Deer Meadows Home Health and Support Services, LLC

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on a review of clinical records (CR), home health agency (HHA) policy, HHA agency patient handbook, and an interview with the administrator, director of rehabilitation and clinical director, the HHA failed to document that the patient was informed about changes in the care to be furnished for two (2) of three (3) CR’s reviewed: CR#1 and CR#3. Findings include: The HHA’s Policy Care Planning Process Policy No. 1-007, reviewed on December 4, 2025 at 11:00 AM, reads in part, “The plan of care will be revised as frequently as deemed necessary by the clinicians based on the ongoing assessments of the patient. The patient/representative/caregiver will be involved in any change in care or services.” The HHA’s Patient Handbook, reviewed on December 4, 2025 at approximately 12:00 PM reads in part under Your Rights and Responsibilities as A Health Care Patient - “be advised in advance of any change in the plan of care before the change is made.” A review of the complaint log on December 2, 2025 at approximately 1:00 PM found that CR#1 phoned the agency on 09/02/2025 to complain that s/he had been discharged from the HHA because of insurance coverage. The complaint investigation documented by the HHA confirmed that the discharge occurred because of a “change in insurance/insurance no longer covering services.” An interview was conducted with the Director of Rehabilitation (DOR), Clinical Director (CD), and Administrator on 12/02/25 at approximately 4:00 PM. The surveyor asked about the declination of services from the managed Medicaid provider. The HHA stated that the agency was informed verbally/via phone that the insurance company would no longer pay for services. HHA personnel also stated that it is not unusual for the insurance company to give minimal to no advance notice of the denial and to not receive written notification. An email exchange between the surveyor and the administrator on 12/08/2025 at approximately 11:10 AM confirmed that CR#1 was discharged in part because of lack of insurance reimbursement and in part because the patient had reached maximum potential per the physical therapy discharge summary. A review of CR’s was conducted on December 2, 2025 starting at 11:00 AM and again on December 4, and December 5 2025 at various times. The Certification Period (CP) and Discharge Date (DD) are indicated below. CR#1 CP 07/03/2025 to 08/31/2025. DD 08/28/2025. A physical therapy (PT) visit was conducted on 08/20/2025. The PT note stated in part, “Patient tolerated therapy well today. Able to ambulate 50 feet with CG (contact guard) assistance. Patient required frequent seated rest breaks although demonstrating significant improvement in ambulation tolerance with decreased assistance. Patient continues to require skilled PT to address LUE/LLE weakness, impaired balance, strength, transfers, gait, stair navigation. Plan for next visit: continue POC.” On the next PT visit dated 08/28/2025, the patient was discharged from the HHA. The PT visit note stated that the patient had reached maximum potential, all goals were met except for one. There was no documentation found that discussion with the patient, regarding the lack of insurance reimbursement, occurred and served as a contributing factor to the discharge. There was no documentation in the clinical record prior to the discharge date, during the PT visit dated 08/20/25, that the patient was informed that s/he was nearing maximum potential, that the payer was no longer reimbursing the HHA for services rendered/no longer authorizing further services, and that discharge was anticipated for the next visit. There was also no evidence that prior to the discharge date, the physician was updated and informed of the impending/anticipated discharge due to the patient nearing maximum potential and problems with insurance reimbursement. CR#3 CP 06/12/2025 to 08/10/2025. DD 08/08/2025. A PT visit was conducted on 7/22/25 at which time the PT documented the following plan for the next visit, “upgrade HPS (home physical therapy services) to increase muscle strength to the next grade, gait training on level with RW (rolling walker), increase dynamic standing balance to good.” Subsequent to the 7/22 visit, PT missed visits occurred on 7/23 due to the patient having a medical appointment and on 7/27 due to the patient requesting to rest on Sunday (7/27). The patient requested a PT visit on 7/29 or 7/31. The next PT visit occurred on 08/08/2025 at which time the patient was discharged from the HHA. The PT discharge summary stated in part, “Reason for Discharge - Goals met/max potential reached” (documented via a check off box). Further documentation stated, “Max potential reached” checkbox. Under goals not met, the PT documented, “all goals met besides - patient will improve 2 min march test from 18 reps to 45 reps in order to demonstrate improvements in functional strength and endurance and patient will improve 30 second sit to stand from 8 to 10x in order to demonstrate improvements in functional strength and endurance. Patient refused any special tests. Patient is ambulatory with walker independently, requires supervision for stairs and outdoor ambulation. Patient has reached max potential.” There was no documentation in the clinical record prior to the discharge date, during the PT visit dated 07/22/205, that the patient was informed that s/he was nearing maximum potential. The PT visit note of 7/22/25 implied that home physical therapy services should be upgraded. There was also no evidence that prior to the discharge date, the physician was updated and informed of the impending/anticipated discharge and/or status of the patient. Discussion with the administrator on December 11, 2025 at 9:00 AM confirmed the above findings.