Every finding on record at Amber Court at Home, LLC

This Statement of Deficiencies is a result of an on-site investigation of Complaint 2645172 conducted at Wellbound CHHA (CCN 337450), located at 7424 13th Avenue, Brooklyn, NY 11228 from 12/11/2025 to 12/12/2025 to evaluate compliance with Federal regulations. The investigation consisted of a review of three (3) clinical records (identified as Patient #1, #2, and #3), complaint log, pertinent policies and procedures and interview with the Administrator, the Director of Patient Services, the Executive Director of Rehabilitation Operations, and the Vice President of Quality and Compliance. Pre-survey activities consisted of review on 12/10/2025 of the agency's Health Commerce System account and compliance history. The findings were reviewed at the exit conference on 12/12/2025. The allegation in Complaint 2645172 was determined to be substantiated. The following deficiencies are being cited as result of the survey: G0572 – Plan of Care G0608 – Coordinate Delivery of Care

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on clinical record review, pertinent policy review, and staff interview, the agency failed to ensure that all patients received the care that is written in the individualized Plan of Care. This was evident for thee (3) of three (3) clinical records reviewed (Patient#1, #2, and #3). Failure to ensure that all patients receive the care that is written in the individualized Plan of Care, has the potential for negative patient outcomes. The findings are: The agency’s “Missed Visits” Policy (Effective 02/21/2014) documents: “In the event that a scheduled visit to a patient cannot be made as scheduled for any reason, including the patient/patient representative’s cancellation of the visit and no rescheduling within the physician/NPP (Nonphysician Practitioner) prescribed frequency can be accomplished: The physician/NPP (Nonphysician Practitioner) must be notified by the clinician/designee that scheduled visit to the patient cannot be made as scheduled either by phone, fax, e-mail or mail.” 1. Patient #1 has a Start of Care date of 07/17/2020 with diagnoses Autistic Disorder, Developmental Disorder of Speech and Language, Congenital Hypotonia documented in the Home Health Certification and Plan of Care for Certification Period 10/19/2025 to 12/17/2025. The Home Health Certification and Plan of Care for the Certification Period 08/20/2025 to 10/18/2025 documents orders for Occupational Therapy Services: “1WK1 (one visit a week for one week), 2WK8 (two visits a week for eight weeks).” The clinical record documents one missed visit in each of the following weeks: 08/20/2025 – 08/23/2025, 08/24/2025 - 08/30/2025, 08/31/2025 – 09/06/2025, 09/07/2025 - 09/13/2025, 09/21/2025 – 09/27/2025. The Occupational Therapy Coordination Notes dated 08/22/2025, 09/02/2025, 09/09/2025, 09/16/2025, and 09/27/2025 document the following for the missed visit dates 08/22/2025, 08/29/2025, 09/05/2025, 09/13/2025, and 09/29/2025, respectively: “Case Management will be notified of missed visit for the MD (Medical Doctor) notification.” The clinical record lacks documented evidence of the physician being notified of the occupational therapy missed visits, in accordance with the agency policy. The Home Health Certification and Plan of Care for the Certification Period 10/19/2025 to 12/17/2025 documents orders for the following services: “OT (Occupational Therapy) 1WK1 (one visit a week for one week);” “ST (Speech Therapy) 1WK1 (one visit a week for one week);” and “(Home Health Aide) 4WK8 (four days a week for eight weeks), 2WK1 (two days a week for one week).” The Speech Therapy Coordination Note dated 10/22/2025 documents: "Missed Visit Notification;" "Date of Missed Visit 10/22/2025 - Start of Care for speech services;" "Physician Notified – Yes;" and “(Parent/Caregiver) has elected to discontinue services with Wellbound Home Healthcare.” The Occupational Therapy Coordination Noted dated 11/1/2025 documents: “Missed OT (Occupational Therapy) visit due to client unavailability on 10/21/2025;” “Case Management will be notified of the missed visit for the MD (Medical Doctor) notification." The Coordination Note dated 10/22/2025 documents: “CM (Case Management) Coordination Note: As per ST (Speech Therapist), CG (caregiver) requested to discontinue services. TC (Telephone call) was made to F/U (follow-up). As per CG (caregiver), they would like to stop therapy services (Occupational Therapy/Speech Therapy) and continue with just HHA (Home Health Aide) services. CG (Caregiver) confirmed that therapy services can stop effective today 10/22/25. Scheduling department was notified.” The clinical record lacks documented evidence of the physician being notified of the caregiver request to discontinue both Occupational/Speech Therapy services and will continue with home health aide services. On 12/12/2025 at 02:05 PM, the Administrator, the Vice President of Quality and Compliance, and the Executive Director of Rehabilitation Operations were interviewed. The Executive Director of Rehabilitation Operations stated: "I don’t see” the notification to the physician. 2. Patient #2 has a Start of Care date of 07/12/2021 with diagnoses Autistic Disorder, Down Syndrome, Social Pragmatic Communication Disorder, Mixed Receptive Expressive Language Disorder documented in the Home Health Certification and Plan of Care for the Certification Period 10/19/2025 to 12/17/2025. The Home Health Certification and Plan of Care for the Certification Period 08/20/2025 to 10/18/2025 documents orders for Speech Therapy services: “2WK9 (two visits a week for nine weeks).” The clinical record documents one missed visit in each of the following weeks: 08/24/2025 - 08/30/2025, 09/21/2025 – 09/27/2025, 09/28/2025 – 10/04/2025, 10/05/2025 – 10/11/2025, and 10/12/2025 – 10/18/2025. The clinical record documents no visits (two missed visits) in each of the following weeks: 08/31/2025 – 09/06/2025, 09/07/2025 -09/13/2025, and 09/14/2025 – 09/20/2025. The clinical record lacks documented evidence of the physician being notified of the speech therapy missed visits, in accordance with the agency policy. On 12/12/2025 at 02:05 PM, the Administrator, the Vice President of Quality and Compliance, and the Executive Director of Rehabilitation Operations were interviewed. The Executive Director of Rehabilitation Operations stated: "the Speech Therapist resigned;” there was “delay in finding coverage for the patient’s service area;” and “nothing in EMR (electronic medical record” notifying the physician. 3. Patient #3 has a Start of Care date of 04/01/2025 with diagnoses Autistic Disorder, Attention Deficit Hyperactivity Disorder, Intellectual Disabilities, Developmental Disorder of Speech and Language documented in the Home Health Certification and Plan of Care for the Certification Period 11/27/2025 to 01/25/2026. The Physician Order dated 10/11/2025 documents orders for Speech Therapy services: “1WK1 (one visit a week for one week), 2WK7 (two visits a week for seven weeks).” The clinical record documents no visits (two missed visits) in each of the following weeks: 10/26/2025 – 11/01/2025 and 11/02/2025 – 11/08/2025. The clinical record lacks documented evidence of the physician being notified of the speech therapy missed visits, in accordance with the agency policy. On 12/12/2025 at 02:05 PM, the Administrator, the Vice President of Quality and Compliance, and the Executive Director of Rehabilitation Operations were interviewed. The Executive Director of Rehabilitation Operations stated: "the Occupational Therapist was going on vacation 10/30 to 11/9;’ “the family was notified and did not want another OT (Occupational Therapist) for coverage;” and notifying the physician is “not in EMR (electronic medical record.”

