Family Care Certified Services Chha (Brooklyn)

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on report review, and staff interviews, the agency failed to ensure that all completed OASIS (Outcome and Assessment Information Set) assessments were transmitted to the CMS (Centers for Medicare & Medicaid Services) within thirty (30) days. This is evident for thirteen (13) clinical records based on review of the HHA Error Summary by Agency Report. Failure to ensure that all completed OASIS (Outcome and Assessment Information Set) assessments are transmitted to the CMS (Centers for Medicare & Medicaid Services) within thirty (30) days, has the potential for negative patient outcomes. The Findings Are: The HHA Error Summary by Agency Report for the period 11/03/2025 through 05/29/2025 documents Error # -3330 Record Submitted Late: The submission date is more than 30 days after M0090 (Start of Care) on this new record… # of Assessments with error nine (9). There is no documented evidence that all completed OASIS (Outcome and Assessment Information Set) assessments are transmitted to the CMS (Centers for Medicare & Medicaid Services) within thirty (30) days. On 06/01/2026 at 4:00 PM, the Administrator/Director of Patient Services was interviewed and did not provide an explanation for the survey findings.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on clinical records review and staff interview the agency failed to ensure that all patients receive services as documented in their individualized plan of care. This was evident for two (2) of seven (7) clinical records reviewed (Patient: #4 and #5). Failure to ensure that all patients receive services as documented in their individualized plan of care has the potential for negative patient outcomes. The Findings Are: 2. Patient #5 has a Start of Care (SOC) date of 06/11/2025 with the following diagnoses “Heart Failure, Hypertension, Arthritis” documented in the Home Health Certification and Plan of Care for the Certification Period 06/11/2025 to 08/09/2025. The Home Health Certification and Plan of Care for the Certification Period 06/11/2025 to 08/09/2025 documents: Wound/Integumentary Interventions AV (arteriovenous) shunt to Right Arm + (positive) for bruit and thrill. The OASIS Nursing Services SOC (start of care) Assessment dated 06/11/2025 documents: on Hemodialysis; goes to dialysis M-W-F (Monday, Wednesday, Friday). Shiley catheter in right upper chest, dressing clean and dry. On 07/08/2025 at 11:47 AM during the home visit, the surveyor noted the catheter on the right chest, no shunt noted on the right arm, and the Patient stated, “this is for the dialysis (pointing at the catheter in his chest)”. The nursing visits dated 06/11/2025, 06/16/2025, 06/19/2025, 06/24/2025, 06/026/2025, and 07/01/2025 lacks documented evidence of the assessment for the AV shunt to the right arm. The clinical record lacks documented evidence of the assessment and documentation of the catheter on the right upper chest. There is no documented evidence of the plan of care being reviewed, services being provided, and revised to reflect the patient’s condition. On 07/09/2025 at 02:17PM, the Administrator/Director of Patient Services, the Director of Rehabilitation, and the Clinical Manager were interviewed and did not provide an explanation for the findings. 1. Patient #4 has a Start of Care date of 05/08/2025 and Discharge date of 06/19/2025 with diagnoses of “Chronic Obstructive Pulmonary Disease, Covid-19, Presence of Automatic (implantable) Cardiac Defibrillator, Essential Primary Hypertension, End Stage Renal Disease” as documented in the Plan of Care for the Certification Period 05/08/2025 to 07/06/2025. The OASIS (Outcome and Assessment Information Set) Nursing Services SOC (Start of Care) dated 05/08/2025 documents “Assessment Summary: Patient attends Dialysis 3X (three times) a week Monday, Wednesday and Friday. He is diabetic and uses Contour next generation for daily checks. Patient has viable shunt in left arm no infection or drainage noted.” The Plan of Care for Certification Period 05/08/2025 to 07/06/2025 documents “Patient Centered goals established in each of the body systems Interventions and Goals; Start Effective Date: 05/08/2025. There is no documented evidence of Integumentary System goals and interventions being established for the left arm dialysis shunt and Endocrine System goals and interventions being established for the blood glucose monitoring parameters including physician notification. The clinical record lacks documented evidence of an individualized plan of care that identifies patient-specific measurable outcomes and goals. On 07/09/2025 at 2:15PM, the Director of Patent Services, Director of Rehab and Clinical Manager were interviewed and did not provide an explanation for the findings.”

