skilled nurse “subsequent visit” notes dated 12/05/2024, 12/07/2024, 12/08/2024, 12//16/2024, 12/18/2024, 12/20/2024,12/23/2024, 12/25/2024, and 12/27/2024 document: “Wound care provided Unstageable Pressure Ulcer Right Heel. Cleanse with Normal Saline, paint with Betadine, apply Betadine soaked gauze to wound bed, cover with gauze dressing, wrap with Kling, secure with tape 3xWeekly;” and rendered wound care as ordered. The skilled nurse visit notes lack documented evidence of the nurse providing wound care as ordered by the physician during the visits on 12/05/2024, 12/07/2024, 12/08/2024, 12//16/2024, 12/18/2024, 12/20/2024,12/23/2024, 12/25/2024, and 12/27/2024. The skilled nurse “subsequent visit” note dated 03/05/2025 documents: “VN (Visiting Nurse) obtained updated order for MD (Medical Doctor) wound care treatment. No eschar noted to wound bed, Betadine not needed to be applied.” The Physician Order dated 03/05/2025 documents the following verbal order: “Skilled Nurse to perform/teach wound care to PU (Pressure Ulcer) Stage 4 RT (Right) Heel. Cleanse with Normal Saline, apply Calcium Alginate with Silver to wound bed, cover with ABD (Abdominal) pad, wrap wit Kling, secure with tape, using clean/septic technique 3xWeek.” The Home Health Certification and Plan of Care for the Certification Period 03/10/2025 to 05/08/2025 documents the continuation of the wound treatment order dated 03/05/2025. The skilled nurse “subsequent visit” notes dated 03/21/2025 documents: Wound care provided “Stage 4 Pressure Ulcer Right Heel. Cleanse with Normal Saline, apply Calcium Alginate with Silver to wound bed then paint eschar with Betadine, cover with abdominal pad, wrap with Kling, secure with tape 3xWeekly;” and rendered wound care as ordered. The skilled nurse visit note dated 03/21/2025 lacks documented of the nurse providing wound care as ordered by the physician. There is no documented evidence that the skilled nurse is providing wound care as ordered by the physician as indicated in the plan of care. On 05/06/2025 at 1:43PM, the Vice President of Quality, the Vice President of Regional Patient Care Service, and the Associate Director of Quality were interviewed about the findings. On 05/06/2025 at 3:45PM, Vice President of Quality stated the agency has “no” additional documentation to provide for the findings.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on clinical records review, policy and procedures, and staff interview, the agency failed to ensure the skilled nurse documents wound evaluation(s) that reflect the wound’s progress. This was evident for one (1) of three (3) clinical records reviewed (Patient #1). Failure to ensure the skilled nurse documents wound evaluation(s) that reflect the wound’s progress has the potential for negative patient outcomes. The findings are: The “Wound Evaluation and Management” Policy (Revised 6/2023) documents: “Wounds require ongoing monitoring and assessment due to continual changes in wound status and/or change in patient’s condition, which may require change in treatment plans.” The Policy inlcludes the following instructions: “Re-evaluation of wounds on each visit;” “Re-evaluation and documentation of the wound should include:” “Weekly wound measurements, and more often if indicated,” “wound bed description,” “clinical evaluation of the wound progress,” and document wound evaluation in patient’s record. 1. Patient #1 has a Start of Care date of 09/11/2024 with the diagnoses Pressure Ulcer of Right Heel, Stage 4; Hypertensive Heart Disease with Heart Failure, Peripheral Vascular Disease, Unspecified. Vascular Dementia, Anxiety Disorder documented in the Home Health Certification and Plan of Care for the Certification Period 03/10/2025 to 05/08/2025. The Home Health Certification and Plan of Care for the Certification Period 09/11/2024 to 11/09/2024 documents orders for skilled nurse visits to perform wound care to unstageable pressure ulcer right heel three times a week. The skilled nurse “subsequent visit” notes dated 09/16/2024, 09/22/2024, 09/23/2024, 09/25/2024, 09/27/2024, 09/30/2024, 10/09/2024, 10/14/2024, 10/21/2024, 10/25/2024, and 11/01/2024 document the there is no signs or symptoms of infection noted to wound site, with no wound description noted. The skilled nurse “subsequent visit” dated 09/25/2024 documents: “right heel now Stage 4 Pressure Ulcer. VN (Visiting Nurse) obtained verbal order from MD (Medical Doctor) for change in wound care treatment.” The skilled nurse visit note lacks documentation of the re-evaluation of the wound to show the progress and change in stage of the right heel pressure ulcer. The Home Health Certification and Plan of Care for the Certification Period 11/10/2024 to 01/08/2025 documents orders for skilled nurse visits to perform wound care to stage 4 pressure ulcer right heel three times a week. The skilled nurse “subsequent visit” notes dated 12/13/2024, 12/14/2024, 01/01/2025, and 01/08/2025 document there was no signs or symptoms of infection noted to wound site, with no wound description in the visit notes. The Home Health Certification and Plan of Care for the Certification Period 01/09/2025 to 03/09/2025 documents orders for skilled nurse visits to perform wound care to stage 4 pressure ulcer right heel three times a week. The skilled nurse “subsequent visit” notes dated 01/10/2025, 01/13/2025, 01/15/2025, 01/20/2025, 01/27/2025, 02/24/2025, 02/28/2025 document there was no signs or symptoms of infection noted to wound site, with no wound description in the visit notes. The Home Health Certification and Plan of Care for the Certification Period 03/10/2025 to 05/08/2025 documents orders for skilled nurse visits to perform wound care to pressure ulcer right heel three times a week. The skilled nurse “subsequent visit” notes dated 03/24/2025, 03/28/2025, 03/31/2025, 04/02/2025, 04/19/2025, and 04/20/2025 document there was no signs or symptoms of infection noted to wound site, with no wound description in the visit notes. The clinical record lacks documented evidence of the nurse performing weekly wound measurement during the following weeks: 09/15/2024 - 09/21/2024, 09/22/2024 - 09/28/2024, 09/29/2024 - 10/05/2024,10/20/2024 - 10/26/2025, 10/27/2024 - 11/02/2024, 11/03/2024 - 11/11/2024, 12/29/2024 - 01/04/2025, 01/05/2025 - 01/11/2025, 01/12/2025 - 01/18/2025, 01/19/2025 - 01/25/2025, 03/16/2025 - 03/22/2025, and 03/30/2025 - 04/05/2025 The Skilled Nurse visit notes dated 09/18/2024, 09/20/2024,10/02/2024, 10/09/2024, 10/18/2024, 11/04/2024, 11/11/2024, 01/17/2025, 03/05/2025, 03/17/2025, 03/19/2025, document the nurse was unable to access wound care management application/tool used for wound documentation due to “frozen screen,” “error message the internet connection is offline” or “application not responding.” The clinical record lacks documentation of the skilled nurse preparing clinical notes that include weekly wound measurements and re-evaluation of the wound each visit in accordance with the agency’s Policy. The clinical record lacks documented evidence of providing a complete picture of the patient’s wound status/condition to assist with monitoring the patient’s progress toward meeting plan of care goal. On 05/06/2025 at 1:43PM, the Vice President of Quality, the Vice President of Regional Patient Care Service, and the Associate Director of Quality were interviewed about the findings. On 05/06/2025 at 3:45PM, Vice President of Quality stated the agency has “no” additional documentation to provide for the findings.”

