Every finding on record at Americare Certified Special Services, Inc.

An on-site investigation of Complaint #2719394 and #2721117 was conducted at Americare Certified Special Services, Inc, located at 5923 Strickland Avenue, Brooklyn, NY 11234 on 02/25/2026 - 02/26/2026. Six (6) clinical records were reviewed and are identified as (Patient #1, #2, #3, #4, #5 and #6) and three (3) Personnel records were reviewed and are identified as (Employee #1, #2 and #3). The Complaint and Incident Log for the period 12/01/2025 to 02/20/2026, active census, Agency's Policies and Procedure were reviewed. The active patient census is 9072. Interviews were conducted throughout the survey with the Director of Patient Services. The allegation in complaint #2719394 was determined substantiated. The allegations in complaint #2721117 were determined substantiated. The following deficiencies are identified as a result of the survey: G 0572 - Plan of Care G 0608 - Coordinate Care Delivery Involving Patient

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on clinical records review and staff interviews, the agency failed to ensure that all patients receive services as documented in their individualized plan of care. This was evident for two (2) of six (6) clinical records reviewed. (Patient #2, and #4). Failure to ensure that all patients receive services as documented in their individualized plan of care has the potential for negative patient outcomes. The Findings Are: 1.Patient #2 has a Start of Care date of 01/03/2026 and discharge date of 02/12/2026 with the following diagnoses Urinary Tract Infection, Multiple Sclerosis, Hyperlipidemia documented on the Home Health Certification and Plan of Care for Certification Period 01/03/2026 to 03/03/2026. The Home Health Certification and Plan of Care for Certification Period 01/03/2026 to 03/03/2026 documents: HHA (Home Health Aide) effective 01/04/2026 4WK1 (four times a week for one week); 5WK3 (five times a week for three weeks); 2WK1 (two times a week for one week). The Physician Order (Supplemental Order) dated 01/20/2026 documents: HHA (Home Health Aide) effective 02/02/2026 5WK1 (five times a week for one week); 3WK1 (three times a week for one week). The Clinical Record documented HHA (Home Health Aide) services being provided week of 01/04/2026 - 1 time per week, week of 01/11/2026 - no visits, week of 01/18/2026 - 4 visits, week of 01/25/2026 - 1 visit, week of 02/01/2026 2 visits, week of 02/08/2026 - 3 visits. There is no documented evidence of the HHA (Home Health Aide) services being provided in accordance with the Home Health Certification and Plan of Care for Certification Period 01/03/2026 to 03/03/2026. On 02/26/2026 at 03:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the finding. 2.Patient #4 has a Start of Care date of 12/13/2025 and discharge date of 02/09/2026 with the following diagnoses Urinary Tract Infection, Chronic Obstructive Pulmonary Disease, Orthostatic Hypotension documented on the Home Health Certification and Plan of Care for Certification Period 12/13/2025 to 02/10/2026. The Home Health Certification and Plan of Care for Certification Period 12/13/2025 to 02/10/2026 documents: HHA effective 12/14/2025 3WK1(three times a week for one week), 5WK4 (five times a week for four weeks). The Physician Order dated 12/30/2025 documents: HHA (Home Health Aide) effective 01/18/2026 5WK3 (five times a week three weeks), 2WK1 (two times a week for one week). The Physician Order dated 02/06/2026 documents: HHA (Home Health Aide) effective 02/01/2026 2WK1 (two times a week for one week), 1WK1 (once a week for one week). The Clinical Record lacks documented evidence of the patient receiving Home Health Aide services. On 02/26/2026 at 03:30 PM, the Director of Patient Services was interviewed and stated that the multiple attempts were made to staff this case, and patient's wife advised no HHA/vendor was available in that area. The wife was offered accept shower aide services, but she refused. The Home Health Certification and Plan of Care for Certification Period 12/13/2025 to 02/10/2026 documents: OT (Occupational Therapy) effective 12/14/2025 1WK1 (once a week for one week). The Physician Order (Supplemental Order) dated 01/06/2026 documents: OT (Occupational Therapy) effective 01/04/2026 1WK1 (once a week for one week). The Physician Order (Supplemental