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on clinical record review, pertinent policy review, and staff interview, the agency failed to coordinate care delivery to meet the patient's needs and involve the patient. This was evident for one (1) of three (3) clinical records reviewed (Patient: #1). Failure to coordinate care delivery to meet the patient's needs and involve the patient, has the potential for negative patient outcomes. The finding is: The agency’s “Missed Visits” Policy (Effective 02/21/2014) documents: “In the even that a scheduled visit to a patient cannot be made as scheduled for any reason, including the patient/patient representative’s cancellation of the visit and no rescheduling within the physician/NPP (Nonphysician Practitioner) prescribed frequency can be accomplished: The clinician or paraprofessional communicates with the patient’s to apprise them of the situation and ensure that he or her needs are met and there is no jeopardy.” 1. Patient #1 has a Start of Care date of 07/17/2020 with diagnoses Autistic Disorder, Developmental Disorder of Speech and Language, Congenital Hypotonia documented on the Home Health Certification and Plan of Care for the Certification Period 10/19/2025 to 12/17/2025. The Home Health Certification and Plan of Care for the Certification Period 08/20/2025 to 10/18/2025 documents: "OT (Occupational Therapy) 1WK1 (one visit a week for one week), 2WK8 (two visits a week for eight weeks).” The Coordination Note dated 10/08/2025 documents: “Recert call was made to the CG (caregiver) on 10/8/2025. CG (Caregiver) was informed of the Recert visit for 10/14/2025 with OT (Occupational Therapist). CG (Caregiver) acknowledged. Had no questions or concerns regarding services.” The Coordination Note dated 10/16/2025 documents: “CM (Case Manager) Coordination Note: TC (Telephone call) from CG (caregiver) on 10/16. (Parent/Caregiver) requested to put OT (Occupational Therapist) on hold. (Parent/Caregiver) reported that OT (Occupational Therapist) reached out last minute today at 8 AM to schedule the recert for the same day. (Parent/Caregiver) stated that patient has a busy schedule and (parent/caregiver) needs to be notified in advance. Additionally, (parent/caregiver) requested a call from OT (Occupational Therapy) supervisor. Director of Rehab Operations was informed.” The clinical record lacks documented evidence of timely and prompt communication with the patient/caregiver regarding the change in the scheduled Recert visit for 10/14/2025. On 12/12/2025 at 02:05 PM, the Administrator, the Vice President of Quality and Compliance, and the Executive Director of Rehabilitation Operations were interviewed. The Executive Director of Rehabilitation Operations stated: "the visit should have been schedule for the Friday (10/17) a day the OT (Occupational Therapist) normally visits;” and “no communication” with caregiver is documented of the change.

An on-site investigation of complaint #109899 was conducted at Wellbound Home Health Agency, located at 7424 13th. Ave., Brooklyn, NY 11228 on 11/13/2024 -11/14/2024. Four (4) clinical records were reviewed identified as (Patient #1, #2, #3 and #4) and two (2) Personnel records were reviewed and are identified as (Employee #1 and #2). The Complaint Log for the period 11/10/2024 to 01/01/2022 and Incident Log for the period 11/10/2024 to 07/01/2024, Active, Discharged, and on Hold census, Agency's Policies and Procedure were reviewed. The active patient census is 1076. The interviews were conducted throughout the survey with the Director of Patient Services/Administrator, the Registered Nurse Audits and Investigation. The allegations in the complaint #109899 were determined substantiated. The following deficiencies are identified as a result of the survey: G 0478 - Investigate complaints made by patient J 1444 - Personnel

Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) The HHA must— (i) Investigate complaints made by a patient, the patient's representative (if any), and the patient's caregivers and family, including, but not limited to, the following topics: (A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; (B) Mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on complaint log review, clinical records review, and staff interviews, the agency failed to ensure all patient’s complaints are investigated. This was evident for two (2) of four (4) clinical records reviewed (Patient #2 and #3). Failure to ensure all patient’s complaints are investigated, has the potential for negative patient outcomes. The Findings Are: 1.Patient #2 has a Start of Care date of 09/28/2020 and discharge date of 09/06/2024 with the following diagnoses "Autistic Disorder, Unspecified Asthma, Developmental Disorder of Speech and Language" documented on the Home Health Certification and Plan of Care for the Certification Period 07/09/2024 to 09/06/2024. Patient #3 has a Start of Care date of 09/28/2020 and discharge date of 09/06/2024 with the following diagnoses "Autistic Disorder, Unspecified Asthma, Developmental Disorder of Speech and Language" documented on the Home Health Certification and Plan of Care for the Certification Period 07/09/2024 to 09/06/2024. The Agency's "Patients Concerns, Complaints, Grievances" policy documents: "Any patient who feels his/her rights have been denied, or who desires to lodge a complaint will be encouraged to contact the Agency staff. Administrative Staff will review each complaint and ensure that all complaints will be investigated and that the individual making the complaint will receive a written response to all written complaints or oral complaints if requested by the individual making the complaint within 15 days of receipt of the complaint. 5.Upon receipt of a written or verbal complaint or grievance, the complainant is directed to the appropriate staff member. Staff will: a) Listen to the complaint expressed by the patient b) Record the complaint on the Complaint Form, and assist the patient in returning a written complaint to the agency c) Document the date the Complaint Form was received in the Complaint Log with a copy of the complaint /concern attached d) Notify the Agency Administrator/DPS/designee of the complaint e) Management/supervisory staff will be designated to conduct an investigation and document the findings/outcome of the investigation on the Complaint Form." The internal email from Case Manager dated 09/13/2024 documents:" I follow up with mom earlier today and she expressed her dissatisfaction with the delivery of the service and is requesting a different person to perform the recertification. Will discuss with the Director of Case Management on further steps." There is no documented evidence of an investigation, resolution and response to the complainant. There is no documented evidence of the complaint being documented in the complaint log. The Agency's "Respect for Patient's Privacy and Property" policy documents: "Visiting staff or scheduler telephones patients, or responsible other, to alert patients of the prospective arrival time of Agency personnel, time of appointment, and scheduled days of service." The clinical record lacks documented evidence of the RN (Registered Nurse) alerting the caregiver of the prospective arrival time or time of appointment. The internal email from the caregiver to Case Manager and Director of Case Management dated 09/16/2024 documents: "... This back and forth has/is causing me major anxiety and feeling unsafe with Wellbound because no one is correcting this nurse unprofessional behavior. I've always asked for a date and appointment time in order to have better structure for my day and just plain respect. My request have been unheard, but the behavior of this nurse still stands and at this point, I'm uncomfortable with anyone in my home that will lie and say that I "refused" services when all of my 5-6 years of being with Wellbound, this has never been an issue. This is an ongoing issue with him and his lack of respect for the patients. I will also be making the necessary steps to find another home care agency that can respect me and not think it's okay for their male employee to just show up to a patients home without proper notification." There is no documented evidence of an investigation, resolution and response to the complainant. There is no documented evidence of the complaint being documented in the complaint log. On 11/13/2024 at 4:45 pm, the Administrator/Director of Patient Services and the Registered Nurse Audits and Investigation were interviewed and did not provide an explanation for the findings.