“Property and person treated with respect CFR(s): 484.50(c)(1) Have his or her property and person treated with respect; This Element is not met as evidenced by: Based on record reviews and staff interview, the agency failed to respect the preferences of the patient/family regarding the services that will be delivered and failed to keep the patient/family informed of the visit schedule and changes requested. This was evident for one (1) of three (3) clinical records reviewed (Patients #1). Failure to respect the preferences and to keep patient/family informed of services to be delivered has the potential risk for negative patient outcomes. The finding is: Patient #1 has a Start of Care date of 12/26/2024, Discharge Date of 12/31/2024, with diagnoses COVID-19, Acute Respiratory Failure with Hypoxia, Unspecified Dementia, Pneumonitis Due to Inhalation of Food and Vomit, Essential Hypertension, Bed Confinement Status documented in the Home Health Certification and Plan of Care for the Certification Period 12/26/2024 to 02/23/2025. The Home Health Certification and Plan of Care for the Certification Period 12/26/2024 to 02/23/2025 documents an order for Physical Therapy services: “1WK2 (one visit a week for two weeks);” “Physical Therapist to evaluate, to determine condition, physical therapy plans and rehabilitation potential.” The Physical Therapist Evaluation dated 12/27/2025 (Friday) documents the Physical Therapist conducted an initial evaluation and the “MD (Medical Doctor) was updated about POC (Plan of Care) 1-2xWx4W (one to two visits a week for four weeks).” The Coordination Note dated 12/27/2024 documents that after the initial evaluation, the patient’s family called (at 2:30PM) and “requested a new PT (Physical Therapist) for rest of services.” The Coordination Note dated 12/27/2024 documents the Regional Vice President’s follow-up call: The patient’s family “wants change in PT (Physical Therapist) as (Physical Therapist) was verbally rough in asking (patient) to get up. (The family) states (family) wants someone more patient.” “(The family) requested change in PT (Physical Therapist).” The Coordination Note dated 12/28/2024 (Saturday) documents the patient’s family called again and stated the following: “called about request for PT (Physical Therapist) change. Doesn’t like one assigned, not comfortable with them. No other request found sent to w/e (weekend) team for follow up.” There is no documented evidence of the agency’s follow-up to the family’s request for a change in the assigned Physical Therapist. The Coordination Note – PT (Physical Therapist) Visit Time Exception dated 12/31/2024 documents the same Physical Therapist that the family requested to be changed is scheduled to visit on 12/31/2024 (Monday). The Coordination Note dated 12/31/2024 documents: the family “called to cancel services immediately,” “CFM (Clinical Field Manager) cancelled services and informed to call MD (Medical Doctor) office for (family) to have referral sent elsewhere.” There is no documented evidence to the agency informing the patient/family that the same Physical Therapist will be returning on 12/31/2024 and if the family is in agreement. There is no documented evidence of the agency considering and respecting the family’s preference and request to change the assigned Physical Therapist with “someone more patient.” On 02/04/2025 at 03:30PM, the Vice President of Quality, the Regional Vice President and the Associate Director of QAPI (Quality Assurance and Performance Improvement) were interviewed. The Regional Vice President stated, the agency “did not have another Physical Therapist available that week” due to the holiday, and “I did not” review the calendar and discuss the scheduled visits with the family.”

“Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) The HHA must— (i) Investigate complaints made by a patient, the patient’s representative (if any), and the patient’s caregivers and family, including, but not limited to, the following topics: (A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; (B) Mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the HHA. This Element is not met as evidenced by: Based on record reviews and staff interview, the agency failed to ensure there is a complete investigation and resolution of all patient/family complaints. This was evident for one (1) of three (3) clinical records reviewed (Patient #1). Failure to ensure the complete investigation and resolution of all patient/family complaints, has the potential for negative patient outcomes. The finding is: Patient #1 has a Start of Care date of 12/26/2024, Discharge Date of 12/31/2024, with diagnoses COVID-19, Acute Respiratory Failure with Hypoxia, Unspecified Dementia, Pneumonitis Due to Inhalation of Food and Vomit, Essential Hypertension, Bed Confinement Status documented in the Home Health Certification and Plan of Care for the Certification Period 12/26/2024 to 02/23/2025. The Home Health Certification and Plan of Care for the Certification Period 12/26/2024 to 02/23/2025 documents an order for Physical Therapy services: “1WK2 (one visit a week for two weeks);” “Physical Therapist to evaluate, to determine condition, physical therapy plans and rehabilitation potential.” The complaint log dated 12/26/2024 documents a complaint received from the patient’s family regarding “Timely Care.” The complaint/grievance report dated 12/26/2024 documents: “Complaint subcategory: Delay in admitting;” “Issue Status: Resolved – Unsubstantiated;” “Issue Resolution Date: 12-26-2024;” “Findings/Investigation Details: Resolved by VP (Vice President) who documented the following: Follow up call with (family) who reports to VP (Vice President) nursing visit when well;” “(Family) reports (family) wants change in PT (Physical Therapist) as (Physical Therapist) was verbally rough in asking (patient) to get up. (Family) wants someone more patient.” “(Family) requested change in PT (Physical Therapist).” The complaint/grievance report documents a complaint investigation/resolution for timely care- Delay in admitting and includes documentation of another complaint about Physical Therapy services. The Coordination Note dated 12/27/2024 documents that after the Physical Therapist evaluation on 12/27/2024 (Friday), the patient’s family called (at 2:30PM) and “requested a new PT (Physical Therapist) for rest of services.” The Coordination Note dated 12/27/2024 documents the Regional Vice President’s communication with the family: “Follow up call with (family) who