Order) dated 01/08/2026 documents: OT (Occupational Therapy) effective 02/01/2026 2WK1 (two times a week for one week), 1WK1 (once a week for one week). The Physician Order (Supplemental Order) dated 01/10/2026 documents: OT (Occupational Therapy) effective 01/04/2026 1WK1 (once a week for one week), 2WK4 (two times a week for four weeks), 1WK1 (once a week for one week). The Physician Order (Supplemental Order) dated 02/06/2026 documents: OT (Occupational Therapy) effective 02/01/2026 2WK1 (two times a week for one week), 1WK1 (once a week for one week). The Clinical Record documented OT (Occupational Therapy) services being provided week of 01/04/2026 - 1 visit/evaluation, week of 01/11/2026 - 2 missed visits, week of 01/18/2026 - 2 visits, week of 01/25/2026 - 2 visits, week of 02/01/2026 - 2 visits, week of 02/08/2026 - 1 visit. The Clinical Coordination Note dated 12/23/2025 documents: Current status: Not able to staff for OT (Occupational Therapy), will ask if more PT (Physical Therapy) is needed so we can supplement OT (Occupational Therapy) with more PT (Physical Therapy). The Clinical Coordination Note dated 01/18/2026 documents: Missed Visit Notification. Date 01/16/2026. Discipline: OT (Occupational Therapy) Visit Status Note: Scheduled OT (Occupational Therapy) visit was not completed on this date due to provider unavailability secondary to a family emergency. Visit to be rescheduled as appropriate. The Clinical Coordination Note dated 01/18/2026 documents: Missed Visit Notification. Date 01/17/2026. Discipline: OT (Occupational Therapy) Visit Status Note: Scheduled OT (Occupational Therapy) visit was not completed on this date due to provider unavailability secondary to a family emergency. Visit to be rescheduled as appropriate. The clinical record lacks documented evidence of the patient receiving an OT (Occupational Therapy) visit for the week of 02/11/2026 as documented in the plan of care, and a delay in initiating OT (Occupational Therapy) services. On 02/26/2026 at 03:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the finding.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on clinical records review, and staff interviews, the agency failed to coordinate care delivery to meet the patient's needs and involve the patient. This was evident for one (1) of six (6) clinical records reviewed. (Patient #2) Failure to coordinate care delivery to meet the patient's needs and involve the patient has the potential for negative patient outcomes. The Findings Are: 1.Patient #2 has a Start of Care date of 01/03/2026 and discharge date of 02/12/2026 with the following diagnoses Urinary Tract Infection, Multiple Sclerosis, Hyperlipidemia documented on the Home Health Certification and Plan of Care for Certification Period 01/03/2026 to 03/03/2026. The Home Health Certification and Plan of Care for Certification Period 01/03/2026 to 03/03/2026 documents: HHA (Home Health Aide) effective 01/04/2026 4WK1 (four times a week for one week); 5WK3(five times a week for three weeks); 2WK1(two times a week for one week). The Physician Order (Supplemental Order) dated 01/20/2026 documents: HHA (Home Health Aide) effective 02/02/2026 5WK1 (five times a week for one week); 3WK1(three times a week for one week). The Clinical Record documented HHA (Home Health Aide) services being provided week of 01/04/2026 - 1 time per week, week of 01/11/2026 - no visits, week of 01/18/2026 - 4 visits, week of 01/25/2026 - 1 visit, week of 02/01/2026 2 visits, week of 02/08/2026 - 3 visits. The home health aide vendor communication notes document the following: The Member Note dated 01/21/2026 documents: Reason: Missed Visit. Visit Date: 01/22/2026, Scheduled Time: 1500-1800, Note: Patient/Family requested no services for the day/shift. The Member Note dated 01/28/2026 documents: Reason: Missed Visit. Visit Date: 01/28/2026, Scheduled Time: 1400-1800, Note: Patient/Family requested no services for the day/shift. The Member Note dated 02/02/2026 documents: Reason: Missed Visit. Visit Date: 02/02/2026, Scheduled Time: 1400-1800, Note: Patient/Family requested no services for the day/shift. There is no documented evidence of the agency/vendor inquiring about why the patient is refusing HHA services on 01/21/2026, 01/28/2026 and 02/02/2026. On 02/26/2026 at 03:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the finding.