“Strengths, goals, and care preferences CFR(s): 484.55(c)(2) The patient’s strengths, goals, and care preferences, including information that may be used to demonstrate the patient’s progress toward achievement of the goals identified by the patient and the measurable outcomes identified by the HHA; This Element is not met as evidenced by: Based on clinical records review and staff interview, the agency failed to ensure that the patient’s strengths, goals, and care preferences, including information that may be used to demonstrate the patient’s progress toward achievement of the goals identified by the Home Health Agency (HHA). This was evident for one (1) of seven (7) clinical records reviewed (Patient #1). Failure to ensure that all patient’s strengths, goals, and care preferences identified by the HHA, has the potential for negative patient outcomes. The Findings Are: Patient #1 has a Start of Care (SOC) date of 02/10/2025 with the following diagnoses “ Hypertension, Alzheimer’s Disease, Dementia” documented in the Home Health Certification and Plan of Care for the Certification Period 04/11/2025 to 06/09/2025. The Physician Order documents: 05/04/2025 Physical Therapy 1 X (times) week for 1 week 05/10/2025 Physical Therapy 1 X (times) week for 4 four weeks. The Physical Therapy Evaluation & Care Plan dated 05/08/2025 documents: Functional Assessment: Roll left and right, Scoot / bridge, Sit to lying on bed, and Lying to sitting on side of bed (bed mobility) with current level of function: Partial/moderate assistance; Sit to Stand and Stand / Pivot (transfer) with current level of function: Substantial/maximal assistance; Chair / bed to chair transfer with current level of function: Dependent; Walking 10 feet current level of function: Substantial/maximal assistance. She presents with periods of confusion, and she is not indicated for restorative physical therapy. The Physical Therapy Visit Note dated 05/29/2025 and 06/05/2025 documents: Goals Improve bed mobility to independent assist within ___ (blank) weeks. Improve transfers to ____ (blank) assist using ___ (blank) within ___ (blank) weeks. Independent with ambulation with ___ (blank) device within ___ (blank) weeks. The Physical Therapy Visit Note dated 05/16/2025 lacks documented goal. The clinical record lacks documented evidence of a complete and accurate goal for the physical therapy – not indicated but will improve with bed mobility from moderate assistance to independent and ambulation from extensive assist to independent. On 07/10/2024 at 03:30PM, the Administrator/Director of Patient Services, the Director of Rehabilitation, and the Clinical Manager were 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 observation, record reviews and staff interview, the agency failed to ensure that all patient’s medications were reviewed and accurately reflected in the patient’s plan of care. This was evident for one (1) of seven (7) clinical records reviewed (Patient #6). Failure to ensure that all patient’s medications are reviewed and accurately reflected in the patient’s plan of care, has the potential for negative patient outcomes. The Findings Are: The Policy Medication Management, Monitoring and Administration reviewed 01/2020 documents “Procedure: Initial Visit: The nurse will conduct a medication inventory. The medication inventory should include all prescribed medications, as well as over the counter medications the patient takes regularly and herbal remedies since these may interfere with or adversely interact with prescribed medication.” 1. Patient #6 has a Start of Care date of 07/02/2025 with diagnoses of “ Essential Primary Hypertension, Radiculopathy, Lumbosacral region, Pain in Right Hip, Pain in Right Knee” documented in the Plan of Care for the Certification Period 07/02/2025 to 08/30/2025. On 07/08/2025 at 12:15PM, an observational home visit was conducted, and the surveyor observed an inhaler at the patient’s bedside, Symbicort 160/4.5 mcg (microgram). The patient’s daughter present during the home visit stated, “I put the inhaler near to her just in case she needs it, it’s easily within her reach, she has Asthma, but she hasn’t use it since her hospital discharge.” The clinical record lacks documented evidence of the inhaler being included in the review of all medications that the patient is currently using. On 07/09/2025 at 2:15PM, the Director of Patent Services and Clinical Manager were interviewed, and the Clinical Manager stated, “I checked all the medications that the patient currently has at home during my initial visit and confirmed with the physician, we will check again.””