A Re-certification Survey was conducted at Wellbound Certified Home Health Agency located at 2004 McDonald Avenue, Suite 2A, Brooklyn, NY 11223 on 6/26/2023 through 06/30/2023. The following statement of deficiencies represents the results of a partial extended re-certification survey of Wellbound Certified Home Health Agency conducted on 6/26/2023 through 06/30/2023 and included complaint investigation # 98231 and # 60374. The allegations in complaint # 98231 were determined to be substantiated. The allegations in complaint # 60374 were determined to be unsubstantiated due to lack of sufficient evidence. A standard re-certification survey was initiated on 06/26/2023. Deficient practices were identified within Level 1 standards in 484.50 Patient Rights , 484.60 Care Planning, Coordination, Quality of Care, and 484.75 Skilled Professional Services resulting in a partial extended survey. The survey consisted of a review of seventeen (17) clinical records identified as Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, and #17 including five (5) discharge records, nine (9) personnel records identified as Employee #1, #2, #3, #4, #5, #6, #7, #8, and #9 for professional and paraprofessional personnel four (4) contracts, and seven (7) observational home visits. The survey included a review of pertinent policies and procedures, Quality Improvement Meeting minutes for the past 12 months, agency’s Admission Packet, the Emergency Preparedness Plan, and Complaint Logs. Pre-survey activities consisted of review on 6/22/23 and 6/23/23 of the agency’s Health Commerce System account, Home Care Registry, Criminal History Record Check, Internet Quality Improvement and Evaluation System (iQIES), for the period 04/2022 - 03/2023, the agency’s compliance with report submissions for the 2021 statistical report and the most recent Emergency Drill. The Director of Patient Services/ Administrator, Compliance Officer and the Quality Improvement Reviewer were interviewed throughout the survey. Findings were reviewed at the exit conference on 6/30/2023. The following deficiencies are identified as a result of the survey: G- 0476- Investigation of complaints G- 0572- Plan of Care G- 0574- Plan of Care must include the following G- 0710- Provide services in the Plan of Care G- 0718- Communication with physicians G- 0808- Onsite Supervisory visit every 14 days G-0818- HH aide supervision elements J-1304- Contracts J-1412- Personnel

Investigation of complaints CFR(s): 484.50(e)(1) Standard: Investigation of complaints. The HHA must-- This STANDARD is not met as evidenced by: Based on Complaint log review, clinical record review, and staff interview, the agency failed to ensure the complete investigation and resolution of all patient complaints. This was evident for two (2) of seventeen (17) clinical records reviewed.(Patient #2 and #4 ). Failure to ensure the complete investigation and resolution of all patient complaints, has the potential for negative patient outcomes. The finding are: 1. Patient #2 (HV) with date of birth 08/05/2016 has a Start of Care date of 02/25/2020 with the following diagnosis "Autistic Disorder" documented in the Home Health Certification and Plan of Care dated 06/09/2023 to 08/07/2023. The Client Coordination Note Report 06/15/2023 documents: 06/15/2023: Spoke to mom she has a few complaints. 1. She has been requesting PT (physical therapy) saying she has been waiting for a replacement for 2 years. 2. She needs a weekend aide, someone that won’t have an issue traveling to her home on the weekends. 3. The ST (Speech Therapy) will be out for a week and she wants someone to cover her sessions because her kids will be losing out on their services. 4. She wants make up OT sessions from April she said she lost about 9 sessions due to the therapist cancelling and not making up the visits. 06/27/2023: Spoke to mom her service is great other than the issues with therapist missing visits and not making them up. There is no documented evidence of an investigation, resolution and response to the complainant. There is no documented evidence of the complaint being documented in the complaint log. On 06/29/2023 at 2:40pm, the Administrator/Director of Patient Services, the Compliance Officer, and the Quality Improvement Reviewer were interviewed and did not provide an explanation for the findings. 2. Patient #4 with date of birth 08/05/2016 has a Start of Care date of 05/14/2020 with the following diagnosis "Autistic Disorder" documented in the Home Health Certification and Plan of Care dated 04/29/2023 to 06/27/2023. The Client Coordination Note Report 06/15/2023 documents: 06/15/2023: Spoke to mom she has a few complaints. 1. She has been requesting PT saying she has been waiting for a replacement for 2 years. 2. She needs a weekend aide, someone that won’t have an issue traveling to her home on the weekends. 3. The ST will be out for a week and she wants someone to cover her sessions because her kids will be losing out on their services. 4. She wants make up OT sessions from April she said she lost about 9 sessions due to the therapist cancelling and not making up the visits. 06/27/2023: Spoke to mom her service is great other than the issues with therapist missing visits and not making them up. There is no documented evidence of an investigation, resolution and response to the complainant. There is no documented evidence of the complaint being documented in the complaint log. that the complaint was logged to include the dates of receipt and resolution. On 06/29/2023 at 2:40pm, the Administrator/Director of Patient Services, the Compliance Officer, and the Quality Improvement Reviewer were interviewed and did not provide an explanation for the findings.