reports to VP (Vice President) nursing visit when well;” “(family) wants (to) change PT (Physical Therapist) as (Physical Therapist) was verbally rough in asking (patient) to get up. (Family) wants some more patient.” “(Family) requested change in PT (Physical Therapist).” The complaint log lacks documented evidence of the complaint received on 12/27/2024 about Physical Therapy services. There is not documented evidence of the agency conducting a complete investigation of the family’s complaint about the Physical Therapist, including interviewing the Physical Therapist and responding to the family’s request for a change in the assigned Physical Therapist. On 02/04/2025 at 03:30PM, the Vice President of Quality, the Regional Vice President, and the Associate Director of QAPI (Quality Assurance and Performance Improvement) were interviewed. The Regional Vice President of Patient Care Services stated, the “Physical Therapist was interviewed” and the family was told that the agency “did not have any Physical Therapist available that week” due to the holiday. The Regional Vice President stated, “I did not” document it.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on record reviews and staff interview, the agency failed to ensure that initial assessments are conducted within the required time frames for all patients. This was evident for one (1) of three (3) clinical records reviewed (Patient: #1). Failure to ensure that initial assessments are conducted within the required time frames for all patients, has the potential for negative outcome. The finding is: Patient #1 has a Start of Care date of 12/26/2024, Discharge Date of 12/31/2024, with diagnoses COVID-19, Acute Respiratory Failure with Hypoxia, Unspecified Dementia, Pneumonitis Due to Inhalation of Food and Vomit, Essential Hypertension, Bed Confinement Status documented in the Home Health Certification and Plan of Care for the Certification Period 12/26/2024 to 02/23/2025. The agency’s First Visit Policy (June 2022) documents: “All referrals are initially in Pending Referrals status until accepted by Clinical Field Manager (CFM);” “Acceptance of the referral must occur timely to meet state and federal requirements for initial assessment visit;” and “Registered Nurse or Physical Therapist make the initial home visit within 24 hours of receipt and acceptance of a community referral or return from institutional placement unless: (1) the patient’s authorized practitioner orders otherwise, or (2) there is written documentation that the patient or family refuses the visit.” The Coordination Note dated 12/17/2024 documents the agency received a referral from an inpatient hospital and the patient’s family was called and a message left at (718 - telephone number).” The Coordination Note – BD (Branch Director) Intake Assessment dated 12/18/2024 documents: “Requested Start of Care: 12/19/2024,” “Anticipated Discharge Date? 12/18/2024,” “Patient agreeable to homecare & visit address confirmed[Y/N]: Yes, confirmed by (family) (718 - telephone number).” The Coordination Notes – Clinical Comment Intake dated 12/19/2024 document: “Several attempts made to reach physician’s office all unsuccessful;” “Reached out to (family) regarding VMD (visiting medical doctor; I am unable to reach physician’s office and do not want to delay SOC any further. (718 - telephone number)) Left MSG (message).” The Coordination Note – Clinical Comment Intake dated 12/20/2024 documents: Family called to follow up on the referral and was informed “referral case is pending;” “email sent to IC (Intake Coordinator);“ “request reason: referral follow-up;” (family) alternate callback number (917- telephone number). The Coordination Note – Intake Coordinator dated 12/21/2024 documents: “Called placed to patient (family) to confirm acceptance of HVMD (home visit medical doctor). No answer / message left.” The VNS Health Referral Form dated 12/23/2024 documents the agency received second referral from the physician who will coordinate and sign the Home Health orders. The second referral documents the patient was discharged from the hospital on 12/18/2024 and list the patient/family’s primary phone (917 - telephone number). The Coordination Note - Follow up dated 12/23/2024 documents: Family called regarding “referral follow-up (SOC(Start of Care) inquiry);” “pending per note. VM (Voicemail) left on 12/21/24 for acceptance call.” “Called CFM (Clinical Field Manager); got VM (voicemail message; sent to the (Clinical Field Manager) for follow-up;” family callback number (917- telephone number). The Coordination Note – Follow up dated 12/26/2024 documents: “Call Notes: (Family) waiting for RN (Registered Nurse) visit. Has been 8 days / paperwork from (Doctor) faxed over and (received)/informed would have CFM (Clinical Field Manager follow up/stated wanted to speak to someone now;” Follow-up comments: “VP (Vice President) called (family) and informed we are following up on (family) call. (Family) does not understand the need to have a community physician for (patient) for home care as hospital physician should be enough.” “VP confirmed address and phone number are correct. (Family) prefers VNS to use (family) cell (917 – telephone number).” “(Clinical Field Manager) followed up with intake and (family) to assign visit for today. RN (Registered Nurse) SOC (Start of Care) today. PT (Physical Therapist) Eval tomorrow is the plan.” The coordinator notes document the family providing an alternate callback number (917 – telephone number) on 12/20/2024 and 12/23/2024. The agency failed to use the alternate callback number the family provided for timely referral acceptance and the coordination of the initial assessment/start of care visit. The “RN OASIS Admission” Visit Note dated 12/26/2024 documents a Start of Care assessment and Inpatient Discharge Date: 12/18/2024. The initial/Start of Care assessment visit is eight (8) days after the patient’s discharge from the hospital. There is no documented evidence of the agency conducting the Initial Assessment visit within 24 hours of receipt and acceptance of community referral or return home from hospital, as specified in the agency’s First Visit Policy. On 02/04/2025 at 03:30PM, the Vice President of Quality Assurance and Performance Improvement, the Regional Vice President of Patient Care Services and the Associate Director of QAPI was interviewed. The Regional Vice President of Patient Care Services stated that we confirmed the preferred phone number (917 – telephone number) on 12/26/2024.”