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on a review of clinical records (CR), home health agency (HHA) policy review, and an interview with the director of rehabilitation (DOR), administrator, and clinical director, the HHA failed to obtain physician orders at the start of care (SOC) for frequency and duration of physical therapy (PT) visits for one (1) of three (3) CR’s reviewed: CR#3. Findings include: The HHA’s Policy Verification of Physician Orders Policy No. 2-002, reviewed on December 4, 2025 at approximately 11:30 AM states in part, “Orders will be obtained from a licensed physician (or allowed practitioner) for care and services to be provided to home health patients.” In an interview conducted with the Director of Rehabilitation (DOR) on December 2, 2025 at 3:00 PM, the DOR stated that the lack of PT frequency and duration orders must be a system issue as the HHA is unable to assign visit frequency and duration into the scheduling system without a physician’s order. A review of CR’s was conducted on December 2, 2025 starting at 11:00 AM, and again on December 4 and December 5, 2025 at various times. The Home Health Certification Period (CP) is indicated below. CR#3 CP 06/12/2025 to 08/10/2025 contained an initial assessment that was completed by skilled nursing on 06/12/2025. The Plan of Care (POC) contained orders for a physical therapy (PT) evaluation, 1 visit per week for 1 week (6/12/25 to 6/14/25). A PT Evaluation was conducted on 06/16/2025. The patient received PT visits on 6/16, 6/24, 7/7 and a recorded missed visit on 7/2/25. There were no orders for the visits. PT frequency and duration orders were not obtained from the physician until 7/9/25. Discussion with the administrator on December 11, 2025 at 9:00 AM confirmed the above findings.”

“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 a review of clinical records (CR), home health agency (HHA) policy, and an interview with the director of rehabilitation, administrator, and clinical director, the HHA failed to obtain a physician’s order for patient discharge from the HHA for three (3) of three (3) CR’s reviewed: CR#1, CR#2, and CR#3. Findings include: The HHA’s Policy Verification of Physician Orders Policy No. 2-002, reviewed on December 4, 2025 at approximately 11:30 AM states in part, “Orders will be obtained from a licensed physician (or allowed practitioner) for care and services to be provided to home health patients.” An interview was conducted with the Director of Rehabilitation on 12/02/2025 at approximately 3:00 PM. The surveyor noted to the DOR that no patient discharge (DC) orders from the HHA were found in the three clinical records reviewed. The DOR stated that the “discharge summary sent to the physician serves as the discharge order.” A review of CR’s was conducted on December 2, 2025 starting at 11:00 AM, and again on December 4 and December 5, 2025 at various times. The Home Health Certification Period (CP) and Discharge Date (DD) are indicted below. CR#1 CP 07/03/2025 to 08/31/2025, DD 08/28/2025 did not contain an order for discharge from the HHA. A review of the Care Coordination section of the DC summary, completed by the physical therapist (PT) on 08/25, found several statements checked “yes,” indicating that the action occurred, which included: “discharge from home health services,” “physician notified of discharge prior to discharge date, per agency policy & timeline;” “all services notified and discontinued,” “physician notified of discharge summary availability,” and “order and summary completed.” There was no documentation containing the date when the physician was notified of the DC (prior to the DC date, per the DC summary), and there was no evidence of a completed order at the time of DC. The CR contained an electronic “yellow sticky note” attached to the DC summary which noted that the DC summary was sent to the physician on 09/16/25,18 days after the discharge occurred. CR#2 CP 06/25/25 to 08/23/25, DD 08/21/25. A review of the Care Coordination section of the discharge (DC) summary (completed by the PT on 08/21) found several statements checked “yes,” indicating that the action occurred, which included: “discharge from home health services,” “physician notified of discharge prior to discharge date, per agency policy & timeline;” “all services notified and discontinued,” “physician notified of discharge summary availability,” and “order and summary completed.” There was no documentation containing the date when the physician was notified of the DC (prior to the DC date, per the DC summary), and there was no evidence of a completed order at the time of DC. The CR contained an electronic “yellow sticky note” attached to the DC summary which noted that the DC summary was sent to the physician on 09/03/2025, 13 days after the discharge occurred, and again on 09/12/2025. CR#3 CP 06/12/2025 to 08/10/2025. DD 08/08/2025. A review of the Care Coordination section of the discharge (DC) summary (completed by the PT on 08/08) found several statements checked “yes,” indicating that the action occurred, which included: “discharge from home health services,” “physician notified of discharge prior to discharge date, per agency policy & timeline;” “all services notified and discontinued,” “physician notified of discharge summary availability,” and “order and summary completed.” There was no documentation containing the date when the physician was notified of the DC (prior to the DC date per the DC summary), and there was no evidence of a completed order at the time of DC. The CR contained an electronic “yellow sticky note” attached to the DC summary which noted “order sent on 8/12.” The physician’s office apparently did not receive the information and requested that it be resent, which was done on 9/12/25. Discussion with the administrator on December 11, 2025 at 9:00 AM confirmed the above findings.”

“Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient’s discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner’s issuing orders for the HHA plan of care, and the patient’s primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any). This Element is not met as evidenced by: Based on a review of clinical records (CR), home health agency (HHA) policy, HHA patient handbook, and an interview with the administrator, director of rehabilitation, and clinical director, the HHA failed to document that prior to discharge, the HHA discussed impending discharge plans with the patient and the responsible physician for two (2) of three (3) CR’s reviewed: CR#1 and CR#3. The HHA’s Policy Care Planning Process Policy No. 1-007, reviewed on December 4, 2025 at 11:00 AM, reads in part, “The plan of care will be revised as frequently as deemed necessary by the clinicians based on the ongoing assessments of the patient. The patient/representative/caregiver will be involved in any change in care or services.” The HHA’s Patient Handbook, reviewed on December 4, 2025 at approximately 12:00 PM reads in part under Your Rights and Responsibilities as A Health Care Patient - “be advised in advance of any change in the plan of care before the change is made.” A review of the complaint log on December 2, 2025 at approximately 1:00 PM found that CR#1 phoned the agency on 09/02/2025 to complain that s/he had been discharged from the HHA because of insurance coverage. The complaint investigation documented by the HHA confirmed that discharge occurred because of a “change in insurance/insurance no longer covering services.” An interview was conducted with the Director of Rehabilitation (DOR), Clinical Director (CD), and Administrator on 12/02/25 at approximately 4:00 PM. The surveyor asked about the declination of services from the managed Medicaid provider. The HHA stated that the agency was informed verbally/via phone that the insurance company would no longer pay for services. HHA personnel also stated that it is not unusual for the insurance company to give minimal to no advance notice of the denial and to not receive written notification. An email exchange between the surveyor and the administrator on 12/08/2025 at approximately 11:10 AM confirmed that CR#1 was discharged in part because of lack of insurance reimbursement and in part because the patient had reached maximum potential per the physical therapy discharge summary. A review of CR’s was conducted on December 2, 2025 starting at 11:00 AM and again on December 4, and December 5 2025 at various times. The Certification Period (CP) and Discharge Date (DD) are indicated below. CR#1 CP 07/03/2025 to 08/31/2025. DD 08/28/2025. A physical therapy (PT) visit was conducted on 08/20/2025. The PT note stated in part, “Patient tolerated therapy well today. Able to ambulate 50 feet with CG (contact guard) assistance. Patient required frequent seated rest breaks although demonstrating significant improvement in ambulation tolerance with decreased assistance. Patient continues to require skilled PT to address LUE/LLE weakness, impaired balance, strength, transfers, gait, stair navigation. Plan for next visit: continue POC.” On the next PT visit dated 08/28/2025, the patient was discharged from the HHA. The PT visit note stated that the patient had reached maximum potential, all goals were met except for one. There was no documentation found that discussion with the patient, regarding the lack of insurance reimbursement, occurred and served as a contributing factor to the discharge. There was no documentation in the clinical record prior to the discharge date, during the PT visit dated 08/20/25, that the patient was informed that s/he was nearing maximum potential, that the payer was no longer reimbursing the HHA for services rendered/no longer authorizing further services, and that discharge was anticipated for the next visit. There was also no evidence that prior to the discharge date, the physician was updated and informed of the impending/anticipated discharge due to the patient nearing maximum potential and problems with insurance reimbursement. CR#3 CP 06/12/2025 to 08/10/2025. DD 08/08/2025. A PT visit was conducted on 7/22/25 at which time the PT documented the following plan for the next visit, “upgrade HPS (home physical therapy services) to increase muscle strength to the next grade, gait training on level with RW (rolling walker), increase dynamic standing balance to good.” Subsequent to the 7/22 visit, PT missed visits occurred on 7/23 due to the patient having a medical appointment and on 7/27 due to the patient requesting to rest on Sunday (7/27). The patient requested a PT visit on 7/29 or 7/31. The next PT visit occurred on 08/08/2025 at which time the patient was discharged from the HHA. The PT discharge summary stated in part, “Reason for Discharge - Goals met/max potential reached” (documented via a check off box). Further documentation stated, “Max potential reached” checkbox. Under goals not met, the PT documented, “all goals met besides - patient will improve 2 min march test from 18 reps to 45 reps in order to demonstrate improvements in functional strength and endurance and patient will improve 30 second sit to stand from 8 to 10x in order to demonstrate improvements in functional strength and endurance. Patient refused any special tests. Patient is ambulatory with walker independently, requires supervision for stairs and outdoor ambulation. Patient has reached max potential.” There was no documentation in the clinical record prior to the discharge date, during the PT visit dated 07/22/205, that the patient was informed that s/he was nearing maximum potential. The PT visit note of 7/22/25 implied that home physical therapy services should be upgraded. There was also no evidence that prior to the discharge date, the physician was updated and informed of the impending/anticipated discharge and/or status of the patient. Discussion with the administrator on December 11, 2025 at 9:00 AM confirmed the above findings.