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on clinical record review and staff interview the agency failed to ensure all patients receive home health services as documented in their individualized plan of care and the physician is notified of any changes. This was evident for two (2) of seventeen (17) clinical records reviewed (Patient: #1 and #16). Failure to ensure all patients receive home health services as documented on their plan of care and the physicians is notified when there is a change has the potential for negative patient outcomes. The findings are: 2. Patient#16 has a start of care date 01/31/2023 with the following diagnoses "Unspecified Open Wound, Right Knee, Spinal Stenosis, Lumbar Region, Primary Generalized Osteoarthritis" documented on the Home Health Certification and Plan of Care for the certification period 01/31/2023 to 03/31/2023. The Supplemental Orders dated 02/16/2023 documents:” OT (Occupational Therapist) Effective 02/12/2023 1wk1(one time per week); 2wk3(two times per week for three weeks); 1wk1(one time per week for one week).” The clinical record lacks documented evidence of the OT visit for the week of 02/19/2023 (one missed visit) and week of 03/05/2023 (one missed visit). There is no documented evidence of the physician being notified of the missed visits and services being provided as documented in the Plan of Care. On 06/29/2023 at 3:00 pm, the Administrator/Director of Patient Services, the Compliance Officer, and the Quality Improvement Reviewer were interviewed and did not provide an explanation for the findings. 1.Patient #1 (HV) with date of birth 11/09/2008 has a Start of Care date of 04/19/2022 with the following diagnosis "Autistic Disorder" documented in the Home Health Certification and Plan of Care dated 06/13/2023 to 08/11/2023. The Home Health Certification and Plan of Care dated 04/10/2023 to 06/08/2023 documents: OT (occupational therapy) 1WK1, 2WK8 (once a week for one week, twice a week for eight weeks); ST (speech therapy) 4WK1, 5WK7, 4WK1 (four times a week for one week, five times a week for seven weeks). The Home Health Certification and Plan of Care dated 06/09/2023 to 08/07/2023 documents: OT effective 06/11/2023 3WK1, 2WK7 (three times a week for one week, twice a week for seven weeks); ST 1WK1, 5WK8 (once a week for one week, five times a week for eight weeks). The Clients Coordination Note Report documents: 04/11/2023 “Missed visit notification; No answer.” 04/18/2023 "MD to be notified; Please be advise the patient will not have OT services between 4/13-4/24 due to clinician unavailable.” “Missed ST visit 4/15.” 04/25/2023 “MD to be notified; Missed speech therapy visit for 4/21/23.” 04/27/2023 “MD to be notified; Missed speech therapy visit for 4/25/23.” 05/02/2023 “Missed speech therapy visit 4/25 06/02/2023 " MD to be notified; Missed occupational therapy visit from 5/31/ to 6/02/23. clinician unavailable". 06/06/2023 “Missed visit notification; No answer.” There is no documented evidence of OT services being provided between 04/23/2023 to 04/29/2023 – missed one visit, 05/28/2023 to 05/30/2023 - missed one visit, and 06/11/2023 to 06/17/2023 – missed one visit. There is no documented evidence of ST services being provided between 05/07/2023 to 05/13/2023 – missed two visits, 05/14/2023 to 05/20/2023 – missed two visits, 05/28/2023 to 06/03/2023 – missed two visits, 06/09/2023 to 06/10/2023 – missed one visit, 06/11/2023 to 06/17/2023 – missed five visits, and 06/18/2023 to 6/24/2023 – missed three visits. There is no documented evidence of the physician being notified of the missed visits and no documented evidence of a discussion with the physician regarding multiple missed services or whether additional intervention is required.. On 06/28/2023 at 12:36pm, the Administrator/Director of Patient Services, the Compliance Officer, and the Quality Improvement Reviewer were interviewed and did not provide an explanation for the findings.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview the agency failed to ensure each patient has an accurate individualized plan of care that includes the patient’s risk for emergency department visits/ hospital re-admission, and all necessary interventions to address the underlying risk factors. This was evident for five (5) of seventeen (17) clinical records reviewed (Patient: #1, #2, #3, #4, and #5). Failure to ensure each patient has an accurate individualized plan of care to address the risk for emergency department / hospital re-admissions has the potential for negative patient outcome. The findings are: 1.Patient #1 (HV) with date of birth 11/09/2008 has a Start of Care date of 04/19/2022 with the following diagnosis "Autistic Disorder" documented in the Home Health Certification and Plan of Care dated 06/13/2023 to 08/11/2023. The individualized plan of care lacks documented evidence of 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. On 06/28/2023 at 12:36pm, the Administrator/Director of Patient Services, the Compliance Officer, and the Quality Improvement Reviewer were interviewed and did not provide an explanation for the findings. 2. Patient #2 (HV) with date of birth 08/05/2016 has a Start of Care date of 02/25/2020 with the following diagnosis "Autistic Disorder" documented in the Home Health Certification and Plan of Care dated 04/10/2023 to 06/08/2023 and 06/09/2023 to 08/07/2023. The individualized plan of care lacks documented evidence of 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. On 06/28/2023 at 12:36pm, the Administrator/Director of Patient Services, the Compliance Officer, and the Quality Improvement Reviewer were interviewed and did not provide an explanation for the findings. 3. Patient #3 (HV) with date of birth 10/12/2018 has a Start of Care date of 07/16/2020 with the following diagnosis "Autistic Disorder" documented in the Home Health Certification and Plan of Care dated 05/02/2023 to 06/30/2023. The individualized plan of care lacks documented evidence of 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. On 06/28/2023 at 12:36pm, the Administrator/Director of Patient Services, the Compliance Officer, and the Quality Improvement Reviewer were interviewed and did not provide an explanation for the findings. 4. Patient #4 with date of birth 08/05/2016 has a Start of Care date of 05/14/2020 with the following diagnosis "Autistic Disorder" documented in the Home Health Certification and Plan of Care dated 04/29/2023 to 06/27/2023. The individualized plan of care lacks documented evidence of 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. On 06/28/2023 at 12:36pm, the Administrator/Director of Patient Services, the Compliance Officer, and the Quality Improvement Reviewer were interviewed and did not provide an explanation for the findings. 5. Patient #5 with date of birth 04/09/2015 has a Start of Care date of 05/11/2021 with the following diagnosis "Autistic Disorder" documented in the Home Health Certification and Plan of Care dated 05/01/2023 to 06/29/2023. The individualized plan of care lacks documented evidence of 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. On 06/28/2023 at 12:36pm, the Administrator/Director of Patient Services, the Compliance Officer, and the Quality Improvement Reviewer were interviewed and did not provide an explanation for the findings.