“Within 48 hours of the patient’s return CFR(s): 484.55(d)(2) Within 48 hours of the patient’s return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This Element is not met as evidenced by: Based on record reviews, agency policy and staff interview, the agency failed to ensure comprehensive assessments are updated and revised within forty-eight (48) hours of the patient’s return to the home from a hospital admission of twenty-four (24) hours or more. This was evident for one (1) of three (3) clinical records reviewed (Patient #2). Failure to ensure comprehensive assessments are updated within 48 hours of a patient’s return from a hospital admission, has the potential for negative patient outcomes. The finding is: Patient #2 has a Start of Care date of 12/23/2024, Discharge Date of 12/31/2024, with diagnoses Pressure Ulcer of Sacral Region Stage 4, Fracture of femur, Hypertensive Heart Disease, Chronic Systolic Congestive Heart Failure, Unspecified Dementias, History of Falling documented in the Home Health Certification and Plan of Care for the Certification Period 12/23/2024 to 02/20/2025. The agency’s Resumption of Care Policy (March 2022) documents: “Resumption of Care visit and comprehensive OASIS assessment to be done within 48 hours of the patient’s return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on a physician-ordered resumption date;” “CFM (Clinical Field Manager) reviews ROC (Resumption of Care) coordination note and adds follow-up comments when processing the ROC (Resumption of Care);””CFM (Clinical Field Manager) creates order Schedule ROC (Resumption of Care) Visit for the Registered Nurse;” and “Scheduler assigns ROC (Resumption of Care) visit to a registered nurse to be made within 48 hours of discharge from an inpatient facility.” The Coordinator Note dated 12/27/2024 documents: “Informed by patient’s (family)/(Caregiver) that patient fell out of the hospital bed. (Caregiver) called 911. Patient taken to (Hospital). As per CG (Caregiver), patient was evaluated. No injuries noted. Patient admitted to hospital for pneumonia.” The hospital Inpatient Clinical Summary dated 12/30/2024 documents the patient was hospitalized from 12/25/2024 to 12/30/2024 and discharged “under the care of Home Health Services.” The Coordinator Note - Resumption of Care dated 12/30/2024 documents a request for the resumption of care to “resume all prior services” and “Follow-up comment entered by (name) CFM (Clinical Field Manager) on 01/03/2025: ROC (Resumption of Care) set up.” The Physician Order entered and dated 01/03/2024 by the Clinical Field Manager documents an order for the Resumption of Care visit: “SN (Skilled Nurse) effective 12/29/2224 (week of) 1WK1(One visit for one week).” The January 2925 visit calendar documents a Registered Nurse/Skilled Nurser visit scheduled for 01/03/2025. The clinical record documents the agency received and entered the physician order to conduct the Resumption of Care visit four (4) days after the patient was discharged from the hospital. There is no documented evidence of the Clinical Field Manager reviewing the Resumption of Care coordination note in a timely manner to prevent delays in processing Resumption of Care, as specified in the agency’s policy. The Coordination Note dated 01/03/2025 documents the agency’s initial communication with the family/caregiver to schedule and confirm the Resumption of Care visit was four days after the patient’s discharge from the hospital. The Coordination Note documents the patient’s family/caregiver “requested the ROC (Resumption of Care) for Monday 1/6/25.” The compliant/grievance report dated 01/14/2025 documents the family/caregiver complained about timely care: “(caregiver) upset about the nurses coming in without sufficient notice.” The clinical record lacks documented evidence of the agency’s communicating with the patient or caregiver immediately after the hospital discharge and/or prior to 01/03/2025 to schedule the resumption of care visit. The clinical record documents a delay in communication with the patient/caregiver regarding the resumption of care visit. The RN Resumption of Care Assessment/ OASIS (Outcome and Assessment Information Set) dated 01/06/2025documents: Date of Assessment Completed: 01/06/2025 and Inpatient Discharge Date: 12/30/2024, seven (7) days after the patient was discharged from the hospital. There is no documented evidence of a Registered Nurse completing the resumption assessment visit within 48 hours of the patient’s return to the home from a hospital admission. On 02/04/2025 at 03:30pm, the Vice President of Quality Assurance and Performance Improvement, the Regional Vice President of Patient Care Services and the Associate Director of QAPI was interviewed. The Regional Vice President of Patient Care Services stated, “the Manager (Clinical Field Manager) did not review the ROC (Resumption of Care) request until 1/3.””

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on record reviews, and staff interviews, the agency failed to coordinate care delivery to meet the patient’s needs and involve the patient/family. This was evident for one (1) of three (3) clinical records reviewed (Patient #1). Failure to coordinate care delivery to meet the patient’s needs and involve the patient/family, has the potential for negative patient outcomes. The finding is: Patient #1 has a Start of Care date of 12/26/2024, Discharge Date of 12/31/2024, with diagnoses COVID-19, Acute Respiratory Failure with Hypoxia, Unspecified Dementia, Pneumonitis Due to Inhalation of Food and Vomit, Essential Hypertension, Bed Confinement Status documented in the Home Health Certification and Plan of Care for the Certification Period 12/26/2024 to 02/23/2025. The Home Health Certification and Plan of Care for the Certification Period 12/26/2024 to 02/23/2025 documents an order for Physical Therapy services: “1WK2 (one visit a week for two weeks);” “Physical Therapist to evaluate, to determine condition, physical therapy plans and rehabilitation potential.” The Physical Therapist Evaluation dated 12/27/2025 (Friday) documents the Physical Therapist conducted an initial evaluation and “MD (Medical Doctor) was updated about POC (Plan of Care) 1-2xWx4W (one to two visit a week for four weeks).” The Coordination Note dated 12/27/2024 documents that after the initial evaluation on 12/27/2024, the patient’s family called (at 2:30PM) and “requested a new PT (Physical Therapist) for rest of services.” The Coordination Note dated 12/27/2024 documents the Regional Vice President’s follow-up call: The patient’s family “wants change in PT (Physical Therapist) as (Physical Therapist) was verbally rough in asking (patient) to get up. (Family)) states (family) wants someone more patient.” “Family)) requested change in PT (Physical Therapist).” The Coordination Note dated 12/28/2025 (Saturday) documents the patient’s family called again and stated the following: “called about request for PT (Physical Therapist) change. Doesn’t like one assigned, not comfortable with them. No other request found sent to w/e (weekend) team for follow up.” The clinical record lacks documented evidence of the agency communicating with patient/family on 12/27/2024 or on 12/28/2024 regarding the family’s request to change the assigned Physical Therapist. The Coordination note – PT (Physical Therapist) Visit Time Exception dated 12/31/2024 documents the same Physical Therapist, that the family accused of being “verbally rough” and lacking patience, is scheduled to visit on 12/31/2024 (Monday). The clinical record lacks documented evidence of the agency informing the patient/family that the same Physical Therapist is scheduled to return on 12/31/2024 and if they are in agreement. The clinical record lacks documented evidence of the agency coordinating and involving the patient/family in care delivery of physical therapy services and the request for changes. On 02/04/2025 at 03:30PM, the Vice President of Quality, the Regional Vice President, and the Vice President Director of QAPI was interviewed. The Regional Vice President of Patient Care Services stated, the agency “did not have another Physical Therapist available that week” due to the holiday, and “I did not” review the calendar and discuss the scheduled visits with the family.”

