Girling Health Care of New York

“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: A straight catheter is used to drain urine from the bladder and is removed immediately. A foley catheter is an indwelling tube that stays in the bladder to continuously drain urine. Patient #4 has a Start of Care date of 02/25/2026 with the following diagnoses of Malignant Neoplasm of Bladder, Unspecified, Anemia, Hematuria, and Thrombocytopenia as documented on the Home Health Certification and Plan of Care for the Period 02/25/2026 to 04/25/2026. The Home Health Certification and Plan of Care for the Period 02/25/2026 to 04/25/2026 documents – patient using straight cath 14” (size14 French catheter) crg (caregiver) assisting with foley care. The Collaboration Note Report (start of care summary) dated 02/25/2026 documents: Foley cath (catheter) will be followed up by MD (Medical Doctor) only. …patient using straight cath 14” (size14 French catheter) crg (caregiver) assisting with foley care. The Home Health Certification and Plan of Care and The Collaboration Note Report (Start of Care Summary) lacks documented evidence of an accurate assessment of patient’s current urinary catheter needs – straight catheter or foley catheter. On 05/19/2026 at 03:10 PM, the Administrator/Director of Patient Services and the Vice President of Clinical Quality 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: Patient #4 has a Start of Care date of 02/25/2026 with the following diagnoses of Malignant Neoplasm of Bladder, Unspecified, Anemia, Hematuria, and Thrombocytopenia as documented on the Home Health Certification and Plan of Care for the Period 02/25/2026 to 04/25/2026. The Home Health Certification and Plan of Care for the Period 02/25/2026 to 04/25/2026 documents – patient using straight cath 14” (size14 French catheter) crg (caregiver) assisting with foley care. SN (Skilled Nurse) assess GU (genitourinary) status incl (including) amount, color, clarity and pain. The RN (Registered Nurse) Teaching Revisit for 03/04/2026, 03/12/2026 and the RN (Registered Nurse) Procedure Visit dated 03/06/2026 does not include an assessment of the GU (genitourinary) status incl (including) amount, color, clarity and pain. The clinical record lacks documented evidence of the genitourinary status assessment as written in the plan of care. On 05/19/2026 at 03:10 PM, the Administrator/Director of Patient Services and the Vice President of Clinical Quality 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 care record review and staff interviews, the governing authority failed to ensure that treatments are provided as ordered. This was evident for one (1) of four (4) clinical care records reviewed (Patient #2). Failure to ensure that treatments are provided as ordered has the potential for negative patient outcomes. The findings are: 1. Patient #2 has a start of care date of 3/01/2024 with the diagnosis Pressure Ulcer of Sacral Region Stage 4, Encounter for Fitting and Adjustment of Urinary Device documented in the Plan of Treatment dated 02/19/2026 to 04/19/2026. The Plan of Treatment dated 02/19/2026 to 04/19/2026 documents: Wound care order as follows: SN (skilled nurse) to cleanse wound with NSS (normal saline solution) solution, pat dry, apply Silvasorb to wound bed, followed with Hydrofera Blue dressing, cut to site, cover with Gentle Sacrum Foam (Optifoam is being used) dressing. Wound care to be done daily. The shipping of supplies for wound supplies are as follows: 12/05/2025 -4 boxes of Gauze, 2 gel Silvasorb 1.5 oz, and 1 box Optifoam bordered 6x6; 12/09/2025 -2 boxes of Optifoam bordered 5x5; 01/09/2026 -2 gel Silvasorb 1.5 oz, 4 saline solution 250 ml each, 3 boxes Optifoam bordered 4x4, 5 each Hydrofera blue 2.5.x2.5; 01/23/2026 -2 gel Silvasorb, 4 saline solution, 3 boxes Optifoam bordered 4x4, 5 each Hydofera blue 2.5x2.5; 03/23/2026- 4 boxes Gauze, 2 boxes Optifoam bordered 5x5. For the Optifoam bordered dressing, 1 box contains 10 per box. On 01/23/2026, three (3) boxes were ordered with a total of 30 dressings. The next order date was 03/23/2026. The supplies cover until 02/23/2026. There is no documented evidence of enough dressings for the period 02/23/2026 to 03/23/2026. For the Hydrofera blue dressing, on 01/23/2026, five (5) each (not a box) of 2.5x2.5, were ordered, 1 piece per day for the wound size of 4x4, will be used. The 5 pieces of Hydrofera blue will only cover for 5 days. There is no documented evidence of enough Hydrofera blue dressing being ordered for the period between 12/05/2025 to 03/23/2026. On 04/20/2026 at 1:30 PM the Administrator/DPS and the Compliance Officer were interviewed and stated, the patient has hired a private wound doctor, who uses his own supplies for the wound treatment, following the primary physician’s order, and leaves some wound supplies in the home which the nurses are using. There is no documented evidence of the documentation and coordination regarding who will provide wound supplies ordering. There is no documented evidence of an adequate order of daily wound supplies. On 05/04/2026 at 1:52 PM the patient’s family member was interviewed and stated, the private physician does not provide supplies. Wound supplies like Silvasorb gel and Optifoam, are not enough so they order from (website name).”

“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 reviews and staff interviews, the agency failed to ensure completion of a comprehensive assessment to accurately reflect the patient’s current health status. This was evident for one (1) of three (3) clinical records reviewed (Patient#1). Failure to ensure completion of a comprehensive assessment to accurately reflect the patient’s status, has the potential for negative patient outcomes. The findings are: Patient#1 has a Start of Care date of 10/15/2025, Resumption of Care date of 11/17/2025 and a discharge date of 12/03/2025 with the following diagnoses “Hypertensive Heart Disease with Heart Failure, Chronic Systolic Congestive Heart Failure, Atherosclerotic Heart Disease, Ischemic Cardiomyopathy, Chronic Atrial Fibrillation, Presence of Aortocoronary Bypass Graft, Presence of Automatic Implantable Cardiac Defibrillator, and Other Long term (Current) Drug Therapy” documented in the Home Health Certification and Plan of Care for the Certification Period 10/15/2025 to 12/13/2025. The Policy “Standards of Care and Practice” Revised November 2024 documents the following: “Procedure No. 3- Ongoing assessments will determine if the standards of care continue to be appropriate for patient needs. If the patient presents with complex medical needs and it is determined at the assessment/reassessment visit that the needs cannot be safely met at home, then the clinician will communicate with the Clinical Supervisor/ Director of Patient Services/ Administrator and the physician to report the need for alternate care. The agency will make arrangement for safe transfer to the appropriate health care facility/ activate 911 emergency services; Procedure#6- Use of standards of care and practice will be evident in the documentation of visits and assessments, as well as in the care planning process.” The Policy” Reassessment/Recertification” Revised November 2024 documents the following: “Purpose: To outline the requirements for ongoing updates to the comprehensive assessment(reassessments) and recertification.; Procedure No. 7- Documentation in the clinical record should support the assessment as well as actions taken in response.” The “Case Communication Report” Entered: 11/14/2025 documents the following: “Subject: Order Cancellation-Missed Visit (Nurse was present in the patient’s home); SOC (Start of Care) was not done; Patient need high level care. 911 called, Badge Number 8376 ; MD (Medical Doctor) informed.” The “ROC (Resumption of Care) Teaching” Visit Date 11/17/2025 contains the SN (Skilled Nursing) SOC/ROC (Resumption of Care) OASIS (Outcome and Assessment Information Set); Clinical notes “ROC (Resumption of Care) completed on 11/17/2025, Booklet was reviewed with patient regarding rights/ responsibilities.” The clinical record lacks documented evidence of a comprehensive assessment being completed during the nurse home visit on 11/14/2025 to accurately reflect the patient’s current health status including the determination of patient’s need for high level of care, which resulted in the EMS 911 call. On 12/17/2025 at 3:30 PM, the Administrator/ Director of Patient Services was interviewed and stated “On 11/14/2025, we sent a nurse to do the ROC (Resumption of Care) assessment but based on the nurse’s findings that time, the patient needs a high level of care, and that’s the reason for calling the EMS (Emergency Medical Services).””

“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 clinical record reviews and staff interviews, the agency failed to ensure comprehensive assessments are updated and revised within 48 hours of the patient’s return to the home from the hospital admission. This was evident for one (1) of three (3) clinical records reviewed (Patient #1). Failure to ensure assessments are updated and revised within 48 hours of the patient’s return to the home from the hospital admission has the potential for negative patient outcome. The findings are: Patient#1 has a Start of Care date of 10/15/2025, Resumption of Care date of 11/17/2025 and a discharge date of 12/03/2025 with the following diagnoses “Hypertensive Heart Disease with Heart Failure, Chronic Systolic Congestive Heart Failure, Atherosclerotic Heart Disease, Ischemic Cardiomyopathy, Chronic Atrial Fibrillation, Presence of Aortocoronary Bypass Graft, Presence of Automatic Implantable Cardiac Defibrillator, and Other Long term (Current) Drug Therapy” documented in the Home Health Certification and Plan of Care for the Certification Period 10/15/2025 to 12/13/2025. The “Transfer to Inpatient Facility (OASIS-E1 V2)” documents the following: “(M0090) Date Assessment Completed: 11/01/2025; (M0100) Reason for Assessment: 6- Transferred to an inpatient facility-patient not discharged from agency; (M0150) Current Payment Sources for Home Care:1- Medicare (traditional fee-for-service); (M2301) Emergent Care: 2-Yes, used hospital emergency department with hospital admission; (M2410) To which Inpatient Facility has the patient been admitted:1-Hospital;(M0906) Discharge/Transfer Date: 11/01/2025.” The “Referral Information #89227132 dated 11/3/2025 documents the following: “MRN (Medical Record Number) 0255622; Arrival Date/Time: 11/1/2025 ,12:05 AM ET (Eastern Time);Projected Discharge Date: 11/4/2025, 11:00 AM ET (Eastern Time) Response Received: 11/03/2025 1:48 PM ET (Eastern Time); Response Reason: Accept” The “Nursing Visit Record-Amerita” (Vendor contract infusion services) documents the following: “Date of Visit: 11/06/2025; Place of Service: Home; Reason for Visit: Other: ROC (Resumption of Care).” The “Nursing Visit Record-Amerita” (Vendor contract infusion services) documents the following: “Date of Visit: 11/12/2025; Place of Service: Home; Reason for Visit: Central Line Dressing Change, Lab draw.” An Internal email from Director of Business Development 11/14/2025, 1:34 PM documents the following: “Subject: Re: Urgent Need ROC- (Patient#1) – RNCM (Registered Nurse Case Manager)- “Name” My apologies- There was a lot of confusion with this patient due to multiple factors including other agencies and change in service area. Girling is active with the patient and as per t/c (telephone call) ROC (Resumption of Care) for today. Please have your team send over their visit dates and notes as soon as possible.” The “ROC (Resumption of Care) Teaching” Visit Date 11/17/2025 documents the SN (Skilled Nursing) SOC/ROC (Resumption of Care) OASIS (Outcome and Assessment Information Set); Clinical notes “ROC completed on 11/17/2025, Booklet was reviewed with patient regarding rights/ responsibilities.” The clinical record lacks documented evidence of a comprehensive assessment within 48 (forty eight) hours of the patient’s return to the home from hospital admission and prior the resumption of Amerita (Vendor contract infusion services) on 11/06/2025 and 11/12/2025. 12/18/2025 at 10:15 AM-, the Administrator/Director of Patient Services and Director of Clinical Quality were interviewed, the Administrator/Director of Patient Services stated, “It was unknown to us that patient has been back home. The email on 11/14/2025 from our Director of Business Development is the only communication regarding the patient’s return to home. What she can remember was it’s the infusion vendor company (Amerita) who called her about the patient was already home. The IV infusion services (Amerita) have been provided in the patient’s home on 11/06/2025 and 11/12/2025. The patient was probably discharged from the hospital either on 11/05 or 11/06 because it’s a continuous IV medication from the hospital.””