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on clinical 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 eight (8) of seventeen (17) clinical records reviewed (Patient: #2, #4, #5, #6, #7, #9, #12,and #14 ). 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: 7.Patient#12 has a start of care date of 06/09/2023 with the following diagnoses "Peripheral Vascular Disease, Non-Pressure Chronic Ulcer of Other Part of Right Lower Leg Limited to Breakdown of Skin" documented on the Home Health Certification and Plan of Care for the Certification Period 06/09/2023 to 08/07/2023. The Home Health Certification and Plan of Care for the Certification Period 06/09/2023 to 08/07/2023 documents: “Skilled Nurse (SN) to perform wound care to Right Lower Leg – cleanse with Normal Saline, pat dry, then apply Xeroform. Covered with DPD (dry protective dressing) – gauze, using clean/aseptic technique. Change dressing every day and PRN (as needed).” The clinical record lacks documented evidence of the SN providing daily wound care on 06/10/2023, 06/11/2023, and 06/14/2023. There is no documented evidence of the SN administering wound treatment as ordered by the physician. On 06/29/2023 at 3:00 pm, the Administrator/Director of Patient Services, the Compliance Officer, and the Quality Improvement Reviewer were interviewed and did not provide an explanation for the findings. 8. Patient#14 (PAE) has a start of care date of 11/23/2022 with the following diagnoses "Type 2 Diabetes Mellitus with Diabetic Neuropathy, Chronic Kidney Disease, Hyperlipidemia" documented on the Home Health Certification and Plan of Care for the Certification Period 11/23/2022 to 01/21/2023. The Home Health Certification and Plan of Care for the Certification Period 11/23/2022 to 01/21/2023 documents: "Novolog Mix 70-30 Flex Pen U-100 Insulin 100 Unit/Ml – 17 unit 2 times Daily Instruction: before Breakfast and Dinner.” The Skilled Nurse Note documents on the following dates: "Injection Novolog 70-30 11/27/2022 AM - 20 Units and PM - 25 Units 11/28/2022 PM - 20 Units 11/29/2022 AM - 20 Units and PM - 20 Units 12/01/2022 AM - 23 Units and PM - 20 Units 12/02/2022 AM - 23 Units 12/03/2022 AM - 25 Units and PM - 20 Units" There is no documented evidence of the SN administering insulin as ordered by the physician. The Supplemental Orders dated 12/28/2022 documents: “Previous order of Novolog is d/c (Novolog Mix 70-30 Flex Pen U-100 insulin 100 unit/ml subcutaneous 2 times daily – 17 Units). Start Date 11/23/2022 and d/c 12/28/2022. Add New order of Novolog 31 U(unit) Q(every) AM and Novolog 25 U(unit) Q(every) PM in place as per MD order. Start Date 12/28/2022." The Skilled Nurse Note dated 1/4/23 documents: " Injection Novolog 70-30 01/04/2023 PM - 31 Units" There is no documented evidence of the SN administering insulin as ordered by the physician. On 06/29/2023 at 3:00 pm, the Administrator/Director of Patient Services, the Compliance Officer, and the Quality Improvement Reviewer were interviewed and did not provide an explanation for the findings. 4.Patient #6 (HV) has a Start of Care date of 11/30/2021 diagnoses "Type 2 Diabetes Mellitus without Complications, Long Term (Current) Use of Insulin" documented in the Home Health Certification and Plan of Care dated 05/24/2023 to 07/22/2023. The Home Health Certification and Plan of Care dated 05/24/2023 to 07/22/2023 documents the following orders for Skilled Nurse (SN) services: “Perform blood sugar (BS) analysis 3 x daily;” “administer SQ (subcutaneous) (Insulin) 3 x daily;” Insulin medication “Novolog Flexpen U-100 Insulin Aspart 100 unit/ml(milliliter) (3ml) Subcutaneous per Instructions: By sliding scale if BS (Blood Sugar) 120-150 = 7 Units, 151-180 = 8 Units, 181-220 = 10 Units, 221-260 = 12 Units, 261-300 = 14 Units, 301-340 = 16 Units.” The LPN (Licensed Practical Nurse) SN “Visit Note Report(s)” document the SN administered 6 Units of Novolog insulin for the patient’s BS results in the range of 120 to 150 on the following dates: 05/24/2023 11:25 AM, 05/25/2023 7AM, 05/26/2023 7AM, 05/26/2023 3PM, 05/27/2023 7AM, 05/28/2023 7AM, 06/01/2023 7AM, 06/02/2023 7AM, 06/04/2023 8:30AM, 06/04/2023 11:15AM, 06/05/2023 7:10AM, 06/09/2023 7:48AM, 06.09/2023 11AM, 06/10/2023 11:25AM, 06/11/2023 8:27AM, 06/11/2023 11:06AM, 06/11/2023 4:46PM, and 06/13/2023 7:41AM. The clinical record lacks documented evidence of the SN administering 7 Units of Novolog in accordance with the BS 120-150 sliding scale as ordered by the physician. The LPN SN “Visit Note Report(s)” document the SN administered 7 Units Novolog insulin for the patient’s BS results in the range of 151 to 180 on the following dates: 05/27/2023 3PM, 06/06/2023 8:15AM, 06/07/2023 8:44AM, 06/08/2023 8:50AM, 06/12/2023 4:10PM, and 06/23/2023 7:55AM. The clinical record lacks documented evidence of the SN administering 8 Units of Novolog in accordance with the BS 151-180 sliding scale as ordered by the physician. The LPN SN “Visit Note Report(s)” document the SN administered 8 Units Novolog insulin for the patient’s BS results in the range of 181 to 220 on the following dates: 05/24/2023 9:05AM, 05/24/2023 3:35PM, 05/30/2023 4:45PM, 05/31/2023 8:44AM, 05/31/2023 11:45AM, 05/31/2023 3:20PM, 06/01/2023 3PM, 06/05/2023 11:05AM, 06/05/2023 4:45PM, 06/06/2023 11:30AM, 06/06/2023 4:50PM, 06/07/2023 4:39PM, 06/08/2023 11:10AM, and 06/12/2023 7:50AM. The clinical record lacks documented evidence of the SN administering 10 Units of Novolog in accordance with the BS 181-220 sliding scale as ordered by the physician. The LPN SN “Visit Note Report(s)” document the SN administered Novolog 14 Units on 06/04/2023 3:50PM, 9 Units on 06/09/2023 4:15PM and 10 Units on 06/10/2023 4:40PM for the patient’s BS results in the range of 221 to 260. The clinical record lacks documented evidence of the SN administering 12 Units of Novolog in accordance with the BS 221-260 sliding scale as ordered by the physician. The LPN SN “Visit Note Report(s)” document the SN administered Novolog 12 Units on 05/30/2023 1PM and on 06/10/2023 8:45AM and administered 7 Units on 06/22/2023 9:22AM for the patient’s BS results in the range of 261 to 300. The clinical record lacks documented evidence of the SN administering 14 Units of Novolog in accordance with the BS 261-300 sliding scale as ordered by the physician. The clinical record lacks documented evidence of the SN administering insulin as indicated in the plan of care. On 06/28/2023 at 12:35pm, the Administrator/Director of Patient Services, the Compliance Officer, and the Quality Improvement Reviewer were interviewed and did not provide an explanation for the findings. 