“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 clinical records review and staff interview the agency failed to complete an investigation of all complaints. This was evident for one (1) of six (6) patient care records reviewed (Patient #1). Failure to complete an investigation of all complaints, has the potential for negative patient outcomes. The Finding Are: 1. Patient #1 has a Start of Care date of 07/21/2023 with the following diagnoses “Pressure Ulcer of Right Buttock, stage 4, other Dystonia, other Hydronephrosis “ documented on the Home Health Certification and Plan of Care for the Certification Period 01/17/2024 to 03/16/2024. The Client Episode Coordination Note dated 03/16/2024 documents: “Numerous calls today from patient Advocate The are the complaints: VNS are responsible for the wounds/conditions, should, be treating differently The clinician should not be packing a wound when it is infected? It appears the patient has been recommended for surgery-and we VNS are responsible Considers it is our responsibility to refer to other MD’s such as wound specialist No VNS folder in the home(Explained as the patient has been active for several months-folder may have been mislaid I explained to the Advocate the Nurse follows the MD orders and there is communication between the clinician and the MD Wound care orders are under the direction of the MD as is all patient care She/and the patient and her sister state they do not know the MD an the Doctor has not seen the patient Note: There is COC Note the MD had an appointment with the patient on 03/08/23 and the documentation indicates constant communication between the Nurse and the MD. ..” There is no documented evidence of a complaint in the complaint log. On 04/04/2024 at 02:00pm, the Vice President of Quality and the Vice President of Regional Patient Services were interviewed and did not provide an explanation for the findings.”

“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 clinical record reviews, and staff interview, the agency failed to ensure each patient’s individualized plan of care included all the required information. This was evident for two (2) of six (6) patient care records reviewed (Patient’s #2 and #3). Failure to ensure individualized plan of care is established for all patients has the potential risk for negative patient outcomes. The findings are: 1. Patient #2 has a Start of Care date of 03/19/2024 with the following diagnoses “Chronic Obstructive Pulmonary Disease with Lower Respiratory Infection, Pneumonia” documented in the Home Health Certification and Plan of Care dated 03/19/2024 to 05/17/2024. The Home Health Certification and Plan of Care dated 03/19/2024 to 05/17/2024 documents: “SN (skilled nurse) 2WK1 (twice a week for one week), 1WK1 (once a week for one week), 1 every 3WK3 (once every three weeks for three weeks).” The Order dated 03/22/2024 documents: “Skilled nurse to perform/teach wound care to R (right) posterior lower leg Skin graft recipient site, cleanse with NS (normal saline), cover with DSD (dry sterile dressing) & gauze wrap TIW (three times a week) & PRN (as needed), may leave open to air if no drainage.” The Client Calendar Report documents the registered nurse visits on: 03/19/2024, 03/22/2024, and 03/29/2024. The Plan of Care lacks documented evidence of the correct frequency for skilled nursing visit including three times a week as per the wound care order. There is no documented evidence of a complete plan of care to meet the patient needs. On 04/04/2024 at 02:00pm, the Vice President of Quality and the Vice President of Regional Patient Services were interviewed and did not provide an explanation for the findings. 2. Patient #3 has a Start of Care date of 07/24/2021 with the following diagnoses “Pressure Ulcer of Sacral Region stage 3, Parkinson’s Disease” documented in the Home Health Certification and Plan of Care dated 03/10/2024 to 05/08/2024. The Home Health Certification and Plan of Care dated 03/10/2024 to 05/08/2024 documents: “SN (skilled nurse) 1WK1 (once a week for one week), 1every2WK8 (once every two weeks for eight weeks).” “Skilled nurse to perform/teach stage III pressure ulcer care. Cleanse with NS (normal saline) apply MediHoney cover with Foam dressing using clean/aseptic technique. QOD (every other day) nurse for skilled observation. Family perform wound care other times.” The Plan of Care lacks documented evidence of the correct frequency for skilled nursing visit including every other day as per the wound care order. There is no documented evidence of a complete plan of care to meet the patient needs. On 04/04/2024 at 02:00pm, the Vice President of Quality and the Vice President of Regional Patient Services were interviewed and did not provide an explanation for the findings.”

“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 clinical record review and staff interview, the agency failed to ensure that treatments are provided as ordered by a physician. This was evident for one (1) of six (6) patient care records reviewed (Patient #3). Failure to ensure that treatments are provided as ordered by the physician has the potential for negative patient outcomes. The findings are: 1. Patient #3 has a Start of Care date of 07/24/2021 with the following diagnoses “Pressure Ulcer of Sacral Region stage 3, Parkinson’s Disease” documented in the Home Health Certification and Plan of Care dated 03/10/2024 to 05/08/2024. The Home Health Certification and Plan of Care dated 03/10/2024 to 05/08/2024 documents: “Skilled nurse to perform/teach stage III pressure ulcer care. Cleanse with NS (normal saline) apply MediHoney cover with Foam dressing using clean/aseptic technique. QOD (every other day) nurse for skilled observation. Family perform wound care other times.” The Visit Note Report dated 03/14/2024 and 03/28/2024 documents: “Skilled nurse for skilled observation of wound cleanse with NS (normal saline) apply Aquacel AG Allevyn QOD (every other day). There is no documented evidence that the wound treatments were administered only as ordered by the physician – order is MediHoney but being treated with Aquacel AG Allevyn. There is no documented evidence of the treatment being provided in accordance with the plan of care. On 04/04/2024 at 02:00pm, the Vice President of Quality and the Vice President of Regional Patient Services were interviewed and did not provide an explanation for the findings.”

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on clinical record reviews, and staff interview, the agency failed to ensure all verbal orders are put in writing. This was evident for one (1) of six (6) patient care records reviewed (Patient #2). Failure to ensure all verbal order are put in writing, has the potential risk for negative patient outcomes. The findings are: 1. Patient #2 has a Start of Care date of 03/19/2024 with the following diagnoses “Chronic Obstructive Pulmonary Disease with Lower Respiratory Infection, Pneumonia” documented in the Home Health Certification and Plan of Care dated 03/19/2024 to 05/17/2024. The Home Health Certification and Plan of Care dated 03/19/2024 to 05/17/2024 documents “Medication: Eliquis 2.5 mg (milligram) tablet 1 tablet 2 times daily; Methocarbamol 500 mg (milligram) tablet 2 tablets 4 times daily.” The Client Episode Coordination Notes Report dated 03/29/2024 documents: “Patient states that Eliquis & (and) Methacarmol (Methocarbamol) were discontinued.” The clinical record lacks documented evidence of the verbal order being put in writing and sent to the physician for verification/authentication of the change in medications. On 04/04/2024 at 02:00pm, the Vice President of Quality and the Vice President of Regional Patient Services were interviewed and did not provide an explanation for the findings.”

“Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on clinical record reviews, and staff interviews, the agency failed to ensure that patient’s care is communicated with the physician. This was evident for one (1) of six (6) patient care records reviewed (Patient #2). Failure to ensure that patient’s care is communicated with the physician, has the potential for negative patient outcomes. The findings are: 1. Patient #2 has a Start of Care date of 03/19/2024 with the following diagnoses “Chronic Obstructive Pulmonary Disease with Lower Respiratory Infection, Pneumonia” documented in the Home Health Certification and Plan of Care dated 03/19/2024 to 05/17/2024. The Home Health Certification and Plan of Care dated 03/19/2024 to 05/17/2024 documents: “OT (Occupation Therapy) effective 03/24/2024 1WK1 (once a week for one week); SN (skilled nurse) 2WK1 (twice a week for one week), 1WK1 (once a week for one week), 1 every 3WK3 (once every three weeks for three weeks).” The Client Episode Coordination Notes Report documents: 03/22/2024 “she is requesting for all visits to be in the afternoon.” 03/26/2024 “per HHAX (home health aide exchange) soc (start of care) 3/29/24.” 04/01/2024 “Spoke with patient; she had multiple issues she wanted to discuss” “she is asking for an OT (occupational therapy) evaluation” “She is also asking for the HHA (home health aide). It was 2:10pm and the aide had not arrived. (Aide service is scheduled from 1-4pm).” 04/01/02024 “Visit Discipline: OT (occupational therapy)” “Reason for missed visit: schedule overload.” The Order dated 03/22/2024 documents: “Skilled nurse to perform/teach wound care to R (right) posterior lower leg Skin graft recipient site, cleanse with NS (normal saline), cover with DSD (dry sterile dressing) & gauze wrap TIW (three times a week) & PRN (as needed), may leave open to air if no drainage.” The Client Calendar Report documents: OT (Occupational Therapy) add-on evaluation on 04/03/2024 and registered nurse visits on: 03/19/2024, 03/22/2024, and 03/29/2024. The Visit Note Report dated 03/29/2024 documents “wound care not provided – observation only”. There is no documented evidence that the physician was notified of no occupational therapy evaluation from 3/24/2024 until 04/02/2024; skilled nurse: missed two visit the week of 03/24/2024, no visits scheduled for the week of 03/31/2024 and wound not treated on 03/29/2024; and delay in aide services. The clinical record lacks documented evidence of all the Clinicians coordinating with the physician to meet the care needs of the patient. On 04/04/2024 at 03:30pm, the Vice President of Quality and the Vice President of Regional Patient Services were interviewed and did not provide an explanation for the findings.”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on clinical record reviews, and staff interviews, the agency failed to coordinate care delivery and involve the patient to ensure patient needs are addressed. This was evident for one (1) of six (6) patient care records reviewed (Patient #2). Failure to ensure that patient’s care is coordinated, and all patient needs are addressed, has the potential for negative patient outcomes. The findings are: 1. Patient #2 has a Start of Care date of 03/19/2024 with the following diagnoses “Chronic Obstructive Pulmonary Disease with Lower Respiratory Infection, Pneumonia” documented in the Home Health Certification and Plan of Care dated 03/19/2024 to 05/17/2024. The Home Health Certification and Plan of Care dated 03/19/2024 to 05/17/2024 documents: “OT (Occupation Therapy) effective 03/24/2024 1WK1 (once a week for one week).” The Client Episode Coordination Notes Report documents: 03/22/2024 “Pt (patient) calling about a complaint.” “she is requesting for all visits to be in the afternoon.” “did not get P/T (physical therapy) and OT (occupational therapy).” 03/26/2024 “Pt (patient name and number) express concern about requesting change P/T (physical therapy), need O/T (occupational therapy) visit update and hha schedule.” 03/26/2024 “CFM (case field manager) returned call to patient and addressed her concerns. She was told that (name) will be her PT (physical therapy) and OT (occupational therapy name) is scheduled to see her on Thursday.” 03/26/2024 “per HHAX (home health aide exchange) soc (start of care) 3/29/24.” 03/28/2024 “Pt (patient name and number) call in regards to a visit P/T (physical therapy) and O/T (occupational therapy) suppose to come today which was a no show. The same thing happen on Tuesday. If I don’t get a call from VNS the next time to cancel visit I am going to the board of health.” “Pt (patient) request status of HHA (home health aide). In reviewing HHA (home health aide) Exchange Auth# 86903 from 03/29/24 to 4/20/24. Informed caller. HHA (home health aide) assigned for 3/29/24 from 9am to 12:00m (noon). Informed caller. Patient is requesting HHA (home health aide) services for in the afternoon for 1 pm to 4 pm.” Agency was notified of afternoon services only on 03/22/2024. 03/28/2024 “CFM (case field manager) called patient and there was no answer. Left VM (voice message) to call back. Follow up needed.” 03/29/2024 “Patient is awaiting occupational therapy.” 04/01/2024 “Spoke with patient; she had multiple issues she wanted to discuss” “she is asking for an OT (occupational therapy) evaluation” “She is also asking for the HHA (home health aide). It was 2:10pm and the aide had not arrived. (Aide service is scheduled from 1-4pm).” 04/01/02024 “Visit Discipline: OT (occupational therapy)” “Reason for missed visit: schedule overload.” The Client Calendar Report documents: OT (Occupational Therapy) add-on evaluation on 04/03/2024. There is no documented evidence that the patient was notified of delay and cancellation in services for occupational therapy and aide services. The clinical record lacks documented evidence of all the Clinicians coordinating with the patient to meet the care needs of the patient. On 04/04/2024 at 03:30pm, the Vice President of Quality and the Vice President of Regional Patient Services were interviewed and did not provide an explanation for the findings.