“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 reviews and staff interviews, the agency failed to ensure all orders are recorded in the plan of care. This was evident for one (1) of three (3) clinical records reviewed (Patient #1). Failure to ensure all orders including any verbal orders are recorded in the patient’s plan of care has the potential for negative patient outcome. The findings are: Patient#1 has a Start of Care date of 10/15/2025, Resumption of Care date of 11/17/2025 and a discharge date of 12/03/2025 with the following diagnoses “Hypertensive Heart Disease with Heart Failure, Chronic Systolic Congestive Heart Failure, Atherosclerotic Heart Disease, Ischemic Cardiomyopathy, Chronic Atrial Fibrillation, Presence of Aortocoronary Bypass Graft, Presence of Automatic Implantable Cardiac Defibrillator, and Other Long term (Current) Drug Therapy” documented in the Home Health Certification and Plan of Care for the Certification Period 10/15/2025 to 12/13/2025. The “Amerita- Product and Nursing Services Agreement” documents the following: “2. Obligations of Agency: a. general- Agency shall purchase from Amerita of New York, Inc. during the term of this agreement the products and nursing services set forth on Schedule A in such quantities or amounts as Agency requests and orders from Amerita of New York Inc. ; f. Prescriptions- Agency shall provide Amerita of New York Inc. with a written prescription or physician order for all products and services related to the therapy that are requested to be supplied by Amerita of New York Inc. to Agency under this agreement, in advance of such products or services being supplied.” The “Nursing Visit Record-Amerita” (Vendor contract infusion services) documents the following: “Date of Visit: 11/06/2025; Place of Service: Home; Reason for Visit: Other: ROC (Resumption of Care).” The “Nursing Visit Record-Amerita” (Vendor contract infusion services) documents the following: “Date of Visit: 11/12/2025; Place of Service: Home; Reason for Visit: Central Line Dressing Change, Lab draw.” The “Interim /Supplemental Order # 1170628 documents the following: “Begin Date:11/17/2025; End Date:12/13/2025; ROC (Resumption of Care) 11/17/2025; To resume 485 Orders (Home Health and Certification and Plan of Care); For order: SN 2WK1, 1WK3; Amerita Care IV authorized a max of 2 SN visits/week, max 2 Hours/ visit for IV infusion; HHA LOC 3WK1, 5WK1, 3WK2, x 4 hours Effective 11/18/2025.” The clinical record lacks documented evidence of the order, including any verbal orders being recorded in the plan of care for the patient’s IV (intravenous) infusion services provided on 11/06/2025 and 11/12/2025. On 12/17/2025 at 4:10 PM, the Administrator/ Director of Patient Services was interviewed and stated, “We are paying the infusion company (Amerita) with the nursing infusion services that they provide with our patients. Girling is in-charge of overall patient’s plan of care.””

“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 ensure coordination of care delivery and involve the patient, representative, and caregiver in the coordination of care activities. This was evident for one (1) of three (3) clinical records reviewed (Patient #1). Failure to ensure coordinated care delivery and involve the patient, representative, and caregiver in the coordination of care activities has the potential for negative patient outcome. The findings are: Patient#1 has a Start of Care date of 10/15/2025, Resumption of Care date of 11/17/2025 and a discharge date of 12/03/2025 with the following diagnoses “Hypertensive Heart Disease with Heart Failure, Chronic Systolic Congestive Heart Failure, Atherosclerotic Heart Disease, Ischemic Cardiomyopathy, Chronic Atrial Fibrillation, Presence of Aortocoronary Bypass Graft, Presence of Automatic Implantable Cardiac Defibrillator, and Other Long term (Current) Drug Therapy” documented in the Home Health Certification and Plan of Care for the Certification Period 10/15/2025 to 12/13/2025. The Policy “Care Coordination” Revised November 2024 documents the following: “Procedure No.4- Care Coordination will include but not limited to: L.) Coordination of care delivery to meet the patient’s needs and involve the patient, representative and caregivers as appropriate in the coordination of care activities; Procedure No. 7.- Organization personnel will communicate changes in a timely manner via telephone, one-on-one meetings, case conferences and home visits. Documentation of all communications will be included in the clinical record on a communication note, case conference summary or clinical note. Documentation will include: the date and time of the communication, individuals involved with the communication, information discussed and the outcome of the communication.” An Internal email from Director of Business Development 11/14/2025, 1:34 PM documents the following: “Subject: Re: Urgent Need ROC- (Patient#1) – RNCM (Registered Nurse Case Manager)- “Name” My apologies- There was a lot of confusion with this patient due to multiple factors including other agencies and change in service area. Girling is active with the patient and as per t/c (telephone call) ROC (Resumption of Care) for today. Please have your team send over their visit dates and notes as soon as possible.” The “Case Communication Report” Entered: 11/14/2025 documents the following: “Subject: Order Cancellation-Missed Visit (Nurse was present in the patient’s home); SOC (Start of Care) was not done; Patient need high level care. 911 called, Badge Number 8376; MD (Medical Doctor) informed.” The clinical record lacks documented evidence of patient, family or authorized representative being involved in the coordination of care delivery specifically the care activity to be provided prior to conducting the nurse’s home visit on 11/14/2025. On 12/18/2025 at 11:21 AM, the Administrator/ Director of Patient Services and Director of Clinical Quality were interviewed, the Administrator/ Director of Patient Services “Our Intake coordinator usually does the phone call to patient/ family or representative for the initial visits before sending the nurse. We document certain instances like if the nurse was not able to get in or if no one is answering the door. Patient#1 is alert and oriented and the patient’s wife allowed our nurse to come inside the home on 11/14/2025.””

“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 the Home Health Aide follows the paraprofessional plan of care for completion of assigned tasks. This was evident for one (1) of six (6) clinical records reviewed (Patient: #1). Failure to ensure the Home Health Aide follows the paraprofessional plan of care for completion of assigned tasks, has potential for negative patient outcomes. The Findings Are: Patient # 1 has a Start of Care date of 12/26/2024 and discharge date of 02/07/2025 with the following diagnoses “Fracture of Medial Orbital Wall, Left Side, Subsequent Encounter for Fracture with Routine Healing, Laceration without Foreign Body of Other Part of the Head, Subsequent Encounter, and Unspecified Dementia, Unspecified Severity Without Behavioral Disturbances, Psychotic Disturbance, Mood Disturbance and Anxiety” documented on 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: “12/30/2024-02/21/2025 - Aide 5 week 8 x 7 hours (five times a week for eight weeks, seven hours a day)”. The “HHA POC (Home Health Aide Plan Of Care)” dated 12/27/2024 documents the following tasks frequency QV (Every Visit): Mouth/ Denture Care; Grooming-Shave; Foot Care; Toileting-Toilet; Prepare Breakfast/Lunch/Dinner; Assist with Walking; and Assist with Home Exercise Programs. There is no documented evidence for completion of the following tasks: “Mouth/ Denture Care”, “Grooming-Shave “, “Foot Care”, and “Assist with Home Exercise Program” on 02/03/2025. There is no documented evidence for completion of the following tasks: “Mouth/ Denture Care”, “Grooming-Shave “, “Foot Care”, “Toileting-Toilet”, “Prepare Breakfast/Lunch/ Dinner”; “Assist with Walking”; and “Assist with Home Exercise Program” on 02/04/2025 and 02/05/2025. There is no documented evidence for completion of “Home Exercise Program” on 02/06/2025. The clinical record lacks documented evidence of the Home Health Aide following the paraprofessional plan of care for completion of assigned tasks. On 03/11/2025 at 2:50PM, the findings were reviewed with the Administrator/Director of Patient Services, and the Director of Clinical Quality and no explanation was provided.”

“Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient’s status at the time of assessment. This Standard is not met as evidenced by: Based on clinical record review and staff interview the agency failed to ensure all encoded OASIS (Outcome and Assessment Information Set) assessments accurately reflect each patient’s status at the time of the assessment. This was evident for three (3) of (13) clinical discharged records reviewed (Patient: #6, #12, and #18). Failure to ensure all encoded OASIS (Outcome and Assessment Information Set) Assessments accurately reflect the patient’s status at the time of the assessment, has the potential for negative patient outcomes. The findings are: 3. Patient # 6 (PAE-Potentially Avoidable Event) has a Start of Care date of 08/23/2023 and discharge date of 10/05/2023 with the following diagnoses “Chronic Obstructive Pulmonary Disease, Hypertensive Heart Disease with Heart Failure, Chronic Kidney Disease” documented on the Home Health Certification and Plan of Care for the Certification Period 08/23/2023 to 10/21/2023. The RN (Registered Nurse) Start of Care OASIS (Outcome and Assessment Information Set) dated 08/23/2023 documents: “(M1600) Urinary Infection 0 - No. The RN (Registered Nurse) Discharge OASIS (Outcome and Assessment Information Set) dated 09/05/2023 documents: “M1600 Urinary Infection 1 - Yes.” The clinical record lacks documented evidence that the patient was treated for UTI. There is no documented evidence of the Discharge OASIS (Outcome and Assessment Information Set)- from agency on 09/05/2023 accurately reflects the patient’s status at the time of assessment. On 01/31/2024 at 04:00 pm, the Director of Patient Services was interviewed and stated that the patient did not have UTI. 2.Patient #18 has a Start of Care date of 02/08/2023 with the following diagnoses “Pressure Ulcer of Sacral Region Stage 2, Type 2 Diabetes Mellitus, Alzheimer’s Disease, Dementia” documented in the Home Health Certification and Plan of Care dated 10/06/2023 to 12/04/2023. The ROC (resumption of care) Procedure dated 04/06/2023 documents: (M1306) Does this patient have at least one Unhealed Pressure Ulcer/Injury at Stage 2 or Higher or designated as Unstageable? Yes (M1311) Stage 2: 0 (M1311) Stage 3: 1 (M1324) Stage the Most Problematic Unhealed Pressure Ulcer/Injury that is Stageable: Stage 3 The LPN (licensed practical nurse) Procedure Visit dated 10/25/2023 documents: “Wound #1 Sacrum, pressure ulcer Stage 3.” “Wound #2 Right buttock pressure ulcer Stage 2.” “Wound #3 Left buttock pressure ulcer Stage 2.” “Wound #4 Right 1st toe, skin tear.” “Patient developed new wnd (wound) Unstageable on Rt (right) buttock.” The D/C (Discharge) Not to Inpatient Facility (OASIS-E [Outcome and Assessment Information Set]) dated 10/31/2023 documents: (M1307) The Oldest Stage 2 Pressure Ulcer that is present at discharge: Was present at the most recent SOC/ROC (start of care/resumption of care) assessment. (M1311) A2. Number of these Stage 2 pressure ulcers that were present at most recent SOC/ROC (start of care/resumption of care): 1 (M1311) B2. Number of these Stage 3 pressure ulcers that were present at most recent SOC/ROC (start of care/resumption of care): - (none) (M1311) Unstageable: Non-removable dressing/device: - (none) (M1311) Unstageable: Slough and/or eschar: - (none) (M1311) Unstageable: Deep tissue injury: - (none) The Discharge OASIS (Outcome and Assessment Information Set) lacks documented evidence of an accurate status of patient: should be Stage 2 – not present at resumption of care, Stage 3 - present at resumption of care, and with new Unstageable on right buttocks 10/25/2023. On 02/02/2024 at 3:53pm, the Administrator/Director of Patient Services, the Vice President of Rehabilitation, and the Clinical Case Manager Supervisor were interviewed and did not provide an explanation for the findings. 1. Patient #12 has a Start of Care of 09/29/2023, Discharge Date of 10/10/2023, with the diagnoses Other Encephalopathy, Convulsions, Chronic Atrial Fibrillation, Type 2 Diabetes Mellitus, Anemia, Retention of Urine, Encounter for Fitting and Adjustment of Urinary Device, documented in the Home Health Certification and Plan of Care dated 09/29/2023 to 11/27/2023. The Registered Nurse Start of Care OASIS (Outcome and Assessment Information Set)/comprehensive assessment note dated 09/29/2023 documents: “patient has Dx (diagnosis) of - UTI (Urinary Tract Infection);” and “(M1600) Urinary Infection: 0 – No.” The Discharge OASIS (Outcome and Assessment Information Set) assessment dated 10/10/2023 documents: “(M1600) Urinary Infection: 1 - Yes.” The Start of Care OASIS (Outcome and Assessment Information Set) comprehensive assessment lacks documented evidence of accurately reflecting the patient’s urinary infection status at the time of assessment. On 02/01/2024 at 4:00 PM, the Administrator/Director of Patient Services, the Clinical Case Manager/Supervisor, and the Vice President of Rehabilitation were interviewed, and did not provide an explanation for the finding.”