5.Patient #7(HV) has a Start of Care date of 08/11/2022 diagnoses "Type 2 Diabetes Mellitus without Complications, Long Term (Current) Use of Insulin" documented in the Home Health Certification and Plan of Care dated 06/07/2023 to 08/05/2023. The Home Health Certification and Plan of Care dated 06/07/2023 to 08/05/2023 documents the following orders for Skilled Nurse (SN) services: “Perform blood sugar analysis x 2 daily;” “administer SQ (Insulin) x 2 daily;” Insulin medications “Novolog Flexpen U-100 Insulin Aspart 100 unit/ml (3ml) Subcutaneous per Instructions: If FBS (Fasting Blood Sugar) 1-150 give 0 Units, 101-200 give 2 Units, 201-250 give 4 Units, 251-300 give 6 Units, 301-350 give 8 Units, 351-400 give 10 Units, > 400 Call MD,” and “Lantus Solostar U-100 Insulin 100 unit/ml (3 ml) Subcutaneous Pen 6 Unit(s) Every PM.” The LPN SN “Visit Note Report(s)” document the SN did not administer insulin as ordered by the physician as indicated in the plan of care on the following dates: 06/08/2023 4:14PM - BS=224, 2 Units Novolog insulin administered (sliding scale BS 201-250, give 4 Units); 06/18/2023 4:05PM - BS=165, No Novolog insulin administered ( sliding scale BS 101-200, give 2 Units), Lantus 6 Units administered 2 times in Left Upper Lower Abdomen and Left Lower Abdomen; 06/22/2023 3:55PM - BS=204, 2 Units Novolog insulin administered (sliding scale BS 201-250, give 4 Units). The clinical record lacks documented evidence the SN administering insulin in accordance with the sliding scale as ordered by the physician as indicated in the plan of care. On 06/28/2023 at 12:35pm, the Administrator/Director of Patient Services, the Compliance Officer, and the Quality Improvement Reviewer were interviewed and did not provide an explanation for the findings. 6.Patient #9 (PAE) has a Start of Care date of 11/12/2020 diagnoses "Type 2 Diabetes Mellitus with Diabetic Neuropathy, Long Term (Current) Use of Insulin" documented in the Home Health Certification and Plan of Care dated 01/01/2023 to 03/01/2023. The Home Health Certification and Plan of Care dated 11/02/2022 to 12/31/2022 documents the following orders for Skilled Nurse (SN) services: “Perform blood sugar analysis twice per day;” “Administer SQ insulin twice per day;” “Report blood sugar levels greater than 400 mg(milligram)/dl(deciliter) or less than 60 mg/dl;” Insulin medications: “Novolog Flexpen U-100 Insulin Aspart 100 Unit/ml (3 ml) Subcutaneous 5 Unit 2 Times Daily, Instructions; Hold for BG (blood glucose) less than 150 mg/dl, give extra 5 Units for BG greater than 350 mg/dl" and “Lantus Solostar U-100 Insulin 100 Unit/ml (3 ml) Subcutaneous Pen 25 Unit(s) Daily.” The LPN SN “Visit Note Report(s)” lacks documented evidence the SN administering Novolog insulin on the following dates: 11/19/2022 8:20AM BS=177, 12/01/2022 9:25AM BS=158, 12:29/2022 8:35AM BS=209, and 12/31/2022 9:39AM BS=180. The clinical record lacks documented evidence of the SN administering Novolog as ordered by the physician. The LPN SN “Visit Note Report” dated 12/21/2022 3:12PM documents the patient’s blood glucose result was 403 and the SN administered 10 Units of Novolog insulin. The clinical record lacks documented evidence of the SN reporting the blood glucose result greater than 400 as ordered by the physician. The LPN SN “Visit Note Report(s)” dated 12/08/2022 9:50AM and 12/21/2022 10:54AM document the SN administered 10 Units Lantus insulin. The clinical record lacks documented evidence of the SN administering 25 units of Lantus insulin as ordered by the physician on 12/08/2022 and 12/21/2022 The LPN SN “Visit Note Report(s)” document the SN administered 24 Units of Lantus insulin on the following dates: 11/02/2022, 11/04/2022, 11/05/2022, 11/07/2022 7:58AM, 11/08/2022 9:00AM, 11/09/2022 8AM, 11/12/2022 9:06AM, 11/13/2022 8:45AM, 11/14/2022 8AM, 11/15/2022 9:08AM, 11/17/2022 8:58AM, 11/19/2022 8:20AM, 11/20/2022 8:50AM, 11/21/2022 7:35AM, 11/22/2022 9:50AM, 11/23/2022 8:15AM, 11/24/2022 8:25AM, 11/27/2022 9:55AM, 11/28/2022 7:41AM, 11/29/2022 9:05AM, 11/30/2022 9:45AM, 12/05/2022 8:10AM, 12/07/2022 8:40AM, 12/10/2022 9:35AM, 12/11/2022 7:35AM, 12/12/2022 9:45AM, 12/14/2022 10AM, 12/15/2022 7:50AM, 12/16/2022 8:44AM, 12/19/2022 9:10AM, 12/20/2022 9:40AM, 12/21/2022 10:54AM, 12/25/2022 9:35AM, 12/27/2022, 12/28/2022, 12/29/2022 8:36 AM, 12/31/2022 9:39AM. The clinical record lacks documented evidence of the SN administering 25 units of Lantus insulin as ordered by the physician. The LPN SN Visit Notes dated 11/06/2022 lack documentation of the SN administering Lantus insulin on 11/06/2022. The clinical record lacks documented evidence of the SN administering 25 units of Lantus insulin as ordered by the physician as indicated in the plan of care. On 06/29/2023 at 2:40pm, the Administrator/Director of Patient Services, the Compliance Officer, and the Quality Improvement Reviewer were interviewed and did not provide an explanation for the findings. 1.Patient #2 (HV) with date of birth 08/05/2016 has a Start of Care date of 02/25/2020 with the following diagnosis "Autistic Disorder" documented in the Home Health Certification and Plan of Care dated 04/10/2023 to 06/08/2023 and 06/09/2023 to 08/07/2023. The Home Health Certification and Plan of Care dated 04/10/2023 to 06/08/2023 documents: OT (occupational therapy) 1WK1, 2WK8 (once a week for one week, twice a week for eight weeks); ST (speech therapy) 4WK1, 5WK7, 4WK1 (four times a week for one week, five times a week for seven weeks). The Home Health Certification and Plan of Care dated 06/09/2023 to 08/07/2023 documents: OT effective 06/11/2023 3WK1, 2WK7 (three times a week for one week, twice a week for seven weeks); ST 1WK1, 5WK8 (once a week for one week, five times a week for eight weeks). There is no documented evidence of OT services being provided between 04/23/2023 to 04/29/2023 , 05/28/2023 to 05/30/2023, and 06/11/2023 to 06/17/2023. There is no documented evidence of ST services being provided between 05/07/2023 to 05/13/2023 , 05/14/2023 to 05/20/2023 , 05/28/2023 to 06/03/2023, 06/09/2023 to 06/10/2023, 06/11/2023 to 06/17/2023, and 06/18/2023 to 6/24/2023. There is no documented evidence of the patient receiving OT and ST services as ordered by the physician as documented in the plan of care. On 06/29/2023 at 2:40pm, the Administrator/Director of Patient Services, the Compliance Officer, and the Quality Improvement Reviewer were interviewed and did not provide an explanation for the findings. 