Centerwell Home Health

“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 clinical record reviews, the Home Health Agency (HHA) Error Report, and staff interviews, the agency failed to ensure that all completed Outcome and Assessment Information Set assessments (M0090) were transmitted to the State/Centers for Medicare and Medicaid Services when completed. This is evident for one (1) of one (1) clinical record reviewed that required transmission (Patient #16). Failure to ensure that all completed Outcome and Assessment Information Set assessments are transmitted to the Centers for Medicare and Medicaid Services contractor or state within 30 (thirty) days has the potential for negative patient outcomes. Pre-survey review of the “Home Health Agency Error Summary Report” on 09/02/2025 revealed the agency has 280 (two hundred eighty) late submissions of the Outcome and Assessment Information Set assessments (M0090) from 09/01/2024 to 09/01/2025. Patient #16 – This 62-year-old patient with the diagnoses of type 2 diabetes mellitus, enterostomy malfunction, and morbid obesity due to excess calories was admitted to the home care agency on 07/23/2025. Review of the Registered Nurse Outcome and Assessment Information Set Start of Care completed by the Registered Nurse revealed the Outcome and Assessment Information Set Assessment (M0090) was completed on 07/23/2025. Review of the Home Health Agency Error Submission Report provided by the agency on 09/08/2025 at 12:30 PM revealed the patient’s Outcome and Assessment Information Set Assessment (M0090) was submitted on 08/27/2025, 35 (thirty-five) days after the assessment was complete. During interview on 09/11/2025 at 04:07 PM, the Branch Director stated the clinical manager responsible for submitting the Outcome and Assessment Information Set Assessments was unavailable at the time of submission, as a result the agency was behind on submitting the report within the required time frame.”

“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 review of the agency’s Outcome Assessment Information Set (OASIS) submissions, clinical records, and interview with staff for one (1) of seventeen (17) patients (Patient #8), the agency failed to ensure the OASIS data accurately reflects the patient’s status at the time of the assessment. Failure to ensure accurate documentation of OASIS data has the potential for negative outcomes. Patient #8 – This 91-year-old patient with diagnoses that include fracture to unspecified neck of left femur and three-part fracture to neck of right humerus was admitted as therapy-only to the home health agency on 05/12/2024 and discharged 07/10/2024. Pre-survey review of the agency’s Outcome and Assessment Information Set (OASIS) submission as reflected on the Internet Quality Improvement and Evaluation System (IQIES) Potentially Avoidable Event Report revealed the patient was listed as having a potentially avoidable event from 05/12/2024 to 07/10/2024 in the category of “emergent care for hypoglycemia/hypoglycemia.” Review of the Physical Therapy (PT) Discharge Data Collection Only- No Visit Made dated 07/10/2024 revealed the PT documented the patient had utilized a hospital emergency department with hospital admission since the most recent start of care for hypo/hyperglycemia and diabetes out of control. Review of the clinical record from 05/12/2024 to 07/10/2024 lacks documentation of the patient being treated at a facility emergency department with subsequent hospitalization. During interview on 09/12/2025 at 09:38 AM, the PT stated the patient went to the emergency department and was hospitalized for uncontrolled diabetes on 07/14/2024 (four days after discharge). The PT incorrectly documented the hospitalization on the discharge documentation dated 07/10/2024.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on review of clinical records and staff interview for five (5) of seventeen (17) patients (Patient #’s: 1, 6, 10, 13, and 14), the agency failed to ensure the clinician conducted an initial assessment of the patient within forty-eight (48) hours of referral, the patient’s return home, or on the physician-ordered start of care date. Failure to conduct the initial assessment within the required time frame has the potential to result in unmet patient needs and negative patient outcomes. The New York Codes, Rules, and Regulations, Title 10, Article 7, Section 763.5(a) Patient Referral and Admission states “The initial patient visit shall be made within twenty-four (24) hours of receipt and acceptance of a community referral or return home from institutional placement unless: (1) the patient’s authorized practitioner orders otherwise; or (2) there is written documentation that the patient or family refuses such a visit.” Patient #1 – This 65-year-old patient with diagnoses that include displaced trimalleolar fracture to left lower leg and displaced bimalleolar fracture to right lower leg was admitted to the home health agency on 08/22/2025. Review of the Referral Summary dated 08/20/2025 revealed the patient was referred to the home health agency for Skilled Nursing (SN), Physical Therapy (PT), and Occupational Therapy (OT) on 08/20/2025. Review of the