“Investigation of complaints CFR(s): 484.50(e)(1) Standard: Investigation of complaints. The HHA must-- This Standard is not met as evidenced by: Based on Complaint log review, clinical record review, and staff interview, the agency failed to ensure all complaints are logged, tracked and investigated. This was evident for one (1) of twenty-six (26) clinical records reviewed. (Patient #22). Failure to ensure all complaints are logged, tracked and investigated has the potential for negative patient outcomes. The findings are: 1.Patient #22 has a Start of Care date of 03/03/23 and discharge date of 4/12/23 with diagnoses “Hypertensive Heart and Chronic Kidney Disease, or Unspecified Chronic Kidney Disease, Heart Failure, unspecified, Acute Myeloblastic Leukemia, Not Having Achieved Remission” documented on the Home Health Certification and Plan of Care for Certification Period 03/03/23 to 05/01/23. The Home Health Certification and Plan of Care for Certification Period 03/03/23 to 05/01/23 documents: home health services being ordered for Patient #22 as follows: “03/07/2023 – 3/19/2023- Aide 4 Week 1; 5 Week1 X 4 hours: ( Four times a week for one week, five times a week for one week for four hours) 03/20/2023 – 4/12/2023 Aide 5 Week 2; 3 Week 1; 2 Week 1 x 4 hours ( five times a week for two weeks, three times a week for one week, two times a week for one week for four hours). The agency’s Complaint/ Grievance Process policy documents: “Patients can freely voice complaints regarding care, treatment or services that are (or fail to be provided or are provided inconsistently or inappropriately. All complaints will be logged, tracked, trended, and filed.” The emails dated 3/14/23 documents: “7:50AM To: On call: “Subject Patient #1 my aide didn’t show up today or yesterday.” 9:08AM Please follow-up with patient regarding her HHA (Home health aide) not showing up. 9:30AM Spoke with son requested t/c (telephone call) from Home health aide supervisor. Very angry that no hha yesterday or today.” 3/14/23 11: 49AM I just received telephone call from Department of Health son reported that Home health aide services had not started, no home health aide yesterday or today. The HHAeXchange Member Calendar documents: Month: March year: 2023: 3/13: Missed Visit The HHA eXchange Duty Sheet documents: “Week (3/11/2023 – 3/17/2023: Tuesday 3/14: Time In: 12:45 Timeout: 16:45 The Case Communication Report Documents: “Entered 4/5/2023: 11:07:12PM: Completed: 4/5/2023 11: 07:24PM: Late Entry: 3/14/23 9:30 a: Case Manager spoke with son Tracy via telephone this morning. He requested telephone call from home health aide supervisor. Caregiver was very angry stating patient has not received services/ home health aide yesterday (3/13/23) or today (3/14/23), dept (department) is following up (Name) has also called to complain.” The agency’s Quality log 2023 lacks documented evidence of the telephone complaint from Patient #1’s son on 3/14/23 regarding no hha services on 3/13 and 3/14/23. The clinical record lacks documented evidence of the agency following its complaint policy and procedure. On 2/1/24 at 3:50PM the Administrator/Director of Patient Services was interviewed and did not provide an explanation for the findings.”

“Content of the comprehensive assessment CFR(s): 484.55(c) 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: This Standard is not met as evidenced by: Based on clinical record review, and staff interview, the agency failed to ensure the comprehensive assessment accurately reflect the patient’s status. This was evident for one (1) of twenty-six (26) clinical records reviewed (Patient: #18). Failure to ensure the comprehensive assessment accurately reflects the patient’s status, has the potential for negative patient outcomes. The findings are: 1.Patient #18 has a Start of Care date of 02/08/2023 with the following diagnoses “Pressure Ulcer of Sacral Region Stage 2, Type 2 Diabetes Mellitus, Alzheimer’s Disease, Dementia” documented in the Home Health Certification and Plan of Care dated 10/06/2023 to 12/04/2023. The Procedure Recert (recertification) dated 06/03/2023 and 08/04/2023 documents wound #2 right buttock Stage 2, wound bed red granulation tissue. The RN (registered nurse) Procedure Revisit documents: 09/26/2023 “Patient’s wound #1 pressure ulcer Stage 3 was noted increased in size and depth with black tissue possibly necrotic to the base of the wound.” “Wound bad black tissue, with moderate/large amount serosanguineous drainage, periwound red, inflamed.” 10/20/2023 “Wound#1: Sacrum (stage 3): Black eschar at wound bed.” There is no documented evidence of an accurate staging of the pressure ulcer – stage 2 with granulation tissue or stage 3 with necrosis, black tissue. The LPN (licensed practical nurse) Procedure Visit dated 10/25/2023 documents: “Wound #1 Sacrum, pressure ulcer Stage 3.” “Wound #2 Right buttock pressure ulcer stage 2.” “Wound #3 Left buttock pressure ulcer Stage 2.” “Wound #4 Right 1st toe, skin tear.” “Patient developed new wnd (wound) Unstageable on Rt(right) buttock.” The D/C (Discharge) Not to Inpatient Facility (OASIS-E [Outcome and Assessment Information Set]) dated 10/31/2023 documents: Unstageable: Non-removable dressing/device: - (none) Unstageable: Slough and/or eschar: - (none) Unstageable: Deep tissue injury: - (none) The Discharge OASIS (Outcome and Assessment Information Set) lacks documented evidence of an accurate status of patient, with new Unstageable wound on right buttocks 10/25/2023. There is no documented evidence of the patient’s accurate health status. On 02/02/2024 at 3:53pm, the Administrator/Director of Patient Services, the Vice President of Rehabilitation, and the Clinical Case Manager Supervisor 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 record review and staff interview the agency failed to ensure all patients receive home health services as documented in their individualized plan of care. This was evident for five (5) of twenty-six (26) clinical records reviewed (Patient: #8, #16, #17, #21and #23). Failure to ensure all patients receive home health services as documented on their plan of care has the potential for negative patient outcomes. The findings are: 1.Patient #23 has a Start of Care date of 10/01/22, and discharge date of 2/23/23 with diagnosis “Unspecified Fracture of the Lower End of the Radius, Subsequent Encounter for Closed Fracture with Routine Healing” on the Home Health Certification and Plan of Care for Certification Period 01/29/23 to 03/29/23. The Home Health Certification and Plan of Care for Certification Period 01/29/23 to 03/29/23 documents: “01/30/23 – 3/29/23: Aide 5 Week 8; 3 Week 1 x 6 hours (Five times a week for eight weeks; three times a week for one week for six hours). HHA to assist patient with personal care, remind patient to take medication, assist with ADL (Activities of Daily Living), Bathing, Grooming, Meal Prep, Dressing, Toileting, Skin care assist, light housekeeping, Meal preparation, Fall prevention program.” The HHAeXchange Plan of Care (POC) documents: Description/ Task: Bath-Shower: Dressing: Skin Care: Foot Care: Prepare Breakfast: Assist with Feeding: Assist with walking: Remind to take medication: Instruction: Every Visit: As Requested: N0. There is no documented evidence of the following Description/ Task: Breakfast, Assist with feeding, Remind to take Medication, Foot Care, Skin Care, Bath/Shower being provided by the aide on 1/30 – 2/3, 2/6, 2/13, 2/17, 2/20, 2/21, and 2/23 The clinical lacks documented evidence of the aide providing all the services as documented in the patient’s individualized plan of care. On 2/1/24 at 3:15PM the Administrator/Director of Patient Services and the Clinical Case Manager/Supervisor were interviewed and did not provide an explanation for the findings. 3.Patient #16 has a Start of Care (SOC) date of 01/16/2024, with the following diagnoses “Parkinson’s Disease, Other Low Back Pain, Pain in Unspecified Joint” documented in the Home Health Certification and Plan of Care dated 01/16/2024 to 03/15/2024. The Home Health Certification and Plan of Care dated 01/16/2024 to 03/15/2024 documents: 01/18/2024 – 1/27/2024 Aide 3 week 1 (three times a week for one week); 6 week 1 (six times a week for one week) x 2 hrs. (for two hours per day); 01/22/2024 - 2/2/2024 Aide 3 week 2 (three times a week for two weeks) x 4hrs (for four hours per day). The Duty Sheet documents aide providing services on: 01/18/2024, 01/22/2024, 01/24/2024, and 01/26/2024. There is no documented evidence of the patient receiving aide services as ordered on the plan of care, missing two visits between 01/18/2024 to 01/21/2024. On 02/01/2024 at 4:15pm, the Administrator/Director of Patient Services, the Vice President of Rehabilitation, and the Clinical Case Manager Supervisor were interviewed and did not provide an explanation for the findings. 4.Patient #17 has a Start of Care (SOC) date of 11/27/2023, with the following diagnoses “Other Fracture of Left Lower Leg, Type 2 Diabetes Mellitus, Hypertensive Heart Disease with Heart Failure” documented in the Home Health Certification and Plan of Care dated 11/27/2023 to 01/25/2024. The Home Health Certification and Plan of Care dated 11/27/2023 to 01/25/2024 documents: “11/29/2023 – 1/25/2024 aide 3 week 1 (three times a week for one week); 5 week 7 (five times a week for seven weeks); 4 week 1 (four times a week for one week). The Duty Sheet documents aide providing services on: 12/01/2023, 12/04/2023 to 12/08/2023, 12/11/2023, 01/03/2024, 01/05/2024, 01/09/2024 to 01/12/2024, 01/15/2024 to 01/19/2024, and 01/23/2024 to 01/26/2024. The Print Visit Detail documents missed aide visit on 12/12/2023, 12/22/2023, and 12/25/2023 to 12/27/2023. There is no documented evidence of the patient receiving aide services as ordered on the plan of care . The patient is missing 2 visits between 11/29/2023 to 12/03/2023, missing 3 visits between 12/11/2023 to 12/17/2023, missing 4 visits between 12/18/2023 to 12/24/2023, missing 3 visits between 01/01/2024 to 01/07/2024, and missing 1 visit on 01/08/2024. On 02/02/2024 at 3:53pm, the Administrator/Director of Patient Services, the Vice President of Rehabilitation, and the Clinical Case Manager Supervisor were interviewed and did not provide an explanation for the findings. 5.Patient #21 has a Start of Care date of 08/12/2023 and a discharge date of 08/21/2023 with the following diagnoses “Rhabdomyolysis, Type 2 Diabetes Mellitus, Atrial Fibrillation” documented in the Home Health Certification and Plan of Care dated 08/12/2023 to 10/10/2023. The Home Health Certification and Plan of Care dated 08/12/2023 to 10/10/2023 documents: “08/15/2023 – 08/25/2023 – Aide 4 Week 2 X 4 hrs (four times a week for two weeks times four hours a day).” The Duty Sheet documents the aide providing services on: 08/16/2023, 08/17/2023, and 08/18/2023. There is no documented evidence of the patient receiving aide services as ordered on the plan of care, the patient is missing one aide visit on 08/15/2023. On 02/02/2024 at 3:53pm, the Administrator/Director of Patient Services, the Vice President of Rehabilitation, and the Clinical Case Manager Supervisor were interviewed and did not provide an explanation for the findings. 