2. Patient #4 with date of birth 08/05/2016 has a Start of Care date of 05/14/2020 with the following diagnosis "Autistic Disorder" documented in the Home Health Certification and Plan of Care dated 04/29/2023 to 06/27/2023. The Home Health Certification and Plan of Care dated 04/29/2023 to 06/27/2023 documents: OT effective 04/30/2023 1WK1, 2WK7, 1WK1 (once a week for one week, twice a week for seven weeks). There is no documented evidence of OT services being provided between 05/28/2023 to 06/03/2023 – missed two visits. There is no documented evidence of the patient receiving OT services as ordered by the physician as documented in the plan of care. On 06/29/2023 at 2:40pm, the Administrator/Director of Patient Services, the Compliance Officer, and the Quality Improvement Reviewer were interviewed and did not provide an explanation for the findings. 3. Patient #5 with date of birth 04/09/2015 has a Start of Care date of 05/11/2021 with the following diagnosis "Autistic Disorder" documented in the Home Health Certification and Plan of Care dated 05/01/2023 to 06/29/2023. The Home Health Certification and Plan of Care dated 05/01/2023 to 06/29/2023 documents: ST 2WK9 (twice a week for nine weeks). There is no documented evidence of ST services being provided between 05/07/2023 to 05/13/2023 – missed one visit, 05/14/2023 to 05/20/2023 – missed two visits, 05/21/2023 to 05/27/2023 – missed one visit, 05/28/2023 to 06/03/2023 – missed one visit. There is no documented evidence of the patient receiving ST services as ordered by the physician as documented in the plan of care. On 06/29/2023 at 2:40pm, the Administrator/Director of Patient Services, the Compliance Officer, and the Quality Improvement Reviewer were interviewed and did not provide an explanation for the findings.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview the agency failed to ensure ongoing communication with all physicians is maintained. This was evident for one (1) of seventeen (17) clinical records reviewed. (Patients#14). Failure to ensure ongoing communication with all physicians is maintained has the potential for negative patient outcome. The findings are: 1.Patient#14 (PAE) has a start of care date 11/23/2022 with the following diagnoses "Type 2 Diabetes Mellitus with Diabetic Neuropathy, Chronic Kidney Disease, Hyperlipidemia" documented on the Home Health Certification and Plan of Care for the certification period 11/23/2022 to 01/21/2023. The Home Health Certification and Plan of Care for the certification period 11/23/2022 to 01/21/2023 documents: “Skilled Nurse to perform Blood Sugar analysis twice daily; Skilled Nurse to report Blood Glucose Levels Greater than 400 mg/dl." The Skilled Nurse Note documents the following blood glucose results:" 11/28/2022(pm) - 547 Mg/Dl 11/29/2022(am) - 427 Mg/Dl 11/30/2022(pm) - 462 Mg/Dl 01/04/2023(am) - 457 Mg/Dl 01/18/2023(am) - 436 Mg/Dl 01/20/2023(pm) - 402 Mg/Dl." There is no documented evidence of the physician being notified regarding the finger stick result (BGL greater than 400). On 06/29/2023 at 3:00 pm, the Administrator/Director of Patient Services, the Compliance Officer, and the Quality Improvement Reviewer were interviewed and did not provide an explanation for the findings.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview the agency failed to ensure that all home health aides providing services to patients receiving skilled services are supervised no less frequently than every two weeks. This was evident for three (3) of five (5) clinical records reviewed for home health aide services (Patient:#2, #3, and #4). Failure to ensure home health aide supervision is conducted every two (2) weeks for patients who are receiving skilled services has the potential for negative patient outcomes. The findings are: 1. Patient #2 (HV) with date of birth 08/05/2016 has a Start of Care date of 02/25/2020 with the following diagnosis "Autistic Disorder" documented in the Home Health Certification and Plan of Care dated 06/09/2023 to 08/07/2023. The Home Health Certification and Plan of Care dated 06/09/2023 to 08/07/2023 documents: Frequency/Duration of Visits: hha (home health aide) 4WK1, 14WK8 (four times a week for one week, fourteen times a week for eight weeks). The Client Calendar Report documents aide services being provided from 06/09/2023 to 06/23/2023. There is no documented evidence of aide supervision every 14 days from 06/09/2023 to 06/23/2023. On 06/28/2023 at 12:36pm, the Administrator/Director of Patient Services, the Compliance Officer, and the Quality Improvement Reviewer were interviewed and did not provide an explanation for the findings. 2. Patient #3 (HV) with date of birth 10/12/2018 has a Start of Care date of 07/16/2020 with the following diagnosis "Autistic Disorder" documented in the Home Health Certification and Plan of Care dated 05/02/2023 to 06/30/2023. The Home Health Certification and Plan of Care dated 05/02/2023 to 06/30/2023 documents: Frequency/Duration of Visits: hha 4WK1, 5WK8 (four times a week for one week, five times a week for eight weeks). The Member Calendar documents aide services being provided from 05/02/2023 to 06/16/2023 five times a week, Monday to Friday. There is no documented evidence of aide supervision every 14 days from 05/25/2023 to 06/16/2023. On 06/28/2023 at 12:36pm, the Administrator/Director of Patient Services, the Compliance Officer, and the Quality Improvement Reviewer were interviewed and did not provide an explanation for the findings. 3. Patient #4 with date of birth 08/05/2016 has a Start of Care date of 05/14/2020 with the following diagnosis "Autistic Disorder" documented in the Home Health Certification and Plan of Care dated 04/29/2023 to 06/27/2023. The Home Health Certification and Plan of Care dated 04/29/2023 to 06/27/2023 documents: Frequency/Duration of Visits: hha 1WK1, 11WK8, 5WK1 (once a week for one week, eleven times a week for eight weeks, five times a week for one week). The Clients Calendar Report documents aide services being provided from 04/29/2023 to 06/17/2023. There is no documented evidence of aide supervision every 14 days from 04/29/2023 to 06/17/2023. On 06/28/2023 at 12:36pm, the Administrator/Director of Patient Services, the Compliance Officer, and the Quality Improvement Reviewer were interviewed and did not provide an explanation for the findings.