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on a review of clinical records (CR) and an interview with the administrator, director of rehabilitation and clinical director, the home health agency (HHA) failed to assure that a discharge summary was sent to the physician within five (5) days after discharge for two (2) of three (3) CR’s reviewed: CR#1 and CR#2. Findings include: A review of CR’s was conducted on December 2, 2025 starting at 11:00 AM, and again on December 4 and December 5, 2025 at various times. The Certification Period (CP) and Discharge Date (DD) are indicated below. CR#1 CP 07/03/2025 to 08/31/2025, DD 08/28/2025. A review of the CR found an electronic “yellow sticky note” attached to the DC summary which stated that the DC summary was sent to the physician on 09/16/25,18 days after the discharge occurred. The DC summary was not sent within 5 days of discharge. CR#2 CP 06/25/25 to 08/23/25, DD 08/21/25. A review of the CR contained an electronic “yellow sticky note” attached to the DC summary which stated that the DC summary was sent to the physician on 09/03/2025, 13 days after the discharge, and again on 09/12/2025. The DC summary was not sent within 5 days of discharge. Discussion with the administrator on December 11, 2025 at 9:00 AM confirmed the above findings.”

“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 a review of clinical records (CR), the home health agency’s (HHA) policy, and an interview with the clinical director, the completion of the initial assessment was not evident within 48 hours of referral for five (5) of seventeen (17) records reviewed: CR#2, CR#9, CR#11, CR#12, CR#14. Findings include: The HHA’s Policy No. 1-016 Initial and Comprehensive Assessment, reviewed on October 10, 2024 at 2:00 PM, reads in part, “The initial assessment visit must be performed within forty-eight (48) hours of the referral, within forty-eight (48) hours of the patient’s return home, on the start of care date ordered by the physician (or allowed practitioner), or at the patient/family request with the approval of the physician (or allowed practitioner).” In an interview with the clinical director, held on October 11, 2024 at approximately 1:30 PM, the clinical director stated that the agency performs initial assessments within forty-eight (48) hours of the referral, and that some of the referral dates entered into the OASIS-E (Outcome and Assessment Information Set) start of care/comprehensive assessments were errors on the part of the clinician completing the assessment. A review of clinical records was conducted on October 8, 2024 starting at 1:30 PM, and continued at various times on October 9, 2024, October 10, 2024, and October 11, 2024. The Start of Care (SOC), and Certification Period (CP) are indicated below. CR#2 SOC 09/09/2024, CP 09/09/2024 to 11/07/2024 contained an OASIS-E Start of Care/ Comprehensive Assessment noting the date of the referral as 09/05/024. The initial/comprehensive assessment was completed on 09/09/2024, four (4) days after the referral date. There were no orders to otherwise indicate a physician-specific start of care date. CR#9 SOC 09/12/2024, CP 09/12/2024 to 11/10/2024 contained an OASIS-E Start of Care/ Comprehensive Assessment noting the date of the referral as 09/09/2024. The initial/comprehensive assessment was completed on 09/12/2024, three (3) days after the referral date. There were no orders to otherwise indicate a physician-specific start of care date. CR#11 SOC 05/27/2024, CP 09/24/2024 to 11/22/2024 contained an OASIS-E Start of Care/ Comprehensive Assessment noting the date of the referral as 05/18/2024. The initial/comprehensive assessment was completed on 05/27/2024, nine (9) days after the referral date. There were no orders to otherwise indicate a physician-specific start of care date. CR#12 SOC 09/09/2024, CP 09/09/2024 to 11/07/2024 contained an OASIS-E Start of Care/ Comprehensive Assessment noting the date of the referral as 09/03/2024. The initial/comprehensive assessment was completed on 09/09/2024, six (6) days after the referral date. There were no orders to otherwise indicate a physician-specific start of care date. CR#14 SOC 03/11/2024, CP 03/11/2024 to 05/09/2024 contained an OASIS-E Start of Care/ Comprehensive Assessment noting the date of the referral as 03/07/2024. The initial/comprehensive assessment was completed on 03/11/2024 four (4) days after the referral date. There were no orders to otherwise indicate a physician-specific start of care date. An interview conducted with the administrator and clinical director on October 11, 2024 starting at 2:50 PM confirmed the above findings.”