2.Patient #8 has a Start of Care date of 12/20/2023 with the diagnoses Pressure Ulcer of Sacral Region Stage 2, Pressure Ulcer of Other Site Stage 3, Pressure Ulcer of Other Site Stage 2, Parkinson’s Disease, Dementia, Depression, Type 2 Diabetes Mellitus, Muscle Weakness documented in the Home Health Certification and Plan of Care dated 12/20/2023 to 02/17/2024. The Home Health Certification and Plan of Care dated 12/20/2023 to 02/17/2024 documents: “SN (Skilled Nurse) to instruct pt(patient)/cg(caregiver) on importance of pressure ulcers prevention, turning/repositioning Q2 (every two) HRS (hours);” and Goals: “Patient/Caregiver will be knowledgeable of skin care and preventions of pressure ulcers within 9 weeks;” “patient will have no new skin breakdown during the certification period.” The start of care comprehensive assessment note dated 12/20/2023 documents the following assessment of the patient: “bed fast, dependent on assistance for mobility (including turning/repositioning) toileting and self-care; three pressure ulcers – Coccyx Pressure Ulcer Stage 2, Left Foot Big Toe Pressure Ulcer Stage 3, and Left Foot 2nd Toe Pressure Ulcer Stage 2”. The Skilled Nurse visit notes dated 12/20/2023, 12/22/2023, 12/25/2023, 12/27/2023, 12/29/2023, 01/01/2024, 01/03/2024, 01/05/2024, and 01/08/2024 lacks documented evidence of the Skilled nurse instructing the patient/caregiver on pressure ulcer prevention and turning/repositioning every two hours, to reduce the risk of developing new pressure ulcers or worsening existing pressure ulcers. The Skilled Nurse visit note dated 01/13/2024, twenty-four (24) days after the start of care, documents the nurse educated the caregiver on turning and repositioning every two hours and to report any change in skin condition. The Skilled Nurse Revisit note dated 01/24/2024 documents the patient developed two new pressure ulcers – Middle Back Right Side Unstageable Pressure Ulcer and Left Shoulder Pressure Ulcer Stage 2. The Skilled Nurse Revisit note dated 01/24/2024 lacks documented evidence of the Skilled Nurse re-educating the patient/caregiver on pressure ulcer prevention and turning/repositioning every two hours. The skilled nurse visit notes lack documented evidence of the nurse instructing and re-educating the patient/caregiver on turning/repositioning every two hours to relieve pressure and prevent skin breakdown. The clinical record lacks documented evidence of the skilled nurse providing pressure ulcer interventions/services as written in the plan of care. On 02/02/2024 at 3:50 PM, the Administrator/Director of Patient Services, the Clinical Case Manager/Supervisor, and the Vice President of Rehabilitation were interviewed, and did not provide an explanation for the finding.”

“Coordination of Care CFR(s): 484.60(d) Standard: Coordination of care. The HHA must: This Standard is not met as evidenced by: Based on clinical record review and staff interview the agency failed to coordinate care delivery to meet the patient’s needs. This was evident for four (4) of twenty-six (26) clinical records reviewed (Patient: #8,#9, #12, and #21). Failure to coordinate care delivery to meet the patient’s needs, has the potential for negative patient outcomes. The findings are: 4.Patient #21 has a Start of Care date of 08/12/2023 and a discharge date of 08/21/2023 with the following diagnoses “Rhabdomyolysis, Type 2 Diabetes Mellitus, Atrial Fibrillation” documented in the Home Health Certification and Plan of Care dated 08/12/2023 to 10/10/2023. The Home Health Certification and Plan of Care dated 08/12/2023 to 10/10/2023 documents: “08/15/2023 – 08/25/2023 – Aide 4 Week 2 X 4 hrs (four times a week for two weeks times four hours a day).” The Case Communication Report documents: 08/14/2023 “NCM (nurse care manager) informed PT/CG (patient/caregiver) due to address location will be difficult for the agency to provide aide services. NCM (nurse care manager) informed PT/CG (patient/caregiver) that all orders placed and will be broadcasted to all hha (home health aide) vendors. 08/15/2023 “Updated hha (home health aide) order placed, eff (effective) 08/21/23 5 day 4 hrs (hours).” The Duty Sheet documents aide providing services on: 08/16/2023, 08/17/2023, and 08/18/2023. There is no documented evidence of the coordination or notification with the patient or family of when the aide services will be provided. On 02/02/2024 at 3:53pm, the Administrator/Director of Patient Services, the Vice President of Rehabilitation, and the Clinical Case Manager Supervisor were interviewed and did not provide an explanation for the findings. 1.Patient #8 has a Start of Care date of 12/20/2023 with the diagnoses “Pressure Ulcer of Sacral Region Stage 2, Pressure Ulcer of Other Site Stage 3, Pressure Ulcer of Other Site Stage 2, Parkinson’s Disease, Dementia, Depression, Type 2 Diabetes Mellitus, Muscle Weakness” documented in the Home Health Certification and Plan of Care dated 12/20/2023 to 02/17/2024. The start of care comprehensive assessment note dated 12/20/2023 documents the following assessment of the patient: bed fast, dependent on assistance for mobility (including turning/repositioning), toileting, and self-care; three pressure ulcers – Wound #1 Coccyx Pressure Ulcer Stage2, Wound #2 Left Foot Big Toe Pressure Ulcer Stage 3, and Wound #3 Left Foot 2nd Toe Pressure Ulcer Stage 2. The Skilled Nurse Revisit note dated 01/24/2024 documents the patient has two new pressure ulcers: “Wound #4 Middle Back, RT (Right), Unstageable (Pressure Ulcer), 4.0x3.0x0.3, wound bed with brown soft eschar, periwound – hyperpigmented, edematous, small SS (serosanguineous) drainage, no tunneling, no odor; and Wound #5 LT(Left) Shoulder PU (Pressure Ulcer) Stage 2, 2.0x2.0x0.2, wound bed – red, periwound – edematous, hyperemic, scant serous drainage, no odor.“ The physician verbal order Entered Date 01/24/2024 documents the following orders for the new wounds: “Taken Date 01/23/2024;” “Wound #4 Treatment: Clean with wound cleanser, pat dry, apply Mupirocin (antibacterial ointment), cover with DSD (dry sterile dressing), fix with bordered gauze, 3xweek (three times a week); Wound #5 Treatment: Clean with wound cleanser, pat dry, apply Triad cream (a zinc oxide treatment), fix with bordered gauze, 3 x week.” On 01/29/2024 at 3:45AM, a home visit was conducted . The Skilled Nurse was observed cleaning Wound #4 and applying Mupirocin ointment to the surrounding tissue (periwound skin); no treatment was applied to the wound bed. The Skilled Nurse was interviewed and stated the Mupirocin “cannot be used on wound bed with eschar.” The Skilled Nurse was interviewed about the treatment of the wound bed. The Skilled Nurse stated, “I will ask the doctor about debriding the wound.” The clinical record lacks documented evidence of the skilled nurse coordinating with the physician to clarify the verbal order taken on 01/23/2024 and the specific treatment for Wound #4 wound bed with eschar. The clinical record lacks documented evidence of communication with the physician to discuss other interventions or durable medical equipment to prevent additional pressure ulcers, such as an alternating pressure mattress. On 02/02/2024 at 3:50 PM, the Administrator/Director of Patient Services and the Clinical Case Manager/Supervisor were interviewed and did not provide an explanation for the finding. 2.Patient #9 has a Start of Care date of 12/20/2023 with the diagnoses “Myasthenia Gravis without (Acute) Exacerbation, Fracture of One Rib Right Side Subsequent Encounter for Fracture with Routine Healing, Rhabdomyolysis, Spinal Stenosis, Malignant Neoplasm of the Nipple and Areola Right Female Breast, Pain in left Shoulder, Anxiety Disorder, Depression, Long Term (Current) Use of Systemic Steroids, History of Falling” documented in the Home Health Certification and Plan of Care dated 12/20/2023 to 02/17/2024. The Home Health Certification and Plan of Care dated 12/20/2023 to 02/17/2024 documents: Skilled Nurse for “medication review/ teaching importance of adhering to treatment plan and med regimen;” and oral medication - “Clonazepam (Anti-anxiety agent) 0.5 mg tablet, take 1 tablet 3 times per day.” The Skilled Nurse Revisit note dated 01/03/2024 documents: patient is “non-compliant; Ineffective drug therapy;” “patient was extremely anxious during the visit;” “patient takes Clonazepam for anxiety; unsure about medication compliance or effectiveness.” The clinical record lacks documented evidence of communication with the physician to discuss medication non-compliance and/or effectiveness. On 01/31/2024 at 3:00 PM, the Administrator/Director of Patient Services was interviewed, and did not provide an explanation for the finding. 3.Patient #12 has a Start of Care of 09/29/2023, Discharge Date of 10/10/2023, with the diagnoses “Other Encephalopathy, Convulsions, Chronic Atrial Fibrillation, Type 2 Diabetes Mellitus, Anemia, Retention of Urine, Encounter for Fitting and Adjustment of Urinary Device” documented in the Home Health Certification and Plan of Care dated 09/29/2023 to 11/27/2023. The Home Health Certification and Plan of Care dated 09/29/2023 to 11/27/2023 documents: “SN (Skilled Nurse) to assess for (Foley) malfunction, s/s (sign/symptoms) UTI (urinary tract infection), complication and actions to take. Pt (Patient) has MD (Medical Doctor) appointment for Foley Cath removal on 10/03;” and safety measures - “bleeding precautions.” The Registered Nurse Start of Care comprehensive assessment note dated 09/29/2023 documents: prior to the start of care, patient was admitted to the hospital and “found to have urine retention, stabilized and D/C (discharged) home with Foley (catheter). (Patient) has MD appointment for Foley removal on 10/03;” “on assessment urine is red clear patient continuously trying to pull out Foley (catheter). Discussed consequences of decision. Refused hospitalization;” “Vital signs WNL (within normal limits). The comprehensive assessment note dated 09/29/2023 documents: “the Skilled Nurse “instructed Pt (Patient) on medication Eliquis (an anticoagulant),” “instructed that nausea, easy bruising, or minor bleeding (such as nose bleeds, bleeding form cuts) may occur;” The Registered Nurse “Missed Visit” note dated 10/05/2023 documents: “Pt (Patient) is at the hospital. (Patient’s spouse) said (spouse) is unsure if the Pt (Patient) is going to (be) discharge in time;” “Physician office notified.” The Physical Therapist “Missed Visit” note dated 10/06/2023 documents: “10/6/23 – PT (Physical Therapist) unable to reach patient or caregiver last couple days, arrived at patient’s apartment but doorman reports patient is still in the hospital. (Physician) notified,” The Registered Nurse revisit note dated 10/10/2023 documents: “Patient has Foley Cath in place, inserted on 09/22/23. Patient had appt (appointment) on 10/03/23. (Patient) states that MD (Medical Doctor) decided that (patient) still needs Foley Cath and has another f/u (follow-up) appt (appointment) on 10/13/23. Urine output at visit 100ml, amber/orange color.” The clinical record lacks documented evidence of communication with the patient/family and physician to discuss patient’s urinary status, including urine discoloration, and the patient’s medical condition/problem requiring a hospital visit on 10/05/2023. On 02/01/2024 at 4:00 PM, the Administrator/Director of Patient Services, the Clinical Case Manager/Supervisor, and the Vice President of Rehabilitation were interviewed, and did not provide an explanation for the finding.”

“Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This Standard is not met as evidenced by: Based on clinical record reviews and staff interview the agency failed to ensure all paraprofessionals receive a complete written home health aide plan of care with instructions when providing patient care. This was evident for seven (7) of thirteen (13) patients receiving aide services (Patient #3, #9, #10, #11, #16, #17, and #21). Failure to ensure all paraprofessionals receive a complete written home health aide plan of care with instructions has the potential for negative patient outcome. The findings are: 5.Patient #16 has a Start of Care (SOC) date of 01/16/2024, with the following diagnoses “Parkinson’s Disease, Other Low Back Pain, Pain in Unspecified Joint” documented in the Home Health Certification and Plan of Care dated 01/16/2024 to 03/15/2024. The Home Health Certification and Plan of Care dated 01/16/2024 to 03/15/2024 documents: 01/18/2024 – 1/27/2024 Aide 3 week 1 (three times a week for one week); 6 week 1 (six times a week for one week) x 2 hrs. (for two hours per day); 01/22/2024 - 2/2/2024 Aide 3 week 2 (three times a week for two weeks) x 4hrs (for four hours per day). The Plan of Care (Aide) dated 01/22/2024 lacks documented evidence of the allergy, diet, DME (durable medical equipment), safety measures, and instruction of aide observations that should be reported to the supervisor. There is no documented evidence of a complete and comprehensive aide’s plan of care. On 02/01/2024 at 4:15pm, the Administrator/Director of Patient Services, the Vice President of Rehabilitation, and the Clinical Case Manager Supervisor were interviewed and did not provide an explanation for the findings. 6.Patient #17 has a Start of Care (SOC) date of 11/27/2023, with the following diagnoses “Other Fracture of Left Lower Leg, Type 2 Diabetes Mellitus, Hypertensive Heart Disease with Heart Failure” documented in the Home Health Certification and Plan of Care dated 11/27/2023 to 01/25/2024. The Home Health Certification and Plan of Care dated 11/27/2023 to 01/25/2024 documents: “ 11/29/2023 – 1/25/2024 aide 3 week 1 (three times a week for one week); 5 week 7 (five times a week for seven weeks; 4 week 1 (four times a week for one week). The Plan of Care (Aide) dated 11/29/2023 lacks documented evidence of the allergy, diet, DME (durable medical equipment), safety measures, and instruction of aide observations that should be reported to the supervisor. There is no documented evidence of a complete and comprehensive aide’s plan of care. On 02/01/2024 at 4:15pm, the Administrator/Director of Patient Services, the Vice President of Rehabilitation, and the Clinical Case Manager Supervisor were interviewed and did not provide an explanation for the findings. 7.Patient #21 has a Start of Care date of 08/12/2023 and a discharge date of 08/21/2023 with the following diagnoses “Rhabdomyolysis, Type 2 Diabetes Mellitus, Atrial Fibrillation” documented in the Home Health Certification and Plan of Care dated 08/12/2023 to 10/10/2023. The Home Health Certification and Plan of Care dated 08/12/2023 to 10/10/2023 documents: “08/15/2023 – 08/25/2023 – Aide 4 Week 2 X 4 hrs (four times a week for two weeks times four hours a day).” The Plan of Care (Aide) dated 08/15/2023 lacks documented evidence of the allergy, diet, DME (durable medical equipment), safety measures, and instruction of aide observations that should be reported to the supervisor. There is no documented evidence of a complete and comprehensive aide’s plan of care. On 02/02/2024 at 3:53pm, the Administrator/Director of Patient Services, the Vice President of Rehabilitation, and the Clinical Case Manager Supervisor were interviewed and did not provide an explanation for the findings. 2.Patient #9 has a Start of Care date of 12/20/2023 with the diagnoses “Myasthenia Gravis without (Acute) Exacerbation, Fracture of One Rib Right Side Subsequent Encounter for Fracture with Routine Healing, Rhabdomyolysis, Spinal Stenosis, Malignant Neoplasm of the Nipple and Areola Right Female Breast, Pain in left Shoulder, Anxiety Disorder, Depression, Long Term (Current) Use of Systemic Steroids” documented in the Home Health Certification and Plan of Care dated 12/20/2023 to 02/17/2024. The Home Health Certification and Plan of Care dated 12/20/2023 to 02/17/2024 documents: “Aide - 1 week 1(one day a week for one week); 3 week 1(three days a week for one week); and 1 week1 x 4H (four hours/ day)” and “nutritional requirement – regular diet; activities permitted – walker, cane; functional limitation – bowel/bladder incontinence, endurance, ambulation, Safety Measures – fall prevention/precaution. The aide Plan of Care dated 01/12/2024 to 03/12/2024 lacks documented evidence written instructions for nutritional requirement/diet, incontinence care, activities permitted/limitations, safety measures, and special observations to report and when to activate 911 for emergency medical services. The clinical record lacks documented evidence of a complete aide plan of care addressing the patient’s needs. On 01/31/2024 at 3:00 PM, the Administrator/Director of Patient Services was interviewed, and did not provide an explanation for the finding. 3.Patient #10 has a Start of Care date of 10/27/2023 with the diagnoses “Generalized osteoarthritis, Low Back Pain, Insomnia, and History of Falling” documented in the Home Health Certification and Plan of Care dated 12/26/2023 to 02/23/2024. The Home Health Certification and Plan(s) of Care dated 10/27/2023 to 12/25/2023 and 12/26/2023 to 02/23/2024 documents: “Aide - 4 week 1(four days a week for one week); 5 week 8 (five days a week for eight weeks) x 4HRS (four hours/day);” Nutritional requirement – high fiber, low fat, low cholesterol, sodium restricted 2 gm/day; Activities permitted – walker, up as tolerated; Functional limitation – bowel/bladder incontinence, endurance, ambulation,; Safety Measures – fall prevention/precaution. The aide Plan(s) of Care dated 10/31/2023 to 12/30/2023 and 11/27/2023 to 01/26/2024 lack documented evidence of written instructions for nutritional/diet requirement, incontinence care, activities permitted/limitations, safety measures, and special observations to report and when to activate 911 for emergency medical services. The clinical record lacks documented evidence of a complete aide plan of care addressing the patient’s needs. On 01/31/2024 at 3:00 PM, the Administrator/Director of Patient Services was interviewed, and did not provide an explanation for the finding. 4.Patient #11 has a Start of Care date of 12/27/2023, Discharge Date of 01/18/2024, with the diagnoses Hypertensive Heart Disease with Heart Failure, Chronic Systolic (Congestive) Heart Failure, Osteoarthritis, Cirrhosis of Liver documented in the Home Health Certification and Plan of Care dated 12/27/2023 to 02/24/2024. The Home Health Certification and Plan of Care dated 12/27/2023 to 02/24/2024 documents: “Aide - 1 Week 1(one day a week for one week); 3 Week 2 (three days a week for two weeks), 2 Week 1 (two days a week for one week) x 4HRS (four hours/day);” Nutritional requirement - Low fat, Low cholesterol, Sodium restricted 2 gm/day; Allergies - Penicillin; Activities permitted – wheelchair, walker, up as tolerated, exercise prescribed; Functional limitation – bowel/bladder incontinence, endurance, ambulation,; Safety Measures – fall prevention/precaution. The aide Plan of Care dated 12/27/2023 to 02/24/2024 lacks documented evidence of written instructions for nutritional/diet requirement, allergies, incontinence care, activities permitted/limitations, safety measures, and special observations to report and when to activate 911 for emergency medical services. The clinical record lacks documented evidence of a complete aide plan of care addressing the patient’s needs. On 02/02/2024 at 3:50 PM, the Administrator/Director of Patient Services, the Clinical Case Manager/Supervisor, and the Vice President of Rehabilitation were interviewed, and did not provide an explanation for the finding. 1.Patient #3 (Home Visit) has a Start of Care date of 12/08/2023 with the following diagnoses “Essential (Primary) Hypertension, Personal History of other Malignant Neoplasm of Bronchus and Lung, Acquired Absence of Lung” documented on the Home Health Certification and Plan of Care for the Certification Period 12/08/2023 to 02/05/2024. The Home Health Certification and Plan of Care for the Certification Period 12/08/2023 to 02/05/2024 documents:” 12/12/2023-02/05/2024 Aide 4 week 1 (four days a week for one week); 5 wk 7 (five times a week for seven weeks); 1 week 1(one day a week for one week).” The clinical record documents home health aide services being provided from 12/12/2023 to 01/30/2024. The clinical record includes the Aide Plan of Care dated 12/12/2023. The Aide Plan of Care dated 12/12/2023 lacks documented evidence of the following: allergy, diet, DME (durable medical equipment), safety measures, specific instructions for the aide. There is no documented evidence of the Aide Plan of Care being complete. On 01/30/2024, a home visit was conducted, the aide plan of care was not observed. The aide plan of care was requested. The aide and the patient’s wife stated: “We don’t have plan of care and the nurse did not provide it.” There is no documented evidence of the patient being provided with a copy of the aide plan of care. On 01/31/2024 at 03:30pm, the Director of Patient Services was interviewed, and did not provide an explanation for the findings.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on clinical record review and staff interview the agency failed to ensure an accurate and comprehensive review of each patient’s medications is conducted. This was evident for three (3) of twenty-six (26) clinical records reviewed (Patient: #9, #12, and #15). Failure to ensure a review of all patients’ current medications are complete, accurate and are reflected in the patient’s plan of care has the potential for negative patient outcomes. The findings are: 3.Patient #15 has a Start of Care (SOC) date of 01/24/2024, with the following diagnoses “Central Cord Syndrome at C(cervical) 5 level of Cervical Spinal Cord, Cervical Disc Disorder at C(cervical) 5 - C(cervical) 6 Level with Radiculopathy, Unspecified Injury of Head” documented in the Home Health Certification and Plan of Care dated 01/24/2024 to 03/23/2024. The Home Health Certification and Plan of Care dated 01/24/2024 to 03/23/2024 documents: Pantoprazole 40mg (milligram) take 1 tablet by oral route every day; Methylprednisolone 4mg tablet by oral route every day; Senna 8.6mg tablet take 2 tablets by oral route every day; Polyethylene Glycol Liquid take 17gm (gram) by oral route every day; Acetaminophen 325mg tablet, take 3 tablets by oral route every 8 hours; Baclofen 5mg tablet, take 1 tablet by oral route 3 times per day every day. On 01/29/2023 at 3:15pm, a home visit was conducted, The patient was interviewed and stated, “I’m taking Acetaminophen and Baclofen when I have pain only. I have not taken the other medications (Methylprednisolone, Pantoprazole, Glycol, and Senna) since I got home.” There is no documented evidence of a review of all medications the patient is currently taking – Acetaminophen (order every 8 hours) and Baclofen (order 3 times a day) being taken as needed only, and patient not taking Methylprednisolone, Pantoprazole, Glycol, and Senna, that are still on active medication list. There is no documented evidence of medication reconciliation. On 01/31/2024 at 3:17pm, the Administrator/Director of Patient Services was interviewed and did not provide an explanation for the findings. 