An on-site investigation of incident 2637079 was conducted at Americare Certified Special Services, Inc., located at 5923 Strickland Avenue, Brooklyn, NY 11234 on 10/09/2025 to 10/17/2025. The survey consisted of a review of ten (10) clinical records identified as (Patients: #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10), three (3) personnel records identified as (Employees: #1, #2, and #3), complaint/incident logs, active pediatric patient census, and pertinent policies and procedures were reviewed. Pre-survey activities consisted of review on 10/08/2025 of the agency's Health Commerce System account and compliance history. The active pediatric patient census is 3181. The agency's the Director of Compliance, the Administrator, and the Director of Patient Service were interviewed. Findings were reviewed at the exit conference on 10/17/2025. The allegation in incident 2637079 was determined to be substantiated. The following deficiencies are being cited as result of the survey: G0798 – Home health aide assignments and duties G0808 – Onsite supervisory visit every 14 days

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on clinical record reviews, and staff interviews, the agency failed to ensure all paraprofessionals receive a complete Home Health Aide plan of care when providing patient care. This was evident for four (4) of ten (10) clinical records reviewed (Patients: #5, #6, #7, and #8). Failure to ensure all paraprofessionals receive a complete Home Health Aide plan of care has potential for negative patient outcomes. The Findings Are: Patient #5 has a Start of Care date of 8/28/2025 with the diagnoses Autistic Disorder, Other Disorders of Psychological Developmental, Developmental Disorder of Speech and Language Unspecified, Restlessness and Agitation, Epilepsy, Unsteadiness on Feet documented in the Home Health Certification and Plan of Care for the Certification Period 8/28/2025 to 10/26/2025. The Home Health Certification and Plan of Care for Certification Period 8/28/2025 to 10/26/2025 documents the following orders for Home Health Aide services: “for assistance with the child’s personal care and ADLS (Activities of Daily Living) secondary to functional limitations,” “Monday, Tuesday and Thursday 4 hours (daily), Friday 9 hours, Saturday 12 hours, Sunday 8 hours;” “increase (home health aide) up to 12 hours (daily) for school closure due to federal holidays, school administrative needs, medical appointments, sick day(s).” The “Pediatric Home Health Aide Plan of Care” lacks documented evidence of a Skilled Professional name, title, and signature, date completed and the patient’s functional limitations, including behavioral challenges. The clinical record lacks documented evidence of an accurate, complete and clear written patient care instructions for a home health aide to follow. On 10/17/2025 at 12:40 PM the Administrator and the Director of Patient Service were interviewed and did not provide an explanation or additional documents for the finding. Patient #7 has a Start of Care date of 9/4/2022 with the diagnoses Autistic Disorder, Muscle Weakness (Generalized), Abnormalities of Gait and Mobility documented in the Home Health Certification and Plan of Care for the Certification Period 8/19/2025 to 10/17/2025. The Home Health Certification and Plan of Care for Certification 8/19/2025 to 10/17/2025 documents the following orders for Home Health Aide services: “for assistance with the child’s personal care and ADLS (Activities of Daily Living) secondary to functional limitations; “Monday - Wednesday 5 hours (daily), Thursday - Friday 7 hours (daily), Saturday - Sunday 12 hours (daily), increase (home health aide) up to 12 hours (daily) for school closure due to federal holidays, school administrative needs, medical appointments, sick day(s);” “patient to be under CG (caregiver/parent) care from August 17, 2025 to August 25, 2025.” The Registered Nurse Pediatric Recertification assessment dated 8/14/2025 documents the