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on clinical care record review and staff interviews, the governing authority failed to provide services that are ordered by the physician as indicated in the plan of care. This was evident for two (2) of six (6) patient care records reviewed (Patient’s #2 and #6). Failure to provide services that are ordered by the physician as indicated in the plan of care, has the potential for negative patient outcomes. The findings are: 1. Patient #2 has a Start of Care date of 03/19/2024 with the following diagnoses “Chronic Obstructive Pulmonary Disease with Lower Respiratory Infection, Pneumonia” documented in the Home Health Certification and Plan of Care dated 03/19/2024 to 05/17/2024. The Home Health Certification and Plan of Care dated 03/19/2024 to 05/17/2024 documents: OT (Occupation Therapy) effective 03/24/2024 1WK1 (once a week for one week). The Order dated 03/22/2024 documents: “Skilled nurse to perform/teach wound care to R (right) posterior lower leg skin graft recipient site, cleanse with NS (normal saline), cover with DSD (dry sterile dressing) & gauze wrap TIW (three times a week) & PRN (as needed), may leave open to air if no drainage.” The Client Calendar Report documents: OT (occupational therapy) add-on evaluation on 04/03/2024 and registered nurse visits on: 03/19/2024, 03/22/2024, and 03/29/2024. The Visit Note Report dated 03/29/2024 documents “wound care not provided – observation only”. The clinical record lacks documented evidence that the patient received occupational therapy the week of 03/24/2024, missed one visit; and skilled nurse missed two visit the week of 03/24/2024, and no visits scheduled for the week of 03/31/2024. There is no documented evidence of the treatment of wound by the skilled nurse on 03/29/2023. The clinical record lacks documented evidence of the patient receiving occupational therapy and skilled nurse services as ordered on the plan of care. On 04/04/2024 at 03:30pm, the Vice President of Quality and the Vice President of Regional Patient Services were interviewed and did not provide an explanation for the findings. 2. Patient #6 has a Start of Care date of 02/17/2024 with the following diagnoses “Chronic Obstructive Pulmonary Disease, Interstitial Pulmonary Disease” documented in the Home Health Certification and Plan of Care dated 02/17/2024 to 04/16/2024. The Resumption of Care dated 03/21/2024 documents: SN (skilled nurse) effective 03/17/2024 2WK3 (twice a week for three weeks); PT (physical therapy) effective 03/24/2024 1WK1 (once a week for one week).” The Client Calendar Report documents: skilled nurse visit on 3/21/2024 and 04/02/2024 and a missed visit on 03/29/2024. The clinical record lacks documented evidence that the patient received skilled nurse: missed one visit the week of 03/17/2024 and 03/24/2024; and physical therapy: missed one visit the week of 03/17/2024. The clinical record lacks documented evidence of the patient receiving skilled nurse services and physical therapy as ordered on the plan of care. On 04/04/2024 at 03:30pm, the Vice President of Quality and the Vice President of Regional Patient Services were interviewed and did not provide an explanation for the findings.”

“Property and person treated with respect CFR(s): 484.50(c)(1) Have his or her property and person treated with respect; This Element is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to ensure that respect for all patient’s preferences regarding services that will be delivered. This was evident for one (1) of six (6) clinical records reviewed (Patient #1). Failure to ensure that patient is treated with consideration, respect, and full recognition of her dignity has the potential for negative patient outcomes. The findings are: 1. Patient #4 has a Start of Care date of 11/12/2023, Discharge Date of 11/16/2023, with diagnoses Primary Osteoarthritis Right Shoulder and Strain of Muscle/Tendon of the Rotator Cuff of Right Shoulder Subsequent Encounter documented in the Home Health Certification and Plan of Care dated 11/12/2023 to 01/10/2024. The Coordination Note dated 11/15/2023 documents the following telephone call from the patient: “Time of Call 11/15/2023 5:08PM;” Call Notes: “(Patient #4) states VNS staff keeps call her and want it to stop. Pt (Patient) states want a message to be sent to (Branch Director). (Patient) wants the staff at VNS Health to stop calling her or she will call police for harassment.” The Clinical Field Manager Coordination Note dated 11/16/2023 (Last Update 11/16/2023 8:53AM) documents the following: “MD (name) is notified about patient refusal of all services from VNS Health.” The Discharge/Transfer Summary Report documents: “Discharged 11/16/2023.” The Home Health Certification and Plan of Care dated 11/12/2023 to 01/10/2024 documents orders for home health aide services three days a week. The Coordination Note dated 11/16/2023 documents the following call from the home health aide vendor: “Time of Call: 11/16/2023 1:57PM;” “Supervisor from personal care (vendor) calling on behalf of (Patient #4) to inform the Branch Clinical manager she contact(ed) the patient to inform her the start (of) services for the (home health aide) schedule for tomorrow starting at 10:00AM to 1:00PM and also inform the name of the (home health aide) assign(ed) for her services; patient refuse to talk to the Supervisor and request she only will speak with (Branch Director) and hang up the phone.” The Coordination Note-(Home Health Aide) Assignment Notification note dated 11/16/2023 documents: “Time of Call: 11/16/2023 2:41PM;” “Comments: Per (Home Health Aide vendor). (start of care) - 11/17/2023; schedule M/W/F, 3hrs (hours), Time 10-1pm; (Permanent) (home health aide’s name).” The Coordination Note dated 11/17/2023 documents: “Time of Call 11/17/2023 9:59 AM;” personal care (vendor) “called about (start of care) for (home health aide) today; (aide) is at door; but patient will only speak to (Branch Director) only or (Registered Nurse). (Patient) D/C(Discharged) 11/16/23.” The Coordination Note dated 11/17/2023 12:01 PM documents another communication from the vendor: “9:40am 11/17 tc (telephone call) rec’d from (home health aide) to inform (vendor supervisor) she arrived at (Patient #4) home and spoke to (patient) who said (patient) told her the nurse or (Branch Director) should be calling her with details of her services. (Supervisor) attempt to speak to (Patient #4) who refused to speak to me. (Home health aide) advised to wait till reach out to Team. 9:47am (telephone call) made to CHHA Team. (Customer Service Representative) was advised (patient) refusing to speak with (vendor Supervisor) or accept (home health aide) into her home, requesting nurse or (Branch Director) to (contact) her. Per (Customer Service Representative) Mbr’s (Member’s) case is discharged as of 11/16 but she will contact Team for confirmation.” There is no documented evidence of the agency immediately communicating with the vendor of the patient’s discharge on 11/16/2023, after notifying the physician on 11/16/2023 in AM. There is no documented evidence of the agency communicating with the patient about the aide arriving to start services on 11/17/2023. There is no documented evidence of the patient being treated with consideration and respect. On 12/07/2023 at 04:30 pm, the Associate Vice President of Quality, the Senior Vice President for Patient Care Services/Administrator/Director of Patient Services, the Vice President for Patient Care Services, the Vice President for Regional Patient Care Services, and the Associate Director of Quality were interviewed and did not provide an explanation for the finding.”