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on clinical records review and staff interview the agency failed to ensure each individualized plan of care includes all the required information. This was evident for three (3) of seven (7) clinical records reviewed (Patient: #3, #4 and #6). Failure to ensure each individualized plan of care includes all the required information, has the potential for negative patient outcomes. The Findings Are: 2. Patient #4 has a Start of Care date of 05/08/2025 and Discharge date of 06/19/2025 with diagnoses of “Chronic Obstructive Pulmonary Disease, Covid-19, Presence of Automatic (implantable) Cardiac Defibrillator, Essential Primary Hypertension, End Stage Renal Disease” documented in the Plan of Care for the Certification Period 05/08/2025 to 07/06/2025. The OASIS (Outcome and Assessment Information Set) Nursing Services SOC (Start of Care) dated 05/08/2025 documents under Fall Risk Assessment “Total 5 (five)”, “A score of 4 (four) or more is considered at risk for falling.” The clinical record lacks documented evidence of fall precaution being included in the individualized plan of care as safety measures to protect patient against injury. On 07/09/2025 at 2:15PM, the Director of Patent Services, Director of Rehab and Clinical Manager were interviewed and did not provide an explanation for the findings. 3. Patient #6 has a Start of Care date of 07/02/2025 with diagnoses of “Essential Primary Hypertension, Radiculopathy, Lumbosacral region, Pain in Right Hip, Pain in Right Knee” documented in the Plan of Care for the Certification Period 07/02/2025 to 08/30/2025. The Plan of Care for Certification Period 07/02/2025 to 08/30/2025 documents the following DME (Durable Medical Equipment)/Supplies Start Effective Date 07/02/2025: “Bedside Commode, Cane, Elevated Toilet Seat, Nebulizer, Walker, Chem Strips, Diapers, Gloves, Glucometer, Hand-Held Shower, Incontinent Supplies, Lancets, Raised Toilet Seat, Rollator, Shower Chair and Tub/Shower Bench.” On 07/08/2025 at 12:15PM, an observational home visit was conducted, and the surveyor observed a Raised Toilet Seat and a Tub/Shower Bench in the patient’s bathroom. The clinical record lacks documented evidence of the specific type of equipment required for the patient being included in the individualized plan of care. On 07/09/2025 at 2:15PM, the Director of Patent Services, Director of Rehab and Clinical Manager were interviewed, the Director of Rehab stated, “The Elevated Toilet Seat and Raised Toilet Seat it’s the same; the Shower Chair and Tub/Shower Bench it’s the same.” 1. Patient #3 has a Start of Care Date of 01/07/2025 and discharge date of 02/28/2025 with the following diagnoses “ Aftercare following Joint Replacement Surgery, Bilateral Primary Osteoarthritis, Essential (Primary) Hypertension” documented in the Plan of Care for the Certification Period from 01/07/2025 to 03/07/2025. The Hospital Discharge Summary dated 01/03/2025 documents: “Keep dressing clean, dry, and intact during self-hygiene. Keep the dressing on.” The PT (Physical Therapy) visit dated 01/07/2025 documents: “Skin Conditions/Integumentary section: Surgical wound, a check mark in the box “other”: non removal dressing” The RN (Registered Nurse) visit dated 01/15/2025, 01/24/2025 documents: “Skin Conditions/Integumentary section: Surgical wound; Location: Right knee; a check mark in the box “other”: non removal dressing; Incision size/appearance: Clean dry no swelling of infection noted. Staples in place” The RN (Registered Nurse) visit dated 01/30/2025 documents: “Skin Conditions/Integumentary section: Surgical wound; Location: Right knee; a check mark in the box “other”: open to air; Incision size/appearance: Clean dry no swelling of infection noted. Staples in place Bandage on knee removed today slight scabbing on right knee, no swelling or infection noted. Educated patient on s/s (signs and symptoms) of infection like having Fever over 101, feeling of overall malaise, green, cloudy or malodorous drainage from wound site, increasing continual pain from wound, redness around wound, swelling of area