1.Patient #9 has a Start of Care date of 12/20/2023 with the diagnoses “Myasthenia Gravis without (Acute) Exacerbation, Fracture of One Rib Right Side Subsequent Encounter for Fracture with Routine Healing, Rhabdomyolysis, Spinal Stenosis, Malignant Neoplasm of the Nipple and Areola Right Female Breast, Pain in left Shoulder, Anxiety Disorder, Depression, Long Term (Current) Use of Systemic Steroids, History of Falling” documented in the Home Health Certification and Plan of Care dated 12/20/2023 to 02/17/2024. The Home Health Certification and Plan of Care dated 12/20/2023 to 02/17/2024 documents the following oral medications: Tylenol 325mg tablet, take 2 tablets every 5 hours as needed; Ultram 50 mg tablet, take 1 tablet every 5 hours as needed, Clonazepam 0.5 mg tablet, take 1 tablet 3 times per day; Paxil 40 mg tablet, take 1 tablet every day; Trazadone 50 mg tablet, take 1 tablet every day; Claritin 10 mg tablet, take 1 tablet every day; Prednisone 2.5 mg tablet, take 1 tablet every day; Omeprazole 20 mg tablet delayed release, take 2 tablets every 24 hours; Arimidex 1 mg every day; Vitamin D3 25 mcg (1000 Unit) tablet, take 1 tablet every 24 hours. The medication profile printed on 01/30/2024 documents the same medications as listed in the Home Health Certification and Plan of Care. The Registered Nurse Start of Care comprehensive assessment dated 12/20/2023 documents: patient is alert and oriented time 3 “but forgetful;” is “non-compliant” with medications, and plan for next visit is “medication compliance/adherence” and “medication education.” The comprehensive assessment lacks documented evidence of the non-compliant medication(s), how the nurse determined the patient’s is non-compliant, and the reason or probable cause for the patient being non-compliant. On 01/30/2024 at 11:40AM, a home visit was conducted to observe the occupational therapist. Following the completion of the visit, the patient was interviewed about the current medications. The patient stated: “I stopped taking the following medication “a while ago”: Prednisone, Paxil, Omeprazole, Tylenol.” The patient confirmed taking the following prescribed medications observed in the home: “Citalopram, filled date 01/19/024, 20 mg tablet, take 1 tablet daily; Baclofen, filled date 12/28/2023 10 mg take 1 tablet four times daily; Alendronate Sodium (Fosamax), filled date 1/13/2024, 70 mg tablet, take 1 tablet once a week. The patient stated, “I have been taking Fosamax for years because I have very bad osteoporosis.” There is no documented evidence of Citalopram, Baclofen and Alendronate Sodium listed in the plan of care and the medication profile. The clinical record lacked documented evidence of the nurse accurately identifying, reviewing, and reconciling all medications that the patient is taking. On 01/31/2024 at 3:00 PM, the Administrator/Director of Patient Services was interviewed, and did not provide an explanation for the finding. 2.Patient #12 has a Start of Care of 09/29/2023, Discharge Date of 10/10/2023, with the diagnoses “Other Encephalopathy, Convulsions, Chronic Atrial Fibrillation, Type 2 Diabetes Mellitus, Anemia, Retention of Urine, Encounter for Fitting and Adjustment of Urinary Device,” documented in the Home Health Certification and Plan of Care dated 09/29/2023 to 11/27/2023. The Registered Nurse Start of Care comprehensive assessment dated 09/29/2023 documents: Skilled Nurse “instructed Pt (Patient) on medication Eliquis (an anticoagulant),” and “instructed that nausea, easy bruising, or minor bleeding (such as nose bleeds, bleeding form cuts) may occur.” The Home Health Certification and Plan of Care dated 09/29/2023 to 11/27/2023 lacks documented evidence of the medication, Eliquis. The clinical record lacked documented evidence of the nurse accurately reconciling and including in the plan of care all medications the patient is currently taking in the home. On 02/01/2024 at 4:00 PM, the Administrator/Director of Patient Services, the Clinical Case Manager/Supervisor, and the Vice President of Rehabilitation were interviewed, and did not provide an explanation for the finding.”

“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 review and staff interview the agency failed to ensure each patient’s individualized plan of care is complete and includes all the required information. This was evident for fifteen (15) of twenty-six (26) clinical records reviewed. (Patients #4, #6, #8,#9, #10,#11, #12, #15, #16, #17, #18, #19, #20, #21,and #26). Failure to ensure the patient’s plan of care is complete and accurate has the potential for negative patient outcome. The findings are: 8.Patient #15 has a Start of Care (SOC) date of 01/24/2024, with the following diagnoses “Central Cord Syndrome at C(cervical) 5 level of Cervical Spinal Cord, Cervical Disc Disorder at C(cervical) 5-C(cervical) 6 Level with Radiculopathy, Unspecified Injury of Head” documented in the Home Health Certification and Plan of Care dated 01/24/2024 to 03/23/2024. The Home Health Certification and Plan of Care dated 01/24/2024 to 03/23/2024 documents: “Patient Risk for Emergent Care and Acute Care Hospitalization: Risk for Emergent Care: Moderate; Risk for Acute Care Hospitalization: Moderate.” The plan of care lacks documented evidence of the description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. There is no documented evidence of the assessment for the moderate risks. On 01/31/2024 at 3:17pm, the Administrator/Director of Patient Services was interviewed and did not provide an explanation for the findings. 9.Patient #16 has a Start of Care (SOC) date of 01/16/2024, with the following diagnoses “Parkinson’s Disease, Other Low Back Pain, Pain in Unspecified Joint” documented in the Home Health Certification and Plan of Care dated 01/16/2024 to 03/15/2024. The Home Health Certification and Plan of Care dated 01/16/2024 to 03/15/2024 documents: “Patient Risk for Emergent Care and Acute Care Hospitalization: Risk for Emergent Care: Moderate; Risk for Acute Care Hospitalization: Moderate.” The plan of care lacks documented evidence of the description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. There is no documented evidence of the assessment for the moderate risks. On 01/31/2024 at 3:17pm, the Administrator/Director of Patient Services was interviewed and did not provide an explanation for the findings. 10.Patient #17 has a Start of Care (SOC) date of 11/27/2023, with the following diagnoses “Other Fracture of Left Lower Leg, Type 2 Diabetes Mellitus, Hypertensive Heart Disease with Heart Failure” documented in the Home Health Certification and Plan of Care dated 11/27/2023 to 01/25/2024. The Home Health Certification and Plan of Care dated 11/27/2023 to 01/25/2024 documents: “Patient Risk for Emergent Care and Acute Care Hospitalization: Risk for Emergent Care: Moderate; Risk for Acute Care Hospitalization: Moderate”. The plan of care lacks documented evidence of the description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. There is no documented evidence of the assessment for the moderate risks. On 02/01/2024 at 4:15pm, the Administrator/Director of Patient Services, the Vice President of Rehabilitation, and the Clinical Case Manager Supervisor were interviewed and did not provide an explanation for the findings. 11.Patient #18 has a Start of Care date of 02/08/2023 with the following diagnoses “Pressure Ulcer of Sacral Region Stage 2, Type 2 Diabetes Mellitus, Alzheimer’s Disease, Dementia” documented in the Home Health Certification and Plan of Care dated 10/06/2023 to 12/04/2023. The Home Health Certification and Plan of Care dated 10/06/2023 to 12/04/2023 documents: “Patient Risk for Emergent Care and Acute Care Hospitalization: Risk for Emergent Care: Moderate; Risk for Acute Care Hospitalization: Moderate.” The plan of care lacks documented evidence of the description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. There is no documented evidence of the assessment for the moderate risks. 12.Patient #19 has a Start of Care date of 02/25/2022 and a discharge date of 03/24/2022 with the following diagnoses “Facial Weakness Following Cerebral Infarction; Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side” documented in the Home Health Certification and Plan of Care dated 02/25/2022 to 04/25/2022. The Home Health Certification and Plan of Care dated 02/25/2022 to 04/25/2022 documents: “Patient Risk for Emergent Care and Acute Care Hospitalization: Risk for Emergent Care: Moderate; Risk for Acute Care Hospitalization: Moderate.” The plan of care lacks documented evidence of the description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. There is no documented evidence of the assessment for the moderate risks. On 02/01/2024 at 4:15pm, the Administrator/Director of Patient Services, the Vice President of Rehabilitation, and the Clinical Case Manager Supervisor were interviewed and did not provide an explanation for the findings. 13.Patient #20 has a Start of Care date of 07/15/2022 and a discharge date of 08/03/2022 with the following diagnoses “Unspecified Cerebrovascular Disease, Primary Generalized Osteoarthritis, Hyperlipidemia” documented in the Home Health Certification and Plan of Care dated 07/15/2022 to 09/12/2022. The Home Health Certification and Plan of Care dated 07/15/2022 to 09/12/2022 documents: “Patient Risk for Emergent Care and Acute Care Hospitalization: Risk for Emergent Care: Moderate; Risk for Acute Care Hospitalization: Moderate.” The plan of care lacks documented evidence of the description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. There is no documented evidence of the assessment for the moderate risks. On 02/01/2024 at 4:15pm, the Administrator/Director of Patient Services, the Vice President of Rehabilitation, and the Clinical Case Manager Supervisor were interviewed and did not provide an explanation for the findings. 