Client Coordination Note dated 08/20/2025 revealed the RN obtained a verbal order for the SN start of care to occur on 08/22/2025. Review of the clinical record lacks documentation the patient was contacted and requested a delay to the start of care. During interview on 09/12/2025 at 11:34 AM, the Clinical Manager stated there is no documentation the patient was contacted on 08/21/2025 and requested a delay to the start of care visit. Patient #10 – This 72-year-old patient with diagnoses that include hypertensive heart and chronic kidney disease with heart failure and acute on chronic diastolic heart failure was admitted to the home health agency on 12/22/2024 and discharged on 02/07/2025. Review of the Skilled Nursing Facility Post Discharge Plan of Care (agency referral) dated 12/17/2024 revealed the patient was referred to the home health agency on 12/17/2024. Review of the Client Coordination Note dated 12/17/2024 revealed the RN obtained a verbal order for the SN start of care to occur on 12/18/2024. Review of the Client Coordination Note dated 12/20/2024 revealed the RN obtained a verbal order for the SN start of care to occur on 12/22/2024. Review of the clinical record lacks documentation the patient was contacted and requested a delay to the start of care. During interview on 09/12/2025 at 11:05 AM, the Clinical Manager stated the 12/18/2024 start of care was delayed as it was a hemodialysis day for the patient. However, the Clinical Manager stated there is no documentation the patient was contacted 12/19/2024 to attempt to reschedule the start of care visit. Patient #13 – This 88-year-old patient with diagnoses that include bilateral primary osteoarthritis of knee and muscle weakness generalized was admitted as therapy-only to the home health agency on 08/20/2025. Review of the Referral Summary dated 08/15/2025 revealed the patient was referred to the home health agency for PT and OT on 08/15/2025. Review of the Client Coordination Note dated 08/19/2025 revealed the RN documented a verbal order was obtained for a PT start of care visit on 08/20/2025. Review of the clinical record lacks documentation the patient was contacted and requested to delay the start of care to 08/20/2025, five (5) days after the referral was sent. During interview on 09/12/2025 at 10:52 AM, the Clinical Manager/Director of Patient Services stated there is no documentation the patient was contacted and delayed the start of care visit. Patient #6 – This 85-year-old patient with the diagnoses of osteoarthritis of lumbosacral spine, paroxysmal atrial fibrillation, chronic diastolic heart disease, and recurrent falls was admitted to the home care agency on 08/17/2025. Review of the Referral Summary dated 07/24/2025 revealed the patient was referred to the home health agency for Skilled Nursing, Physical Therapy, and Occupational Therapy on 07/24/2025. Review of the Client Coordination Note dated 08/15/2025 revealed the Registered Nurse obtained a verbal order for the SN start of care to occur on 08/17/2025. Review of the clinical record lacks documentation the patient was contacted and requested a delay to the start of care. During interview on 09/09/2025 at 03:46 PM, the Clinical Manager stated start of care was delayed because the agency was waiting on information from the physician’s office. However, the Clinical Manager stated there is no documentation the patient was contacted, and the physician was notified of the delay to the start of care visit. Patient #14 – This 66-year-old patient with the diagnoses of type 2 diabetes mellitus with hyperglycemia, postmenopausal, and essential hypertension was admitted to the home care agency on 08/23/2025. Review of the Referral Summary dated 08/18/2025 revealed the physician ordered the start of care for 08/19/2025 and further indicated that the patient “Needs care tomorrow.” Review of the clinical record lacks documentation the patient was contacted and requested a delay to the start of care. During interview on 09/11/2025 at 02:30 PM, the Clinical Manager acknowledged there was a delay to the start of care for the patient but stated they were unsure why the delay occurred.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information: (1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on clinical record review and staff interview for one (1) of seventeen (17) patients (Patient #10), the agency failed to ensure the initial comprehensive assessment if of sufficient scope to identify patient needs. Failure to ensure the initial comprehensive assessment accurately reflects the patient status and needs has the potential for unmet patient needs and negative patient outcomes. Patient #10 – This 72-year-old patient with diagnoses that include hypertensive heart and chronic kidney disease with heart failure and acute on chronic diastolic heart failure was admitted to the home health agency on 12/22/2024 and discharged on 02/07/2025. A.) Review of the Home Health Certification and Plan of Care from 12/22/2024 to 02/19/2025 revealed an order for humalog junior kwikpen 100-unit (u) per milliliter (ml) subcutaneous three (3) times daily: - no injection for blood sugar 0 to 250; - 4 units for blood sugar 51(251) to 