of wound, skin around wound hot to touch. Patient verbalized also that MD encourage him to shower area without rubbing vigorously.” The RN (Registered Nurse) visit dated 02/07/2025 documents: “Skin Conditions/Integumentary section: Surgical wound; Location: Right knee arthroplasty; Incision size/appearance: Incision clean and clear from infection no swelling or discharge noted.” The RN (Registered Nurse) visit dated 02/20/2025 documents: “Skin Conditions/Integumentary section: Surgical wound; a check mark in the box “other”: non removal dressing in place. Wound identified? “Yes” Skin remains dry and intact; skin warm and dry to touch. Surgical site healing well.” The individualized Plan of Care with a Certification Period from 01/07/2025 to 03/07/2025 does not include location, assessment, interventions, goals for surgical incision to the right knee. There is no documented evidence of a complete Plan of Care. On 07/09/2025 at 2:15PM, the Director of Patent Services, the Director of Rehabilitation, and the Clinical Manager 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 records review and staff interview, the agency failed to ensure that treatments are administered in accordance with physician orders. This was evident for four (4) of seven (7) clinical records reviewed (Patient: #3, #4, #5 and #6). Failure to ensure that treatments are administered in accordance with physician orders, has the potential for negative patient outcomes. The Findings Are: 4. Patient #5 has a Start of Care (SOC) date of 06/11/2025 with the following diagnoses “Heart Failure, Hypertension, Arthritis” documented in the Home Health Certification and Plan of Care for the Certification Period 06/11/2025 to 08/09/2025. The Home Health Certification and Plan of Care for the Certification Period 06/11/2025 to 08/09/2025 documents: MD (medical doctor) did not order weight monitoring and fluid restrictions. The Skilled Nurse Visit Note documents: 06/24/2025 “include ice cubes in 1000 cc (cubic centimeters) fluid restriction.” 067/01/2025 “SN (skilled nurse) instructed client to adhere to prescribed diet including 1000 cc (cubic centimeter) fluid restriction as recommended by MD (medical doctor). On 07/08/2025 at 11:47 AM during the home visit, the surveyor noted the nurse is giving instructions to patient regarding fluid restriction of 1000 cc (cubic centimeter) per day. There is no documented evidence of the physician order for 1000 cc fluid restriction. On 07/09/2025 at 02:17PM, the Administrator/Director of Patient Services, the Director of Rehabilitation, and the Clinical Manager were interviewed and did not provide an explanation for the findings. 2. Patient#4 has a Start of Care date of 5/08/2025 and Discharge date of 06/19/2025 with diagnoses of “Chronic Obstructive Pulmonary Disease, Covid-19, Presence of Automatic (implantable) Cardiac Defibrillator, Essential Primary Hypertension, End Stage Renal Disease” documented in the Plan of Care for the Certification Period 05/08/2025 to 07/06/2025. The Medication Profile documents “Tafluprost (PF) (preservative free) 0.0015% ml, Ophthalmic ,1 drop daily evenings, New, Start Effective Date:05/15/2025, electronically signed by RN (Registered Nurse “Name”) 05/15/2025. The clinical record lacks documented evidence of an accurate order for Tafluprost (PF) 0.0015% ml. Ophthalmic specifying whether for the left, right or both eyes. On 07/10/2025 at 9:30AM, the Director of Patent Services was interviewed and did not provide an explanation for the findings. 