“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 a review of clinical records (CR), home health agency policies, and an interview with the clinical director, the agency failed to assure that all physician orders were recorded in the plan of care (POC) for eight (8) of seventeen (17) records reviewed; CR#1, CR#3, CR#4, CR#5, CR#6, CR#11, CR#13, and CR#14. Findings include: The HHA’s Policy No. 1-026 Missed Visits, reviewed on October 11, 2024 at 9:00 AM states in part, “Missed visits will be communicated to the clinical supervisor and the patient’s physician (or allowed practitioner). A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record. If a visit is missed and not rescheduled the clinician will notify the physician (or allowed practitioner) of the missed visit if there is a potential for clinical impact upon the patient. The physician (or allowed practitioner) will decide if the visit may be skipped, or additional intervention is required by the organization....If an aide visit is missed the aide will contact the case manager or clinical supervisor and the manager/supervisor will take the appropriate measures stated above.” The HHA’s Policy No. 2-002 Verification of Physician Orders reviewed on October 11, 2024 reads in part, “Orders will be obtained from a licensed physician (or allowed practitioner) for care and services to be provided to home health patients.” In an interview with the clinical director, held on October 11, 2024 at approximately 1:30 PM, the clinical director stated that wound care orders are supposed to transmit to the CMS Home Health Certification and Plan of Care from the OASIS-E Start of Care Assessment for physician review and approval. The clinical director stated that there must be a glitch in the system and plans to look into why the information is not transmitting. A review of clinical records was conducted on October 8, 2024 starting at 1:30 PM, and continued at various times on October 9, 2024, October 10, 2024, and October 11, 2024. The Start of Care (SOC), and Certification Period (CP) are indicated below. CR#1 SOC 09/22/2024, CP 09/22/2024 to 11/20/2024 contained a CMS Home Health Certification and Plan of Care (POC) with orders for a Home Health Aide (Aide) two (2) visits per week for six (6) weeks. An aide missed visit (MV) occurred on 09/26/2024. A MV note in the CR noted that the reason for the MV was cancellation of care and no services needed. The physician was not notified of the cancellation of aide services. There was no physician order to discontinue aide services. CR#3 SOC 08/17/2024, CP 08/17/2024 to 10/25/2024. The patient was referred to the HHA for management of a stage 3 right buttock pressure ulcer (bedsore). The OASIS-E (Outcome and Assessment Information Set) Start of Care Assessment completed on 08/17/2024 documented the presence of the pressure ulcer and cleansing of the wound with normal saline, soaking the wound with vashe (wound solution), patting the wound dry, packing the wound with sterile packing and covering the wound with foam dressing every other day and as needed. The patient was visited by skilled nursing (SN) for wound management on 08/17/2024, 08/21/2024, 08/23/2024, 08/26/2024, 08/28/2024, 08/30/2024, 09/04/2024, 09/11/2024, 09/13/2024, 09/16/2024, 09/18/2024, 09/20/2024, 09/23/2024, 09/25/2024, 09/27/2024, 09/30/2024, 10/02/2024, 10/04/2024, 10/07/2024. A review of the CMS Home Health Certification and Plan of Care (POC) initiated on 08/17/2024 found that there were no orders from the physician for wound care management. An order for wound care was not found in the CR until 09/16/2024. This was confirmed by the clinical director. The POC contained orders for SN visits 3 visits per week for 4 weeks. For the week of 09/01/2024, two (2) of three (3) SN visits were missed (at family request). There was no documentation that the physician was notified. CR#4 SOC 06/032024, CP 08/02/2024 to 09/30/2024. The patient was referred to the HHA for management of two (2) non-pressure chronic ulcers to the lower extremity. The OASIS-E Recertification completed on 07/31/2024 documented that the patient was being recertified