300; - 6 units for blood sugar 301 to 350; - 8 units for blood sugar 351 to 400; and - if blood sugar over 400 hold insulin and call physician (MD). Review of the Registered Nurse (RN) Outcome and Assessment Information Set (OASIS) Admission Visit dated 12/22/2024 revealed the RN documented the patient has diabetes, does not test blood glucose, is unable to report blood glucose reading as has not checked it today and can prepare and administer injectable medication. The documentation lacks an assessment of the diabetic supplies in the home and the patient’s ability to test blood glucoses three times daily to administer sliding scale insulin three times daily. During interview on 09/11/2025 at 02:40 PM, the RN stated being unable to review the identified documentation due to no electronic access to discharged patient records and cannot recall the identified patient. During interview on 09/11/2025 at 02:47 PM, the Clinical Manager/Director of Patient Services stated there is no documentation of how the patient will check blood glucoses and administer insulin per a sliding scale three times daily. B.) Review of the Skilled Nursing Facility Post Discharge Plan of Care (agency referral) dated 12/17/2024 revealed the patient has the following: - a right chest dialysis catheter covered with a dressing; - a pressure area to the coccyx requiring area to be washed, apply Triad cream and dry dressing daily; and - a right arm skin tear requiring cleansing with normal saline and applying a dry non-adherent dressing. Review of the RN OASIS Admission Visit dated 12/22/2024 revealed the RN documented the patient has some bruising to Integumentary and does not have a pressure ulcer, stasis ulcer or surgical wound. The assessment lacks documentation of the presence of the right chest dialysis catheter and dressing status, and the status of the coccyx pressure ulcer and right arm skin tear as identified in the agency referral. During interview on 09/11/2025 at 02:40 PM, the RN stated being unable to review the identified documentation due to no electronic access to discharged patient records and cannot recall the identified patient. During interview on 09/11/2025 at 02:59 PM, the Clinical Manager/Director of Patient Services stated the assessment lacks documentation of the right chest dialysis catheter and dressing, the coccyx pressure ulcer and the right arm skin tear.”

“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 interview with agency staff, two (2) of seventeen (17) clinical records (Patient #’s: 13 and 15) lack documentation of a complete review of all medications the patient currently uses to identify any potential adverse effects, drug reactions, or concerns. Failure to conduct a complete medication review and to ensure the medication regime is appropriate has the potential for patient harm. Patient #13 – This 88-year-old patient with diagnoses that include bilateral primary osteoarthritis of knee and muscle weakness generalized was admitted as therapy-only to the home health agency on 08/20/2025. Review of agency policy entitled “Medication Review and Documentation” revised 10/2024 revealed “If a therapist is not authorized by their state practice act to perform a review of patient medications, the Clinical Manager (or designee) will perform the drug regimen review/medication reconciliation process…..within five days of the Start of Care date.” Review of the Physical Therapy (PT) Outcome and Assessment Information Set (OASIS) Admission visit dated 08/20/2025 revealed the PT documented a drug regimen review was conducted and no issues were found. Review of the Client Medication Report revealed the Registered Nurse conducting the medication review on 09/09/2025, twenty (20) days after the start of care visit. During interview on 09/12/2025 at 10:55 AM, the Clinical Manager/Director of Patient Services acknowledged the drug regimen review failed to be completed by the RN within the required time frame. Patient #15 – This 88-year-old patient with the diagnoses of unspecified mononeuropathy of bilateral lower limbs, hyperlipidemia, and essential hypertension was admitted to the home care agency on 08/20/2025. A.) Review of the Referral Summary dated 08/11/2025 revealed the following orders: -Lidocaine (Lidoderm) 4% adhesive patch medicated use daily as needed for pain. -Melatonin 5 mg (milligram) tablet, one tablet at bedtime. Review of the Home Health Certification and Plan of Care (POC) for certification period 08/20/2025 to 10/18/2025 lacks an order for the Lidocaine and Melatonin. B.) Review of the Home Health Certification and Plan of Care for certification period 08/20/2025 to 10/18/2025 revealed the following orders: -Citalopram 20 mg tablet, one tablet daily for depression. Review of the Referral Summary dated 08/11/2025 lacks the order for the Citalopram. Review of the Physical Therapy Outcome and Assessment Information Set Admission visit dated 08/20/2025 revealed the PT documented a drug regimen review was conducted and no issues were found. During interview on 09/12/2025 at 10:25 AM, the Physical Therapist stated that the discrepancies were not identified during the medication review, so the physician was not notified.”