3. Patient# 6 has a Start of Care date of 07/02/2025 with diagnoses of “Essential Primary Hypertension, Radiculopathy, Lumbosacral region, Pain in Right Hip, Pain in Right Knee” documented in the Plan of Care for the Certification Period 07/02/2025 to 08/30/2025. The Medication Profile documents “Start Date: 07/02/2025, Existing, Desoximetasone 0.25%, External topical application, twice per day AM/PM; Start Date: 07/02/2025, Existing, Albuterol Sulfate 2.5mg/3ml, 0.083% ml, Inhalation 1 (one) puff every 6hr (six hours)/ PRN/ As Needed.” On 07/08/2025 at 12:15PM, an observational home visit was conducted, the patient’s daughter present during the home visit stated, “I’m applying the Desoximetasone ointment to my Mom’s under breast folds, stomach folds and in between her thighs, this Albuterol Sulfate 2.5mg/3ml is her nebulizer solution, she has not use it thankfully coz she does not have any wheezing since her hospital discharge.” The clinical record lacks documented evidence of accurate orders for Desoximetasone 0.25% specifying to which affected area for topical application and the use of Albuterol Sulfate 2.5mg/3ml. 0.083% ml specifying via nebulizer machine.” On 07/09/2025 at 2:15PM, the Director of Patent Services and Clinical Manager were interviewed, the Director of Patient Services stated, “We’ll double check all the orders and will call the doctor.” 1. Patient #3 has a Start of Care Date of 01/07/2025 and discharge date of 02/28/2025 with the following diagnoses “ Aftercare following Joint Replacement Surgery, Bilateral Primary Osteoarthritis, Essential (Primary) Hypertension” documented in the Plan of Care for the Certification Period from 01/07/2025 to 03/07/2025. The Hospital Discharge Summary dated 01/03/2025 documents: “ Expected Medication List at Discharge: Doxycycline hyclate 100 mg capsule take 1 capsule (100 mg total) by mouth 2 (two) times a day for 14 days. Indications: Infection of the skin and/or soft tissue.” The Plan of Care for the Certification Period from 01/07/2025 to 03/07/2025 documents: “Doxycycline Monohydrate 100 mg; oral; 2 tablets, twice per day. Start Effective Date: 01/07/2025” (no medication duration) The Medication Profile dated 01/07/2025 documents:” Doxycycline Monohydrate 100 mg; oral; 2 tablets, twice per day, Antibacterials; Date teaching performed:01/07/2025, d/c (discharge) date is blank” The PT OASIS SOC/ROC (Physical Therapy Outcome and assessment Information Set Start of Care/Resumption of Care) dated 01/07/2025 documents: “Medications: (N0415) High-Risk Drug Classes: Use Indication: F. Antibiotic: “NO” patient is not taking antibiotic” The PT (Physical Therapy) visit dated 01/15/2025, 01/17/2025, 01/21/2025 and 01/23/2025 documents: “Objective: Medication change since last visit? “None reported/Identified” The RN (Registered Nurse) visit dated 01/15/2025 documents:” Medication change since last time? “NO” All medication including dosage and frequency were reconciled. NO discrepancies noted; the patient has adequate medication supply on hand.” The RN (Registered Nurse) visit dated 01/24/2025 documents:” Medication change since last time? “NO” All medication including dosage and frequency were reconciled. Patient verbalized he has taken his Doxycycline medication. Patient currently Doxycycline 100 mg2 x daily for 14 days. Educated patient that Doxycycline is an antibiotic used to treat or prevent infection. Side effects may include vomiting and nausea, and sunlight sensitivity medications including dosage and frequency were reconciled. No discrepancies noted; the patient has adequate medication supply on hand.” The RN (Registered Nurse) visit dated 02/07/2025 documents: “Medication change since last time? “NO” Patient verbalized he has completed his Doxycycline 100 md 2 x daily for 14 days.” The RN (Registered Nurse) visit dated 02/20/2025 documents: “All medications including dosage and frequency were reviewed and reconciled. No discrepancies noted; the patient has adequate medication supply on hand.” The RN AOSIS (Registered Nurse Outcome and Assessment Information Set) Discharge Non-Visit dated 02/28/2025 documents:” Medications: (N0415) High-Risk Drug Classes: Use Indication: F. Antibiotic: “NO” patient is not taking antibiotic. Medications Patient is on at Discharge section: Active: Doxycycline Monohydrate 100 mg cap(s) Oral 2 tablets twice per day. New start effective date: 01/07/2025.” There is no documented evidence of an interim order to continue/discontinue Doxycycline Monohydrate 100 mg start effective date 01/07/2025, and for Doxycycline 100 md 2 x daily for 14 days on 02/07/2025. On 07/09/2025 at 02:15 PM, the Director of Patent Services stated that the patient was ordered Doxycycline 100 mg 2 capsules twice daily for 10 days from 01/07/2025 to 01/17/2025. The Registered Nurse failed to update the medication profile on 01/17/2025.”