“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 clinical record review and staff interview, the agency failed to ensure that services and treatments are administered only as ordered by the physician for each patient. This was evident for one (2) of six (6) clinical records reviewed. (Patient #2 and #6). Failure to ensure that treatments are administered only as ordered by the physician has the potential to result in poor quality of care. The findings are: 1. Patient #4 has a Start of Care date of 11/12/2023, Discharge Date of 11/16/2023, with diagnoses Primary Osteoarthritis Right Shoulder and Strain of Muscle/Tendon of the Rotator Cuff of Right Shoulder Subsequent Encounter documented in the Home Health Certification and Plan of Care dated 11/12/2023 to 01/10/2024. The Registered Nurse Start of Care assessment notes dated 11/12/2023 document: patient has a non-removeable dressing in place on the Right Shoulder Surgical Incision site; “presents for right should scope, SAD (Shoulder Subacromial Decompression), RCR (Rotator Cuff Repair), distal clavicle resection with Dr. (name) on 11/08/23; same day surgency under regional anesthesia for a pre-operative diagnosis of traumatic tear of right rotator cuff, arthritis of right shoulder region, and biceps tenonitis on right.” “Surgical wound covered by steri-strip and 1 incision.” The After Visit Summary/Discharge Instructions dated 11/08/2023 document the following postoperative care instructions for the patient: “You may shower on postoperative day #3. Remove the Dressing and all the gauze pads. Leave steri-strips (special white band-aids) in place;” “you may apply soap to your neck and allow the soapy water to run over your shoulder;” “Pat the shoulder dry with a towel and apply new waterproof band-aids over the surgical incision;” “Do not submerge the incision in water;” “November 20, 2023 Post-OP (visit) with PA (Physician Assistant).” The Home Health Certification and Plan of Care dated 11/12/2023 to 01/10/2024 documents: “Skilled Nurse (SN) to perform teach wound care to surgical incision at right shoulder coved with steri strips, observation only.” The Registered Nurse/Skilled Nurse Start of Care assessment notes dated 11/12/2023 document: patient has a non-removeable dressing in place on the Right Shoulder Surgical Incision; “presents for right should scope, SAD (Shoulder Subacromial Decompression), RCR (Rotator Cuff Repair), distal clavicle resection with Dr. (name) on 11/08/23; same day surgency under regional anesthesia for a pre-operative diagnosis of traumatic tear of right rotator cuff, arthritis of right shoulder region, and biceps tenonitis on right.” “Surgical wound covered by steri-strip and 1 incision not included in the picture attached by Dermabind (Dermabond).” The subsequent Skilled Nurse Visit note dated 11/15/2023 documents: “Right shoulder incision site dressing removed by VN (visiting nurse). VN (Visiting nurse) covered the incision site with gauze because (Patient #4) insisted to cover the incision site despite the fact MD recommendation remove dressing 3 days post-surgery and leave it open to air.” The Coordination Note date 11/15/2023 documents the patient called and reported the following: “Your RN (Registered Nurse/Skilled Nurse) did not have tape and couldn’t dress the wound properly.” The clinical record lacks documented evidence of an order for the Skilled Nurse to remove the surgical dressing and cover with gauze. There is no documented evidence of the Skilled Nurse communicating with the physician to clarify postoperative wound care instructions. including the Post-op instructions given to the patient on 11/08/2023 to apply waterproof band-aid, and to obtain the wound care orders to change the dressing. There is no documented evidence that the services and treatments were administered only as ordered by the physician. On 12/07/2023 at 04:30 pm, the Associate Vice President of Quality, the /Senior Vice President for Patient Care Services/Administrator/Director of Patient Services, the Vice President for Patient Care Services, the Vice President for Regional Patient Care Services, and the Associate Director of Quality were interviewed and did not provide an explanation for the finding. 2. Patient #6 has a Start of Care date of 10/29/2023 with diagnoses Pressure Ulcer pf Sacra; Region Stage 2, Encounter for Fitting and Adjustment of Urinary Device, Other Retention of Urine, Personal History of Urinary (Tract) Infections Primary, Bed Confinement Status documented in the Home Health Certification and Plan of Care dated 10/29/2023 to 12/27/2023. The Registered Nurse SOC assessment notes dated 10/29/2023 document: Patient “hospitalized from 10/11 – 10/27 for complicated UTI (Urinary Tract Infection), Course of ABT (Antibiotic) completed;” “(Patient) has Foley (catheter) urine retention;” “Per (Patient), Foley (catheter) change is due this week between 11/1 – 11/3.” “(Patient) requested if possible, can nurse take over Foley (catheter) change since he is bedbound. (Patient) was instructed that (Medical Doctor) will need to be contacted to get order to do so.” The Coordination Note-Physician Communication dated 10/30/2023 documents: “Summary of information provided: Attempted to reach (Medical Doctor) to reconfirm wound care frequency and if (visiting nurse) can start providing monthly (catheter) change for (Patient). (Visiting nurse) was instructed to call back (tomorrow) when (Medical Doctor) office open.” The Registered Nurse Visit Note dated 11/05/2/2023 documents: “Patient) inquired about Foley and if could be changed;” “(Patient) was last seen by Urologist (name) in June. But voiced that Foley was changed early in October. (Visiting nurse) suggested to (family member) if Foley is due now he will need to go to ER to have it changed.” The Registered Nurse Visit Note dated 11/06/2023 documents: “Patient inquiring about replacing Foley catheter. (Visiting nurse) has ordered supplies in the meantime. Patient unwilling to go to (Emergency Room) for treatment at this time.” The Registered Nurse Visit Note dated 11/08/2023 documents: “Foley (catheter) in Parachute (Medical Equipment/Supplies ordering and tracking system) pending delivery.” The Coordination Note dated 11/10/2023 documents: “(Patient’s family member) states the (Patient) catheter is leaking. (Patient) has supplies at home. Requests (Registered Nurse) visit for today.” The Registered Nurse Visit Note dated 11/10/2023 documents: “(Patient) received Foley bag and Foley (catheter), but not universal tray to perform Foley care. Foley not in proper placement as (Patient)) was found soiled in own urine and feces and drainage bag was noted empty.” “EMS (Emergency Medical Services) activated.” The clinical record lacks documented evidence of the nurse obtaining an order to perform Foley catheter change, including the required supplies. On 12/07/2023 at 04:30 pm, the Associate Vice President of Quality, the Senior Vice President for Patient Care Services/Administrator/Director of Patient Services, the Vice President for Patient Care Services, the Vice President for Regional Patient Care Services, and the Associate Director of Quality were interviewed and did not provide an explanation for the finding.”