“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 review of clinical records and staff interviews for two (2) of seventeen (17) patients (Patient #’s 10 and 17) the agency failed to develop individualized plans of care that are complete and accurate and address the total needs of the patients. Failure to ensure that a comprehensive individualized plan of care is developed has the potential for unmet patient needs. Patient #10 – This 72-year-old patient with diagnoses that include hypertensive heart and chronic kidney disease with heart failure and acute on chronic diastolic heart failure was admitted to the home health agency on 12/22/2024 and discharged on 02/07/2025. A.) Review of the Skilled Nursing Facility (SNF) Post Discharge Plan of Care (agency referral) dated 12/17/2024 revealed the patient is on a renal diet with 1500 milliliter (ml) fluid restriction in a twenty-four (24) hour period due to end stage renal disease and is on hemodialysis. Review of the Home Health Certification and Plan of Care from 12/22/2024 to 02/19/2025 revealed the patient is ordered a cardiac diet. Review of the clinical record lacks documentation regarding the fluid restriction and renal diet ordered in the agency referral. During interview on 09/11/2025 at 02:29 PM, the Clinical Manager stated there is no documentation of follow-up on the dietary orders on the referral. B.) Review of the Home Health Certification and Plan of Care from 12/22/2024 to 02/19/2025 revealed the patient is ordered the following: - to administer sliding scale short acting insulin three (3) times daily; - to administer long-acting insulin once daily; - is documented to not monitor blood sugars in home; and - medications are not available to be viewed in the home. - Skilled Nurse to observe/assess diabetes, identify changes and intervene to minimize complication, teach related diabetes management to include disease process, nutrition, medications, activities, and personal/environment. The plan of care lacks documentation of diabetic supplies used in the home and who manages the diabetes and insulin administration as the patient does not test blood glucoses. During interview on 09/11/2025 at 02:40 PM, the Clinical Manager stated the plan of care fails to specify the identified items. Patient #17 – This 78-year-old patient with diagnoses that include urinary tract infection and type 2 diabetes mellitus was admitted to the home health agency on 07/07/2025. Review of the Home Health Certification and Plan of Care from 07/07/2025 to 09/04/2025 revealed the Registered Nurse (RN) documented the patient is ordered to take insulin glargine- 100 units per ml subcutaneous 26 units daily. Review of the Clinically Significant Medication Issue Coordination Note dated 07/07/2025 revealed the RN documented the basaglar (glargine) insulin is not in the home. The physician was contacted and approves the patient not to take it. Review of the clinical record lacks documentation of an order to discontinue the identified insulin. During interview on 09/12/2025 at 10:21 AM, the RN stated the patient was taking the insulin as ordered and made an error regarding the insulin not being taken and being discontinued when documenting in the identified Coordination Note.”