14.Patient #21 has a Start of Care date of 08/12/2023 and a discharge date of 08/21/2023 with the following diagnoses “Rhabdomyolysis, Type 2 Diabetes Mellitus, Atrial Fibrillation” documented in the Home Health Certification and Plan of Care dated 08/12/2023 to 10/10/2023. The Home Health Certification and Plan of Care dated 08/12/2023 to 10/10/2023 documents: “Patient Risk for Emergent Care and Acute Care Hospitalization: Risk for Emergent Care: Moderate; Risk for Acute Care Hospitalization: Moderate.” The plan of care lacks documented evidence of the description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. There is no documented evidence of the assessment for the moderate risks. On 02/02/2024 at 3:53pm, the Administrator/Director of Patient Services, the Vice President of Rehabilitation, and the Clinical Case Manager Supervisor were interviewed and did not provide an explanation for the findings. 15.Patient #26 has a Start of Care date of 12/15/2023 with the following diagnoses “Encounter for Fitting and Adjustment of Urinary Device; Atherosclerotic Heart Disease, Chronic Kidney Disease stage 3, Type 2 Diabetes Mellitus” documented in the Home Health Certification and Plan of Care dated 12/15/2023 to 02/12/2024. The Home Health Certification and Plan of Care dated 12/15/2023 to 02/12/2024 documents: “Patient Risk for Emergent Care and Acute Care Hospitalization: Risk for Emergent Care: Moderate; Risk for Acute Care Hospitalization: Moderate.” The plan of care lacks documented evidence of the description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. There is no documented evidence of the assessment for the moderate risks. On 02/02/2024 at 3:53pm, the Administrator/Director of Patient Services, the Vice President of Rehabilitation, and the Clinical Case Manager Supervisor were interviewed and did not provide an explanation for the findings. 3.Patient #8 has a Start of Care date of 12/20/2023 with the diagnoses “Pressure Ulcer of Sacral Region Stage 2, Pressure Ulcer of Other Site Stage 3, Pressure Ulcer of Other Site Stage 2, Parkinson’s Disease, Dementia, Depression, Type 2 Diabetes Mellitus, Muscle Weakness” documented in the Home Health Certification and Plan of Care dated 12/20/2023 to 02/17/2024. The Home Health Certification and Plan of Care dated 12/20/2023 to 02/17/2024 documents: “Patient risk for Emergent Care and Acute Care Hospitalization: Risk for Emergent Care: Moderate; Risk for Acute Care Hospitalization: Moderate”. The individualized Home Health Certification and Plan of Care lacks documented evidence of a description of the moderate risk specific to Patient #8. On 02/01/2024 at 3:50 PM, the Administrator/Director of Patient Services, the Clinical Case Manager/Supervisor, and the Vice President of Rehabilitation were interviewed, and did not provide an explanation for the findings. 4.Patient #9 has a Start of Care date of 12/20/2023 with the diagnoses “Myasthenia Gravis without (Acute) Exacerbation, Fracture of One Rib Right Side Subsequent Encounter for Fracture with Routine Healing, Rhabdomyolysis, Spinal Stenosis, Malignant Neoplasm of the Nipple and Areola Right Female Breast, Pain in left Shoulder, Anxiety Disorder, Depression, Long Term (Current) Use of Systemic Steroids, History of Falling” documented in the Home Health Certification and Plan of Care dated 12/20/2023 to 02/17/2024. The Home Health Certification and Plan of Care dated 12/20/2023 to 02/17/2024 documents: “Patient risk for Emergent Care and Acute Care Hospitalization: Risk for Emergent Care: Moderate; Risk for Acute Care Hospitalization: Moderate.” The individualized Home Health Certification and Plan of Care lacks documented evidence of a description of the moderate risk specific to Patient #9. On 01/31/2024 at 3:00 PM, the Administrator, Director of Patient Services and Clinical Manager was interviewed, and did not provide an explanation for the finding. 5.Patient #10 has a Start of Care date of 10/27/2023 with the diagnoses “Generalized osteoarthritis, Low Back Pain, Insomnia, and History of Falling” documented in the Home Health Certification and Plan of Care dated 12/26/2023 to 02/23/2024. The Home Health Certification and Plan(s) of Care dated 10/27/2023 to 12/25/2023 and 12/26/2023 to 02/23/2024 documents “Patient risk for Emergent Care and Acute Care Hospitalization: Risk for Emergent Care: Moderate; Risk for Acute Care Hospitalization: Moderate.” The individualized Home Health Certification and Plans of Care lack documented evidence of a description of the moderate risk specific to Patient #10. On 01/31/2024 at 3:00 PM, the Administrator/Director of Patient Services was interviewed, and did not provide an explanation for the finding. 6.Patient #11 has a Start of Care date of 12/27/2023, Discharge Date of 01/18/2024, with the diagnoses “Hypertensive Heart Disease with Heart Failure, Chronic Systolic (Congestive) Heart Failure, Osteoarthritis, Cirrhosis of Liver” documented in the Home Health Certification and Plan of Care dated 12/22/2023 to 02/24/2024. The Home Health Certification and Plan of Care dated 12/27/2023 to 02/24/2024 documents: “Patient risk for Emergent Care and Acute Care Hospitalization: Risk for Emergent Care: Moderate; Risk for Acute Care Hospitalization: Moderate.’ The individualized Home Health Certification and Plan of Care lacks documented evidence of a description of the moderate risk specific to Patient #11. On 02/02/2024 at 3:50 PM, the Administrator/Director of Patient Services, the Clinical Case Manager/Supervisor, and the Vice President of Rehabilitation were interviewed, and did not provide an explanation for the finding. 7.Patient #12 has a Start of Care date of 01/12/2024 (Readmission) with the diagnoses “Dementia, Asthma, History of Falling, Other Reduce Mobility” documented in the Home Health Certification and Plan of Care dated 01/12/2024 to 03/11/2024. The Home Health Certification and Plan of Care dated 01/12/2024 to 03/11/2024 documents: “Patient risk for Emergent Care and Acute Care Hospitalization: Risk for Emergent Care: Moderate; Risk for Acute Care Hospitalization: Moderate”. The individualized Home Health Certification and Plan of Care lacks documented evidence of a description of the moderate risk specific to Patient #12. On 02/01/2024 at 4:0 PM, the Administrator/Director of Patient Services, the Clinical Case Manager/Supervisor, and the Vice President of Rehabilitation were interviewed, and did not provide an explanation for the finding. 1. Patient # 4 has a Start of Care date of 08/17/2023 and discharge date of 01/01/2024 with the following diagnoses “Encounter for Fitting and Adjustment of Urinary Device, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Unspecified Atrial Fibrillation” documented on the Home Health Certification and Plan of Care for the Certification Period 12/15/2023 to 02/12/2024. The Home Health Certification and Plan of Care for the Certification Period 12/15/2023 to 02/12/2024 documents: “Patient risk for Emergent Care and Acute Care Hospitalization: Risk for Emergent Care: Moderate Risk for Acute Care Hospitalization: Moderate.” There is no documented evidence of a description of the patient’s moderate risk on the Home Health Certification and Plan of Care for the Certification Period 12/15/2023 to 02/12/2024. 2. Patient # 6 has a Start of Care date of 08/23/2023 and discharge date of 10/05/2023 with the following diagnoses “Chronic Obstructive Pulmonary Disease, Hypertensive Heart Disease with Heart Failure, Chronic Kidney Disease” documented on the Home Health Certification and Plan of Care for the Certification Period 08/23/2023 to 10/21/2023. The Home Health Certification and Plan of Care for the Certification Period 08/23/2023 to 10/21/2023 documents: “Patient risk for Emergent Care and Acute Care Hospitalization: Risk for Emergent Care: Moderate Risk for Acute Care Hospitalization: Moderate.” There is no documented evidence of a description of the patient’s moderate risk on the Home Health Certification and Plan of Care for the Certification Period 08/23/2023 to 10/21/2023. On 02/02/2024 at 03:30 pm, the Administrator/Director of Patient Services was 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 all treatments, drugs, and services are ordered by a physician for each patient. This was evident for one (1) of twenty-six (26) clinical records reviewed. (Patient #18). Failure to ensure all treatments are administered as ordered by the physician has the potential for negative patient outcomes. The findings are: 1.Patient #18 has a Start of Care date of 02/08/2023 with the following diagnoses “Pressure Ulcer of Sacral Region Stage 2, Type 2 Diabetes Mellitus, Alzheimer’s Disease, Dementia” documented in the Home Health Certification and Plan of Care dated 04/09/2023 to 06/07/2023. The Home Health Certification and Plan of Care dated 04/09/2023 to 06/07/2023 documents:” Wound #1, Stage 3, Tx (treatment): cleanse with Normal Saline, pat dry, apply Santyl, pack with gauze and cover with foam dressing daily.” The clinical record documents the nurse treating wound #1 Sacrum pressure ulcer stage 3 with: “Cleanse with normal saline, pat dry, pack wound with Hydrofera Blue Ready Antibacterial foam dressing, with foam dressing daily on 05/10/2023 and 05/18/2023; and cleanse with NS (normal saline) pat to dry apply Santyl on slough, Hydrofera Blue foam cover with DSD (dry sterile dressing) secure with bordered gauze on 05/24/2023 and 06/03/2023. There is no documented evidence of an interim or supplemental order for the treatment of Hydrofera Blue to the sacrum. There is no documented evidence that the wound treatment order in the plan of care is being followed. The RN (registered nurse) Procedure Revisit documents: 05/10/2023 “Wound #2 right buttock; TX (treatment): cleanse wound with normal saline, pat dry, cover with dry dressing daily.” This is the first documentation of wound #2, new ulcer. 05/18/2023 “wound #2 to right buttocks; TX (treatment): cleanse wound with normal saline, pat dry, cover with dry dressing daily.” The Home Health Certification and Plan of Care dated 06/08/2023 to 08/06/2023 documents: wound #2 right buttock tx (treatment): cleanse wound with Normal Saline, pat dry, cover with dry dressing daily. The clinical record documents nurse treating wound #2 right buttock pressure ulcer stage 2 with: Cleanse wound with normal saline, pat dry, cover with bordered gauze dressing daily. Apply Nystatin powder to the periwound on 07/18/2023 and 07/25/2023; and cleanse wound with normal saline, pat dry, apply Silver Sulfadiazine, cover wound with bordered gauze daily. Apply nystatin powder to the periwound on 08/04/2023. There is no documented evidence of an interim or supplemental order for the treatment on 05/10/2023 and 05/18/2023, Nystatin to the periwound, and Silver Sulfadiazine to the right buttock. There is no documented evidence that the wound treatment order in the plan of care is being followed. On 02/02/2024 at 3:53pm, the Administrator/Director of Patient Services, the Vice President of Rehabilitation, and the Clinical Case Manager Supervisor were interviewed and did not provide an explanation for the findings.”