for continued wound management. It was further documented that the 2 wounds were cleansed with normal saline, calcium alginate with silver (used for wound care) applied, wounds were wrapped and scheduled to be changed three times weekly. The patient was visited by SN for wound management on 08/02/2024, 08/05/2024, 08/07/2024, 08/09/2024, 08/12/2024, 08/14/2024, 08/16/2024, 08/19/2024, 08/21/2024, 08/23/2024, 08/26/2024, 08/28/2024, 08/30/2024, 09/06/2024, 09/09/2024, 09/11/2024, 09/13/2024, 09/18/2024, 09/20/2024, 09/23/2024, 09/25/2024, 09/27/2024, 09/30/2024. A review of the POC initiated on 08/02/2024 found that there were no orders from the physician for wound care management, nor were there any subsequent verbal orders for wound care management. This was confirmed by the clinical director. CR#5 SOC 09/15/2024, CP 09/15/2024 to 11/13/2024 contained a verbal physician order dated 09/15/2024 stating that “clinician spoke to physician, physician in agreement with aide being added one (1) to two (2) times per week for seven (7) weeks.” Aide MV occurred on 09/17/2024, 09/19/2024, 09/24/2024, 09/26/2024 and 10/03/2024. There were no further visits after 10/03/2024. MV notes were present in the CR for the aforementioned dates, but there was no evidence that the physician was notified of the missed visits or that an order was obtained to discontinue aide services. CR#6 SOC 09/26/2024, CP 09/26/2024 to 11/24/2024 contained a POC with orders for 2 liters oxygen via nasal cannula. The OASIS-E Start of Care dated 09/26/2024 noted under the Special Treatments, Procedures, and Programs Section that oxygen therapy was intermittent, though the actual SN assessment noted that the patient was receiving oxygen at 2 liters per minute via nasal cannula. The assessment also noted that the patient is dyspneic or noticeably short or breath with minimal exertion. SN visit notes on 10/01/2024, 10/03/2024 and 10/08/2024 note that the patient was receiving oxygen at 2 liters per minute via nasal cannula. PT visit notes on 09/30/2024, 10/02/2024, 10/08/2024, and 10/10/2024 note that the patient was on room air (no oxygen). A home visit observation on 10/10/2024 (for observation of physical therapy services) found that the patient was not receiving any oxygen during the treatment. The observation by the surveyor confirmed that the patient becomes dyspneic or noticeably short of breath with minimal exertion. The patient was also observed to have a deep, congested cough. There was no evidence in the clinical record to clarify with the physician if the oxygen was intended to be continuous or intermittent. A social work evaluation occurred on 09/27/2024, but there was no physician order evident in the CR for a social work evaluation. CR#11 SOC 05/27/2024, CP 09/24/2024 to 11/22/2024. The patient was referred to the HHA for wound management. The POC contained orders for SN visits two (2) times per week for eight (8) weeks. During the week of 09/29/2024, there were no SN visits. There were no notes in the CR pertaining to the MV, nor was there evidence that the physician was notified. CR#13 SOC 02/20/2024, CP 02/20/2024 to 04/19/2024. The POC contained orders for SN visits 2 visits per week for 7 weeks. After 03/19/2024, there were no further SN visits. There were no MV notes, no physician order to cancel SN services, nor was there a SN discharge evident in the CR. CR#14 SOC 03/11/2024, CP 03/11/2024 to 05/09/2024. The POC contained orders for Nitroglycerin (used for chest pain) sublingual (under the tongue) 0.4 mg 1 tab (tablet) every 5 minutes prn (as needed) chest pain. The medication profile contained the same order. The OASIS-E Start of Care contained a drug regimen review which noted no issues found during review. There was no attempt to contact the physician to clarify the nitroglycerin order in order to apply a qualifier as to how many times the NTG should be taken and subsequent interventions (call 911, go to the emergency department) if the chest pain did not subside. An interview conducted with the administrator and clinical director on October 11, 2024 starting at 2:50 PM confirmed the above findings.”