“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 interview with agency staff, for two (2) of seventeen (17) patients (Patient #’s: 10 and 17), the agency failed to ensure services and treatments are administered in accordance with physician orders. Failure to provide services and treatments as ordered has the potential to result in poor quality of care. Patient #10 – This 72-year-old patient with diagnoses that include hypertensive heart and chronic kidney disease with heart failure and acute on chronic diastolic heart failure was admitted to the home health agency on 12/22/2024 and discharged on 02/07/2025. A.) Review of the Home Health Certification and Plan of Care from 12/22/2024 to 02/19/2025 revealed orders to assess/instruct on daily weight and keep a log. Notify physician of for weight greater than 158 pounds. Review of the Registered Nurse (RN) Outcome and Assessment Information Set (OASIS) Admission Visit dated 12/22/2024 revealed the RN documented the patient’s weight is 168 pounds. Review of the clinical record lacks documentation the authorized provider was notified of the patient’s weight being greater than 158 pounds. During interview on 09/11/2025 at 02:50 PM, the RN stated being unable to review the identified documentation due to no electronic access to discharged patient records and cannot recall the identified patient. During interview on 09/11/2025 at 02:52 PM, the Clinical Manager stated there is no documentation the physician was notified of the identified weight as ordered. B.) Review of the Home Health Certification and Plan of Care from 12/22/2024 to 02/19/2025 revealed an order to assess/instruct on obtaining daily weight and keeping log. If patient is unable to weigh obtain lower extremity circumference each visit and notify physician of increase of two (2) centimeters (cm) or greater. Review of the RN Subsequent Visit dated 12/26/2024 revealed the RN documented the patient has edema to bilateral lower extremities and patient reports she needs a scale to monitor daily weights. The assessment lacks documentation of a weight or lower extremity circumferences being obtained. During interview on 09/12/2025 at 09:28 AM, the RN stated being unable to review the identified documentation due to no electronic access to discharged patient records and cannot recall the identified patient. During interview on 09/12/2025 at 09:30 AM, the Clinical Manager states there is no documentation of a weight or lower extremity circumferences being obtained during the identified visit. Patient #17 – This 78-year-old patient with diagnoses that include urinary tract infection and type 2 diabetes mellitus was admitted to the home health agency on 07/07/2025. Review of the Home Health Certification and Plan of Care from 07/07/2025 to 09/04/2025 revealed the patient wears a continuous blood glucose monitor and is checking blood sugars twice daily. The licensed professional is to report a fasting blood glucose less than 60 or greater than 250 to the authorized provider. Review of the RN Subsequent Visit dated 08/18/2025 revealed the RN documented the patient reports fasting blood glucoses within the last week ranging from 116 to 260. Review of the clinical record lacks documentation the authorized provider was notified of the fasting blood sugar ranging greater than 250. During interview on 09/12/2025 at 08:44 AM, the RN stated due to an oversight the physician was not notified of the identified glucose ranges being greater than 250.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on review of clinical records and interviews with staff for two (2) of seventeen (17) patients (Patient #’s 4 and 10), the agency failed to ensure the physician is notified of changes in the patient’s condition or needs that suggest the plan of care may need to be altered. Failure to promptly notify the physician to changes in the patient’s condition or needs that may suggest that outcomes are not being achieved and/or the plan of care should be altered has the potential to result in unmet patient needs and negative patient outcomes. Patient #4 – This 91-year-old patient with the diagnoses of pressure ulcer of sacral region, stage 4, osteomyelitis of vertebral column, and paraplegia was admitted to the home care agency on 08/23/2025. Review of the OT (Occupational Therapy) Add ON Evaluation Visit dated 08/27/2025 revealed the OT documented the patient had edema of the lower extremities. Review of the clinical record lacks documented evidence that the physician was notified of the patient’s lower extremity edema. During an interview on 09/12/2025 at 10:45 AM, the Clinical Manager stated the OT was unavailable for interview and acknowledged there was no documentation in the clinical records that the physician was notified of the patient’s lower extremity edema. Patient #10 – This 72-year-old patient with diagnoses that include hypertensive heart and chronic kidney disease with heart failure and acute on chronic diastolic heart failure was admitted to the home health agency on 12/22/2024 and discharged on 02/07/2025. A.) Review of the Skilled Nursing Facility Post Discharge Plan of Care (agency referral) revealed the patient is ordered to wear oxygen 2 liters per minute via