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on clinical record review and staff interview the agency failed to ensure there is a continual involvement of all skilled professional staff involved in the patient’s plan of care. This was evident for one (1) of twenty-six (26) clinical records reviewed (Patient #18). Failure to ensure there is ongoing interdisciplinary and continual involvement of all skilled professionals involved in the patient’s plan of care has the potential for negative patient outcome. The findings are: 1.Patient #18 has a Start of Care date of 02/08/2023 with the following diagnoses “Pressure Ulcer of Sacral Region Stage 2, Type 2 Diabetes Mellitus, Alzheimer’s Disease, Dementia” documented in the Home Health Certification and Plan of Care dated 10/06/2023 to 12/04/2023. The registered nurse visits documents with granulation on wound #2 right buttock Stage 2 on: 06/03/2023, 07/18/2023, 07/25/2023, 08/04/2023, 08/14/2023, 08/23/2023, 08/31/2023, 09/06/2023, 09/13/2023, 09/20/2023, and 09/26/2023; and wound #3 left buttocks Stage 2 on: 07/18/2023, 07/25/2023. The RN (registered nurse) Procedure Revisit documents: 09/26/2023 “Patient’s wound #1 pressure ulcer Stage 3 was noted increased in size and depth with black tissue possibly necrotic to the base of the wound.” “Wound bad black tissue, with moderate/large amount serosanguineous drainage, periwound red, inflamed.” 10/20/2023 “Wound#1: Sacrum (stage 3): Black eschar at wound bed.” There is no documented evidence of an accurate staging of the pressure ulcer – stage 2 with granulation tissue and stage 3 with necrosis, black tissue. The Procedure Recert (recertification) Visit dated 10/05/2023 documents: “Wound #2 Right buttock pressure ulcer Stage 2, wound bed red, serosanguineous drainage, periwound red and inflamed.” “Wound #3 left buttock pressure ulcer Stage 2, wound bed red, serosanguineous drainage, periwound red and inflamed.” “Tx (treatment) for wound #2 & #3: cleanse wound with Normal Saline, pat dry, apply Santyl to wound bed, cover with abdominal pad.” (Santyl is a debriding agent, removes necrotic/dead tissue from a wound.) There is no documented evidence of a clear / accurate wound assessment for a stage 2 pressure ulcer being treated with a debriding agent. There is no documented evidence of the RN accurate assessment of patient’s health status. On 02/02/2024 at 3:53pm, the Administrator/Director of Patient Services, the Vice President of Rehabilitation, and the Clinical Case Manager Supervisor were interviewed and did not provide an explanation 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 record review and staff interview the agency failed to ensure all Registered Nurses (RN)/ (SN) (skilled nurses) clinical notes are complete and accurately document the care provided. This was evident for two (2) of twenty-six (26) clinical records reviewed. (Patient #8 and #9). The findings are: 1.Patient #8 has a Start of Care date of 12/20/2023 with the diagnoses Pressure Ulcer of Sacral Region Stage 2, Pressure Ulcer of Other Site Stage 3, Pressure Ulcer of Other Site Stage 2, Parkinson’s Disease, Dementia, Depression, Type 2 Diabetes Mellitus, Muscle Weakness documented in the Home Health Certification and Plan of Care dated 12/20/2023 to 02/17/2024. The start of care comprehensive assessment note dated 12/20/2023 documents the following assessment of the patient: bed fast, dependent on assistance for mobility (including turning/repositioning) toileting, and self-care; three pressure ulcers – Coccyx Pressure Ulcer Stage 2, Left Foot Big Toe Pressure Ulcer Stage 3, and Left Foot 2nd Toe Pressure Ulcer Stage 2. The “Wound/Ulcer Management” Policy (Revised 08/2023) documents: “Wound assessment must include the following: wound location, size; stage (for pressure ulcers only); color of wound bed; drainage color, amount, consistency, odor (if present); condition of surrounding tissue; edema (if present) for each wound separately”. The Skilled Nurse visit notes dated 12/25/2023, 12/27/2023, 12/29/2023, 01/01/2024, 01/03/2024, 01/08/2024, 01/13/2024, and 01/15/2024 lacks documented evidence of the wound assessment and description in accordance with the agency Wound/Ulcer Management Policy. The Skilled Nurse Revisit note dated 01/24/2024, after the verbal order Taken Date, documents the patient developed two new pressure ulcers – Middle Back Right Side Unstageable Pressure Ulcer and Left Shoulder Pressure Ulcer Stage 2. The physician verbal order Entered Date 01/24/2024 documents the following: “Taken Date 01/23/2024;” “Update wounds SN Report;” “New rounds #4 and #5 developed. SN obtained verbal order from NP (Nurse Practitioner) (name) for W/C (wound care) for #4 and #5.” The Skilled Nurse Revisit Note dated 01/22/2024 documents the skilled nurse conducted a visit one day prior to taking the verbal order on 01/23/2024. The Skilled Nurse Revisit note lacks documented evidence of the wound assessments of the two new wounds. On 01/29/2024 at 3:45AM, a home visit was conducted to observe the Skilled Nurse. The Skilled Nurse was observed performing wound care to Wound #4 and Wound #5. The Skilled Nurse was interviewed and stated Wound #4 started “about three weeks ago” and Wound #4 started “about two weeks ago. “ The Skilled Nurse revisit notes for the two and three weeks prior to 01/29/2024, weeks of 01/08/2024 and 01/15/2024, lack documented evidence of wound assessments for Wound #4 and Wound #5. On 02/02/2024 at 3:50 PM, the Administrator/Director of Patient Services, the Clinical Case Manager/Supervisor, and the Vice President of Rehabilitation were interviewed, and did not provide an explanation for the finding. 2.Patient #9 has a Start of Care date of 12/20/2023 with the diagnoses Myasthenia Gravis without (Acute) Exacerbation, Fracture of One Rib Right Side Subsequent Encounter for Fracture with Routine Healing, Rhabdomyolysis, Spinal Stenosis, Malignant Neoplasm of the Nipple and Areola Right Female Breast, Pain in left Shoulder, Anxiety Disorder, Depression, Long Term (Current) Use of Systemic Steroids documented in the Home Health Certification and Plan of Care dated 12/20/2023 to 02/17/2024. The Home Health Certification and Plan of Care dated 12/20/2023 to 02/17/2024 documents: Skilled Nurse for “medication review/ teaching importance of adhering to treatment plan and med regimen;” and oral medication, “Clonazepam (Anti-anxiety agent) 0.5 mg tablet, take 1 tablet 3 times per day.” The Skilled Nurse Revisit note dated 01/03/2024 documents: patient is “non-compliant; Ineffective drug therapy;” “patient was extremely anxious during the visit;” “patient takes Clonazepam for anxiety; unsure about medication compliance or effectiveness.” The clinical record lacks documented evidence of how the skilled nurse determined the patient is non-compliant with taking the medication. On 01/31/2024 at 3:00 PM, the Administrator/Director of Patient Services was interviewed, and did not provide an explanation for the finding.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient’s home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This Element is not met as evidenced by: Based on clinical record review and staff interview the agency failed to ensure that all home health aides providing services to patients receiving skilled services are supervised no less frequently than every fourteen (14) days. This was evident for one (1) of eleven (11) clinical records reviewed for patients receiving home health aide services (Patient: #24). Failure to ensure that home health aide supervision is conducted no less frequently than every fourteen (14) days for patients receiving skilled services has the potential for negative patient outcomes. The findings are: 1.Patient#24 has a Start of Care date of 09/10/2022 and discharge date of 11/15/2022 with the following diagnoses “Chronic Obstructive Pulmonary Disease, Unspecified Protein-Calorie Malnutrition, Chronic Kidney Disease, stage 3” documented on the Home Health Certification and Plan of Care for the Certification Period 09/10/2022 to 11/08/2022. The Home Health Certification and Plan of Care for the Certification Period 09/10/2022 to 11/08/2022 documents:” 09/14/2022 - 09/23/2022 - Aide 3 week 1(three times a week for one week); 5 week 1(five times a week for one week).” The Supplemental Order dated 09/13/2022 documents: “Begin Date:09/14/2022; End Date: 09/23/2022 HA (home health aide) 3 week 1(three times a week for one week), 5 week 1(five times a week for one week).” The Supplemental Order dated 09/16/2022 documents: “Begin Date:09/26/2022; End Date:10/20/2022 HA (home health aide) 3 week 1(three times a week for one week), 5 week 1(five times a week for one week).” The Duty Sheet documents hha (home health aide) services being provided from 09/14/2022 to 10/07/2022. The Clinical Record documents the Skilled Nurse conducted hha (home health aide) supervision on 09/14/2022. The clinical record lacks documented evidence of the home health aide supervision from 09/14/2022 to 10/07/2022. There is no documented evidence of the home health aide being supervised every (14) fourteen days. On 02/05/2024 at 02:00 pm, the Director of Patient Services and Vice President of Rehabilitation were interviewed and did not provide an explanation for the findings.”

“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 review and staff interview the agency failed to ensure supervisory visits of the home health aide includes an evaluation of the elements in the plan of care. This is evident for two (2) of eleven (11) clinical records of patients receiving home health aide services (Patient #16 and 17). Failure to ensure the home health aide supervisory visit includes an evaluation of the elements in the plan of care has the potential for negative patient outcome. The findings are: 1.Patient #16 has a Start of Care (SOC) date of 01/16/2024, with the following diagnoses “Parkinson’s Disease, Other Low Back Pain, Pain in Unspecified Joint” documented in the Home Health Certification and Plan of Care dated 01/16/2024 to 03/15/2024. The Home Health Certification and Plan of Care dated 01/16/2024 to 03/15/2024 documents: 01/18/2024 – 1/27/2024 Aide 3 week 1 (three times a week for one week); 6 week 1 (six times a week for one week) x 2 hrs. (for two hours per day); 01/22/2024 - 2/2/2024 Aide 3 week 2 (three times a week for two weeks) x 4hrs (for four hours per day). The RN (registered nurse) Teaching Revisit dated 01/24/2024 documents: “Discipline Supervised: Aide; Supervisory Visit Type: Routine supervisory visit; Was employee present during supervisory visit? Yes; Was the patient/family treated with respect? Yes; Was plan of care followed? Yes; Patient/Caregiver Response to Care: Satisfied with care provided; Did Aide Communicate Effectively with Patient and Caregiver: Yes.” The Duty Sheet documents aide providing services on: 01/18/2024, 01/22/2024, 01/24/2024, and 01/26/2024. There is no documented evidence that the aide supervision includes: maintaining an open communication process, demonstrating competency with assigned task, complying with infection prevention and control, and reporting changes in the patient’s condition. On 02/01/2024 at 4:15pm, the Administrator/Director of Patient Services, the Vice President of Rehabilitation, and the Clinical Case Manager Supervisor were interviewed and did not provide an explanation for the findings. 2.Patient #17 has a Start of Care (SOC) date of 11/27/2023, with the following diagnoses “Other Fracture of Left Lower Leg, Type 2 Diabetes Mellitus, Hypertensive Heart Disease with Heart Failure” documented in the Home Health Certification and Plan of Care dated 11/27/2023 to 01/25/2024. The Home Health Certification and Plan of Care dated 11/27/2023 to 01/25/2024 documents: “11/29/2023 – 1/25/2024 aide 3 week 1 (three times a week for one week); 5 week 7 (five times a week for seven weeks; 4 week 1 (four times a week for one week). The RN (registered nurse) Teaching Revisit dated 12/05/2023 documents: “Supervisory Visit: NA (not applicable).” “Clinical Note: SN (skilled nurse) performed hha (home health aide) supervision with the aide present. Patient is happy with hha (home health aide) services, the patient is being treated by the hha (home health aide) with respect. The plan of care is being followed as instructed.” The Duty Sheet documents aide providing services on: 12/01/2023, 12/04/2023 to 12/08/2023, 12/12/2023, 01/03/2024, 01/05/2024, 01/09/2024 to 01/12/2024, 01/15/2024 to 01/19/2024, 01/23/2024 to 01/26/2024, and 01/26/2024. There is no documented evidence that the aide supervision includes: maintaining an open communication process, demonstrating competency with assigned task, complying with infection prevention and control, and reporting changes in the patient’s condition. On 02/01/2024 at 4:15pm, the Administrator/Director of Patient Services, the Vice President of Rehabilitation, and the Clinical Case Manager Supervisor were interviewed and did not provide an explanation for the findings.”