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on clinical records review and staff interview, the agency failed to coordinate care delivery to meet the patient’s needs. This was evident for two (2) of seven (7) clinical records reviewed. (Patients #4 and #6). Failure to ensure coordinated care delivery to meet the patient’s needs has the potential for negative patient outcome. The findings are: The Policy Coordination of Care reviewed 06/2019 documents “B. Coordination Functions: The nurse assures that agency caregivers are clear about who is doing what for the patient. The primary mechanism used is making the plan of care available to all caregivers. The nurse assumes responsibility for the communication of many changes in the patient’s condition, physician orders or care plan; 6. The nurse assures that all patient communication related to care coordination is clearly documented in the patient’s record on a timely basis.” 1. Patient #4 has a Start of Care date of 05/08/2025 and Discharge date of 06/19/2025 with diagnoses of “Chronic Obstructive Pulmonary Disease, Covid-19, Presence of Automatic (implantable) Cardiac Defibrillator, Essential Primary Hypertension, End Stage Renal Disease” documented in the Plan of Care for the Certification Period 05/08/2025 to 07/06/2025. The OASIS (Outcome and Assessment Information Set) Nursing Services SOC (Start of Care) dated 05/08/2025 documents the following: “Equipment Currently in the home: Wheelchair, Walker, Cane, Tub/Shower Bench; Patient/family able to use all equipment/supplies safely? Yes; Activities Permitted: Cane; Start Effective Date 05/08/2025.” The Physical Therapy Evaluation and Care Plan dated 05/13/2025 documents “DME (Durable Medical Equipment)/Supplies: Bath Bench, Cane, Rolling Walker; Activities Permitted: Cane; Start Effective Date 05/13/2025.” The Plan of Care for Certification Period 05/08/2025 to 07/06/2025 documents “DME (Durable Medical Equipment)/Supplies, Start Effective Date 05/08/2025: Bath Bench, Cane, Rolling Walker; Activities Permitted, Start Effective Date 05/08/2025: Cane, Exercises Prescribed, Transfer Assistance, Up as Tolerated.” The clinical record lacks documented evidence of the interdisciplinary coordination of care for the patient’s permitted activities including the use of wheelchair, walker, rolling walker and tub/shower bench. On 07/09/2025 at 2:15PM, the Director of Patent Services, Director of Rehab and Clinical Manager were interviewed and did not provide an explanation for the findings. 2. Patient #6 has a Start of Care date of 07/02/2025 with diagnoses of “Essential Primary Hypertension, Radiculopathy, Lumbosacral region, Pain in Right Hip, Pain in Right Knee” documented in the Plan of Care for the Certification Period 07/02/2025 to 08/30/2025. The OASIS (Outcome and Assessment Information Set) Nursing Services SOC (Start of Care) dated 07/02/2025 documents “Blood Sugar Glucometer: Use Glucometer Type: Unable to find at time of visit; How often checked: Daily; Blood sugar monitoring done daily by caregiver; Notify MD (Medical Doctor) if blood glucose less than 70mg/dl (milligrams per deciliter) or more than 450mg/dl.” On 07/08/2025 at 12:15PM, during the observational home visit, the patient’s daughter was interviewed about the patient’s blood sugar monitoring and stated, “We cannot find my Mom’s glucometer, we ordered it and will be delivered soon. My daughter has one at work, and the nurse (“Name”) might have a glucometer and will probably take her blood sugar during today’s visit.” The clinical record lacks documented evidence of the coordination of care with the physician regarding the permissible use of shared glucometer to meet the patient’s need. On 07/09/2025 at 2:15PM, the Director of Patent Services and Clinical Manager were interviewed, the Clinical Manager stated, “. It was previously discussed during my initial visit that the patient can use the granddaughter’s glucometer who is also working as a health care worker.””

“Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on clinical records review and staff interview, the agency failed to ensure that the written visit schedule is provided to the patient. This was evident for two (2) of seven (7) clinical records reviewed (Patients #5 and #6). Failure to ensure that the written visit schedule provided to the patient has the potential for negative patient outcome. The findings are: 2. Patient# 6 has a Start of Care date of 07/02/2025 with diagnoses of “Essential Primary Hypertension, Radiculopathy, Lumbosacral region, Pain in Right Hip, Pain in Right Knee” documented in the Plan of Care for the Certification Period 07/02/2025 to 08/30/2025. On 07/08/2025 at 12:15PM, during the observational home visit, the surveyor reviewed the admission packet provided to the patient, there is no written visit schedule of Skilled Nursing and Physical Therapy included in the packet. The patient’s daughter was interviewed and stated, “We don’t have a calendar of visits. My Mom was initially approved for 3 (three) Skilled Nursing visits and 3 (three) Physical Therapy visits.” There is no documented evidence of the written visit schedule by Skilled Nursing and Physical Therapy being provided to the patient and caregiver. On 07/09/2025 at 2:15PM, the Director of Patent Services, Director of Rehab and Clinical Manager were interviewed and did not provide an explanation for the findings. 1. Patient #5 has a Start of Care (SOC) date of 06/11/2025 with the following diagnoses “Heart Failure, Hypertension, Arthritis” documented in the Home Health Certification and Plan of Care for the Certification Period 06/11/2025 to 08/09/2025. On 07/08/2025 at 11:47 AM during the home visit, the surveyor checked the admission packet and did not find the visit schedule, clarified with the nurse and stated, “We don’t have a calendar or visit schedule”. There is no documented evidence of the visit schedule, including frequency of visit by HHA personnel in the patient home. On 07/09/2025 at 02:17PM, the Administrator/Director of Patient Services, the Director of Rehabilitation, and the Clinical Manager were interviewed and did not provide an explanation for the findings.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to ensure that treatments are administered only as ordered by the physician for each patient. This was evident for one (1) of three (3) clinical records reviewed. (Patient #1). Failure to ensure that treatments are administered only as ordered by the physician has the potential for negative patient outcomes. The findings are: 1.Patient #1 has a Start of Care date of 06/14/2021 with the following diagnoses “Chronic Venous Hypertension with Ulcer of Bilateral Low Extremity, Non-Pressure Chronic Ulcer of other Part of Right Lower Leg with other Specified Severity, Non-Pressure Chronic Ulcer of other Part of Left Lower Leg with other Specified Severity “ documented on the Plan of Care dated 12/01/2023 to 01/29/2024. The Plan of Care dated 12/01/2023 to 01/29/2024 documents:” SN (Skilled Nurse) to apply Unna Boot to Right Lower Leg: Apply Unna Boot and Ace Bandage 1 x week by SN (Skilled Nurse) as preventative treatment. Start Effective Date: 11/27/2023.” The Skilled Nurse Visit Note dated 12/05/2023, 12/07/2023, 12/14/2023, 12/26/2023, 12/28/2023 documents: “Interventions/Education Provided: Wound to right lower extremity cleanse with NS (Normal Saline), pat dry. Unna boot applied to wound, covered with Kling and secured with Ace bandage.” The Interventions/Education Provided section dated 12/05/2023, 12/07/2023, 12/14/2023, 12/28/2023 documents: “ Interventions: SN (Skilled Nurse) to apply Unna Boot to Right Lower Leg: Apply Unna Boot and Ace Bandage 2 x week by SN.” The Plan of Care dated 12/01/2023 to 01/29/2024 documents:” SN (Skilled Nurse) to apply Unna Boot to Left Lower Leg: Apply Unna Boot and Ace Bandage 1 x week by SN. Start Effective Date: 11/27/2023. SN (Skilled Nurse) to provide Wound to Left Lower Leg Inner, lower aspect: remove outer dressing only, apply dry sterile gauze, secure with Kling bandage and ACE bandage 2 x week. Start Effective Date: 11/27/2023.” The Skilled Nurse Visit Note dated 12/05/2023, 12/07/2023, 12/12/2023, 12/14/2023, 12/19/2023, 12/22/2023, 12/26/2023, 12/28/2023 documents: “Interventions/Education Provided: Wound to left medial leg cleanse with NS (Normal Saline), pat dry covered with DSD (Dry Sterile Dressing), wrapped with Kling and secured with Ace bandage. SN Wound/Integumentary Interventions: SN to apply Unna Boot to Left Lower Leg: Apply Unna Boot and Ace Bandage 2 x week by SN.” The Skilled Nurse Visit Note dated 01/05/2024 documents: “Interventions/Education Provided: Nurse cleansed venous ulcer to left lateral ankle with NS (Normal Saline), applied DSD (Dry Sterile Dressing), Unna Boot Kling and Ace wrap. Patient has a dorsal wound to the left dorsal foot cleansed wound with NS (Normal Saline), applied Silvadene cream DSD (Dry Sterile Dressing), and Kling wrap wound is granular with small serous drainage etiology of wound is unknown. VN (Visiting Nurse) called PCP (Primary Care Physician) and obtained wound care orders. “ There is no documented evidence of an interim or supplemental orders for the change in the wound care treatment. There is no documented evidence of the SN (Skilled Nurse) administering wound treatment only as ordered by the physician. On 01/22/2024 at 05:15 pm, the Director of Patient Services was interviewed and did not provide an explanation.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on clinical record review, and staff interview the agency failed to provide services that are ordered by the physician as indicated in the plan of care. This was evident for one (1) of three (3) clinical records reviewed. (Patient #2). Failure to provide services that are ordered by the physician as indicated in the plan of care, has the potential for negative patient outcomes. The Findings Are: 1.Patient #2 has a Start of Care date of 11/27/2023 with the following diagnoses “Pressure Ulcer of Right Buttock, stage 2, Hypertensive Heart Disease with Heart Failure, Type 2 Diabetes Mellitus without Complication “ documented on the Plan of Care for the Certification Period dated 11/27/2023 to 01/25/2024. The Plan of Care dated 11/27/2023 to 01/25/2024 documents: ” RN (Registered Nurse)/DNP/LVN (Licensed Vocational Nurse):2 x week for 3 weeks starting 11/28/2023 Start Date:11/28/2023 End Date: 12/16/2023; RN (Registered Nurse)/DNP/LVN (Licensed Vocational Nurse): 3 x week for 1 week starting 12/17/2023 Start Date: 12/17/2023 End Date: 12/23/2023; RN (Registered Nurse)/DNR/LVN (Licensed Vocational Nurse): 1 x wee for 4 weeks starting 12/24/2023 Start Date: 12/24/2023 End Date:01/20/2024.” There is no documented evidence of the RN (Registered Nurse) providing care for the patient: week of 11/27/2023 - 2 (two) missed visits; week of 12/03/2023 - 1 (one) missed visit, week of 12/10/2023 - 1 (one) missed visit, week of 12/17/2023 -1 (one) missed visit. There is no documented evidence of the patient receiving RN (Registered Nurse) services as ordered on the plan of care. On 01/22/2024 at 05:15 pm, the Director of Patient Services was interviewed and did not provide an explanation.”