nasal cannula. The frequency of use is not specified. Review of the Registered Nurse (RN) Outcome and Assessment Information Set (OASIS) Admission Visit revealed the RN documented the patient was not using oxygen at the time of the visit and the patient stated they are trying to wean off the oxygen that is ordered. Review of the Home Health Certification and Plan of Care from 12/22/2024 to 02/19/2025 lacks orders for oxygen use. Review of the clinical record lacks documentation the authorized practitioner was reported of the patient self-weaning oxygen use and verified the oxygen orders could be discontinued. During interview on 09/11/2025 at 02:45 PM, the RN stated being unable to review the identified documentation due to no electronic access to discharged patient records and cannot recall the identified patient. During interview on 09/11/2025 at 02:47 PM, the Clinical Manager stated there was no documentation the authorized practitioner was notified of the patient not using the oxygen and discontinuing the use of oxygen. B.) Review of the RN OASIS Admission Visit dated 12/22/2024 revealed the RN documented the patient does not test blood glucose levels and reports taking the injectable medication as prescribed. Review of the Home Health Certification and Plan of Care from 12/22/2024 to 02/19/2025 revealed orders for Humalog junior kwikpen 100 units per milliliter (ml) subcutaneous following the sliding scale three (3) times daily: - no injection for blood sugar 0-250; - 4 units for blood sugars 51 (251) to 300; - 6 units for blood sugars 301 to 350; - 8 units for blood sugar 351 to 400; and - if over blood sugar over 400, hold insulin and call physician. Review of the clinical record lacks documentation the physician was notified the patient is not testing blood glucoses three (3) times daily for sliding scale insulin administration. During interview on 09/11/2025 at 03:10 PM, the RN stated being unable to review the identified documentation due to no electronic access to discharged patient records and cannot recall the identified patient. During interview on 09/11/2025 at 03:12 PM, the Clinical Manager stated there is no documentation the physician was notified of the patient not testing blood glucoses three times daily for sliding scale insulin administration. C.) Review of the Home Health Certification and Plan of Care from 12/22/2024 to 02/19/2025 revealed orders for the following: - Humalog junior kwikpen 100 units per milliliter (ml) subcutaneous following the sliding scale three times daily: - no injection for blood sugar 0-250; - 4 units for blood sugars 51 (251) to 300; - 6 units for blood sugars 301 to 350; - 8 units for blood sugar 351 to 400; and - if over blood sugar over 400, hold insulin and call physician. - Assess/instruct on daily weight and keeping log. Notify physician of weight gain of 2-3 pounds in twenty-four (24) hours or 5 pounds in one week. - Notify authorized practitioner of weight greater than 158 pounds. Review of the RN Subsequent Visit dated 12/26/2024 revealed the RN documented the patient states not having the materials needed to test blood sugar as her continuous meter and supplies are at another location. Additionally, the patient states a scale is needed to perform daily weights. Review of the clinical record lacks documentation the authorized practitioner was notified of the patient not checking blood glucoses to administer sliding scale insulin and inability to perform daily weights as ordered. During interview on 09/12/2025 at 09:20 AM, the Clinical Manager acknowledged there is no documentation the RN notified the physician of the noncompliance with blood glucose checks and daily weights as ordered. During interview on 09/12/2025 at 09:22 AM, the RN stated being unable to view the documentation in a discharged record but should have notified the physician to report the patient not following the plan of care. Patient #10 – This 72-year-old patient with diagnoses that include hypertensive heart and chronic kidney disease with heart failure and acute on chronic diastolic heart failure was admitted to the home health agency on 12/22/2024 and discharged on 02/07/2025. A.) Review of the Skilled Nursing Facility Post Discharge Plan of Care (agency referral) revealed the patient is ordered to wear oxygen 2 liters per minute via nasal cannula. The frequency of use is not specified. Review of the Registered Nurse (RN) Outcome and Assessment Information Set (OASIS) Admission Visit revealed the RN documented the patient was not using oxygen at the time of the visit and the patient stated they are trying to wean off the oxygen that is ordered. Review of the Home Health Certification and Plan of Care from 12/22/2024 to 02/19/2025 lacks orders for oxygen use. Review of the clinical record lacks documentation the authorized practitioner was reported of the patient self-weaning oxygen use and verified the oxygen orders could be discontinued. During interview on 09/11/2025 at 02:45 PM, the RN stated being unable to review the identified documentation due to no electronic access to discharged patient records and cannot recall the identified patient. During interview on 09/11/2025 at 02:47 PM, the Clinical Manager stated there was no