HH aide supervision elements CFR(s): 484.80(h)(4)(i-vi) Home health aide supervision must ensure that aides furnish care in a safe and effective manner, including, but not limited to, the following elements: (i) Following the patient's plan of care for completion of tasks assigned to a home health aide by the registered nurse or other appropriate skilled professional; (ii) Maintaining an open communication process with the patient, representative (if any), caregivers, and family; (iii) Demonstrating competency with assigned tasks; (iv) Complying with infection prevention and control policies and procedures; (v) Reporting changes in the patient's condition; and (vi) Honoring patient rights. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview the agency failed to ensure the home health aide (hha) furnished care in a safe and effective manner by ensuring aide supervision includes the home health aide supervision elements. This was evident for three (3) of seventeen (17) clinical records reviewed. (Patient #1, #2, and #3). Failure to ensure aides supervision includes all of the aide supervision elements has the potential for negative patient outcome. The finding are: The Administrative Policy and Procedure Manual for Home Health Aide Supervision dated 11/3/2022 documents: Home Health Aide supervision must ensure that aides furnish care in a safe and effective manner, including, but not limited to, the following elements: • Following the patient’s plan of care for completion of tasks assigned to a Home Health Aide by the registered nurse or another appropriate skilled professional. • Maintaining an open communication process with the patient, representative or (if any), caregiver, and family. • Demonstrating competency with assigned tasks. • Complying with infection prevention and control policies and procedures. • Reporting changes in the patient’s condition. • Honoring patient rights. 1.Patient #1 (HV) with date of birth 11/09/2008 has a Start of Care date of 04/19/2022 with the following diagnosis "Autistic Disorder" documented in the Home Health Certification and Plan of Care dated 06/13/2023 to 08/11/2023. The Home Health Certification and Plan of Care dated 06/13/2023 to 08/11/2023documents: hha (home health aide) 5WK1, 7WK7 (five times a week for one week, seven times a week for seven weeks). The Member Calendar documents aide providing services from 06/13/2023 to 06/23/2023, daily. The Visit Note Report dated 06/20/2023, 06/22/2023, and 06/26/2023 documents: Supervisory Functions – Is Patient/Caregiver satisfied with current care being provided? YES. There is no documented evidence of the aide supervision including: following the patient’s plan of care, maintaining an open communication process, demonstrating competency with assigned task, complying with infection prevention and control, reporting changes in the patient’s condition, and honoring patient rights. On 06/28/2023 at 12:36pm, the Administrator/Director of Patient Services, the Compliance Officer, and the Quality Improvement Reviewer were interviewed and did not provide an explanation for the findings. 2. Patient #2 (HV) with date of birth 08/05/2016 has a Start of Care date of 02/25/2020 with the following diagnosis "Autistic Disorder" documented in the Home Health Certification and Plan of Care dated 04/10/2023 to 06/08/2023 and 06/09/2023 to 08/07/2023. The Home Health Certification and Plan of Care dated 04/10/2023 to 06/08/2023 documents: hha 13WK1, 16WK7, 19WK2, 16WK2, 11WK1 (thirteen times a week for one week, sixteen times a week for seven weeks, nineteen times a week for two weeks, sixteen times a week for two weeks, eleven times a week for one week). The Client Calendar Report documents aide providing services from 04/10/2023 to 06/08/2023. The Visit Note Report by speech therapist with supervisory from 04/10/2023 to 06/08/2023 documents: Supervisory Functions – Is Patient/Caregiver satisfied with current care being provided? YES. There is no documented evidence of the aide supervision including: following the patient’s plan of care, maintaining an open communication process, demonstrating competency with assigned task, complying with infection prevention and control, reporting changes in the patient’s condition, and honoring patient rights. On 06/28/2023 at 12:36pm, the Administrator/Director of Patient Services, the Compliance Officer, and the Quality Improvement Reviewer were interviewed and did not provide an explanation for the findings. 3. Patient #3 (HV) with date of birth 10/12/2018 has a Start of Care date of 07/16/2020 with the following diagnosis "Autistic Disorder" documented in the Home Health Certification and Plan of Care dated 05/02/2023 to 06/30/2023. The Home Health Certification and Plan of Care dated 05/02/2023 to 06/30/2023 documents: hha 4WK1, 5WK8 (four times a week for one week, five times a week for eight weeks). The Member Calendar documents aide services being provided from 05/02/2023 to 06/16/2023 five times a week, Monday to Friday. The Visit Note Report dated 05/11/2023 documents: Supervisory Functions – Is Patient/Caregiver satisfied with current care being provided? YES. There is no documented evidence of the aide supervision including: following the patient’s plan of care, maintaining an open communication process, demonstrating competency with assigned task, complying with infection prevention and control, reporting changes in the patient’s condition, and honoring patient rights. On 06/28/2023 at 12:36pm, the Administrator/Director of Patient Services, the Compliance Officer, and the Quality Improvement Reviewer were interviewed and did not provide an explanation for the findings.