documentation the authorized practitioner was notified of the patient not using the oxygen and discontinuing the use of oxygen. B.) Review of the RN OASIS Admission Visit dated 12/22/2024 revealed the RN documented the patient does not test blood glucose levels and reports taking the injectable medication as prescribed. Review of the Home Health Certification and Plan of Care from 12/22/2024 to 02/19/2025 revealed orders for Humalog junior kwikpen 100 units per milliliter (ml) subcutaneous following the sliding scale three (3) times daily: - no injection for blood sugar 0-250; - 4 units for blood sugars 51 (251) to 300; - 6 units for blood sugars 301 to 350; - 8 units for blood sugar 351 to 400; and - if over blood sugar over 400, hold insulin and call physician. Review of the clinical record lacks documentation the physician was notified the patient is not testing blood glucoses three (3) times daily for sliding scale insulin administration. During interview on 09/11/2025 at 03:10 PM, the RN stated being unable to review the identified documentation due to no electronic access to discharged patient records and cannot recall the identified patient. During interview on 09/11/2025 at 03:12 PM, the Clinical Manager stated there is no documentation the physician was notified of the patient not testing blood glucoses three times daily for sliding scale insulin administration. C.) Review of the Home Health Certification and Plan of Care from 12/22/2024 to 02/19/2025 revealed orders for the following: - Humalog junior kwikpen 100 units per milliliter (ml) subcutaneous following the sliding scale three times daily: - no injection for blood sugar 0-250; - 4 units for blood sugars 51 (251) to 300; - 6 units for blood sugars 301 to 350; - 8 units for blood sugar 351 to 400; and - if over blood sugar over 400, hold insulin and call physician. - Assess/instruct on daily weight and keeping log. Notify physician of weight gain of 2-3 pounds in twenty-four (24) hours or 5 pounds in one week. - Notify authorized practitioner of weight greater than 158 pounds. Review of the RN Subsequent Visit dated 12/26/2024 revealed the RN documented the patient states not having the materials needed to test blood sugar as her continuous meter and supplies are at another location. Additionally, the patient states a scale is needed to perform daily weights. Review of the clinical record lacks documentation the authorized practitioner was notified of the patient not checking blood glucoses to administer sliding scale insulin and inability to perform daily weights as ordered. During interview on 09/12/2025 at 09:20 AM, the Clinical Manager acknowledged there is no documentation the RN notified the physician of the noncompliance with blood glucose checks and daily weights as ordered. During interview on 09/12/2025 at 09:22 AM, the RN stated being unable to view the documentation in a discharged record but should have notified the physician to report the patient not following the plan of care. Patient #4 – This 91-year-old patient with the diagnoses of pressure ulcer of sacral region, stage 4, osteomyelitis of vertebral column, and paraplegia was admitted to the home care agency on 08/23/2025. Review of the OT (Occupational Therapy) Add ON Evaluation Visit dated 08/27/2025 revealed the OT documented the patient had edema of the lower extremities. Review of the clinical record lacks documented evidence that the physician was notified of the patient’s lower extremity edema. During an interview on 09/12/2025 at 10:45 AM, the Clinical Manager stated the OT was unavailable for interview and acknowledged there was no documentation in the clinical records that the physician was notified of the patient’s lower extremity edema.”

“Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient’s updated comprehensive assessment, and contain information concerning the patient’s progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This Element is not met as evidenced by: Based on a review of clinical records and staff interview for one (1) of seventeen (17) patients (Patient #10), the agency failed to ensure updated plans of care reflect current information from the patient’s updated comprehensive assessment. Failure to ensure the plan of care is updated and revised to reflect patient needs, has the potential to result in negative patient outcomes. Patient #10 – This 72-year-old patient with diagnoses that include hypertensive heart and chronic kidney disease with heart failure and acute on chronic diastolic heart failure was admitted to the home health agency on 12/22/2024 and discharged on 02/07/2025. A.) Review of the Physical Therapy (PT) Safe Stride Add On Visit dated 12/30/2024 revealed the PT documented the patient is non-compliant with oxygen use. The initial oxygen saturation assessed was 81% upon arrival. The patient was instructed to place the oxygen on and the oxygen saturation increased to 93%. Education was provided on the importance of using oxygen at all times. Review of the clinical record lacks orders updating the plan of care regarding oxygen use. During interview on 09/11/2025 at 02:17 PM, the PT stated an order for oxygen was not obtained as the PT assumed the oxygen was previously ordered.”

“Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on review of clinical records and interview with agency staff, for one (1) of seventeen (17) patients (Patient #1), the agency failed to ensure there was communication with all physicians involved in the patient’s care following the patient’s physician appointment. Failure to follow-up for physician appointments places patients at risk for negative outcomes and potential for hospital admission. Patient #1 – This 65-year-old patient with diagnoses that include displaced trimalleolar fracture to left lower leg and displaced bimalleolar fracture to right lower leg was admitted to the home health agency on 08/22/2025. Review of the Referral Summary (agency referral) dated 08/20/2025 revealed the patient has a follow-up appointment with their primary care physician on 08/25/2025. Review of the clinical record for the week of 08/24/2025 to 08/30/2025 revealed the patient was seen by the Occupational Therapist (OT) on 08/26/2025 and the Registered Nurse (RN) on 08/28/2025. Review of the OT Add-On Evaluation visit dated 08/26/2025 lacks documentation of follow-up regarding the 08/25/2025 primary care physician appointment. Review of the RN Subsequent Visit dated 08/28/2025 lacks documentation of follow-up regarding the 08/25/2025 primary care physician appointment. During interview on 09/12/2025 at 11:39 AM, the Clinical Manager stated a PointCare Visit Alert Coordination Note was created on 08/20/2025 as a reminder to all clinicians of the 08/25/2025 physician appointment and acknowledged the clinicians failed to follow-up during the identified visits.”

“Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This Element is not met as evidenced by: Based on clinical record review and staff interview, for one (1) of seventeen (17) patients (Patient #17) the agency failed to ensure effective communication and coordination of patient care occurred between disciplines. Failure to ensure interdisciplinary communication and coordination of care occurs has the potential to place patients at risk for inappropriate and inadequate care. Patient #17 – This 78-year-old patient with diagnoses that include urinary tract infection and type 2 diabetes mellitus was admitted to the home health agency on 07/07/2025. Review of the New York State (NYS) Licensed Practical Nurse (LPN) Visit dated 08/08/2025 revealed the LPN documented the patient reports seeing the hematologist today, is starting a new medication, polysaccharide iron complex, and is awaiting the medication to be delivered by the pharmacy. Review of the Registered Nurse (RN) Subsequent Visit dated 08/18/2025 revealed this was the first visit that occurred after the 08/08/2025 LPN visit. The visit lacks documentation of follow-up of the new polysaccharide iron complex to ensure the medication is in the home, providing instruction and updating the plan of care with the new medication upon verification. During interview on 09/12/2025 at 08:50 AM, the RN stated they failed to follow-up on the new medication during the 08/18/2025 visit.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on review of clinical records and interviews with agency staff, for one (1) of seventeen (17) patients (Patient #16), receiving skilled nursing services, the Skilled Nurse (SN) failed to prepare or document complete clinical and progress notes. Failure to prepare or document complete clinical and progress notes has the potential for unmet patient needs. Patient #16 – This 62-year-old patient with the diagnoses of type 2 diabetes mellitus, enterostomy malfunction, and morbid obesity due to excess calories was admitted to the home care agency on 07/23/2025. Review of the Licensed Practical Nurse (LPN) Visit Note dated 09/08/2025 revealed the following documentation: Architectural/Home: Patient lives alone.Patient receives assistance from person residing in the home. During interview on 09/12/2025 at 11:38 AM, the Clinical Manager stated the LPN was not available for interview. The Clinical Manager acknowledged the identified documentation was inconsistent and it was unclear if the patient lived alone or with other persons in the home.”

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on review of clinical records and interviews with staff, for one (1) of five (5) patients (Patient #4), the agency failed to ensure that a comprehensive assessment consistent with the patient’s needs was performed within five (5) calendar days after the Start of Care (SOC). Failure to ensure a comprehensive assessment is complete and accurate has the potential for unmet patient needs and possible negative outcomes. The agency failed to ensure that a comprehensive assessment consistent with the patient’s needs was performed within five (5) calendar days after the SOC as evidenced by the following: Patient #4 – This 74-year-old therapy only patient with diagnoses of bilateral primary osteoarthritis of hip, unspecified dementia, anxiety disorder and history of falls was admitted to the home care agency on 10/21/2023. Review of the physician referral for home care dated 10/21/2023 revealed the patient was referred to the agency on 10/21/2023 and requested to be evaluated for Physical Therapy (PT) and Occupational Therapy (OT). Review of the OT Add- On Evaluation dated 10/27/2023 revealed the OT performed an initial assessment of the patient on 10/27/2023 (6 (six) days after the start of care). Review of the clinical record from 10/21/2023 to 10/27/2023 lacks documented evidence the OT attempted to contact the patient. During interview on 11/08/2023 at 09:05 AM, the OT stated the initial visit on 10/27/2023 was when she received the referral to evaluate the patient. During interview on 11/08/2023 at 09:07 AM, the Branch Director stated that he was not aware the visit should have been done within (5) calendar days after SOC.”