following: Patient “is minimal verbal, uses simple phases and gestures to communicate. (Patient) has fine motor delay, mild abnormal walking/gait. Requires prompting and support with ADLS (Activities of Daily Living); “primary focus on (patient’s) safety and assist with ADLS (Activities of Daily Living).” The “HHA (Home Health Aide) Plan of Care” signed and dated 08/14/2025 by the Registered nurse lacks documented evidence that the patient’s behavioral challenges include communication. The clinical record lacks documented evidence of an accurate, complete and clear written patient care instructions for a home health aide to follow. On 10/17/2025 at 12:40 PM the Administrator and the Director of Patient Service were interviewed and did not provide an explanation or additional documents for the finding. Patient #8 has a Start of Care date of 8/22/2025 with the diagnoses Autistic Disorder, Unspecified Intellectual Disabilities, Attention Deficit Hyperactivity Disorder Unspecified Type, Developmental Disorder of Speech and Language Unspecified, Other Forms of Scoliosis documented in the Home Health Certification and Plan of Care for the Certification Period 8/22/2025 to 10/20/2025. The Home Health Certification and Plan of Care for Certification Period 8/22/2025 to 10/20/2025 documents following orders for Home Health Aide services: “for assistance with the child’s personal care and ADLS (Activities of Daily Living) secondary to functional limitations,” “Monday - Friday 11 hours (daily), Saturday - Sunday 12 hours (daily), increase (home health aide) up to 12 hours (daily) for school closure due to federal holidays, school administrative needs, medical appointments, sick day(s).” The Registered Nurse Pediatric Admission assessment dated 8/22/2025 documents the following: patient is “mostly nonverbal, very few words. Ambulates independently with unsteady gait and balance due to Scoliosis;” at “risk for elopement; requires constant supervision." The Speech Therapy evaluation note dated 9/12/2025 documents: parent “reports that pt (patient) can speak in sentences, but only when (patient) wants to/requesting (e.g. ‘I want a snack’). Pt (Patient) will repeatedly request until (patient) needs or met or (patient) will be aggressive (i.e. scratch or hit) people. Pt (Patient) will walk around the house in circles and mumble/make nonspeech sound to (self).” The “Pediatric Home Health Aide Plan of Care” signed and dated 8/22/2025 by the Registered nurse lacks documented evidence of the patient’s behavioral challenges/indication include hyperactive and aggression. The clinical record lacks documented evidence of an accurate, complete and clear written patient care instructions for a home health aide to follow. On 10/17/2025 at 12:40 PM the Administrator and the Director of Patient Service were interviewed and did not provide an explanation or additional documents for the finding. 1. Patient #6 has a Start of Care date of 08/21/2025 with the following diagnoses Autistic Disorder, Unspecified Intellectual Disabilities, Down Syndrome, Unspecified Speech Disturbances, Thyrotoxicosis documented in the Home Health Certification and Plan of Care for the Certification Period 8/21/2025 to 10/19/2025. The Home Health Certification and Plan of Care for Certification Period 8/21/2025 to 10/19/2025 documents the following orders for Home Health Aide services: “ HHA(Home Health Aide) effective 08/24/2025 6wk8 (six times a week for eight weeks); Monday –Saturday 7 hours, increase HHA (Home Health Aide) to 12 hours for school closer due to federal holidays, school administrative needs, medical appointments, sick day(s). Home Health Aide for assistance with the child’s personal care ADL (Activity of Daily Living)’s secondary to functional limitations.” The Pediatric Home Health Aide Plan of Care dated 08/21/2025 lacks documented evidence of patient’s functional limitations, including behavioral challenges. The clinical record lacks documented evidence of an accurate, complete and clear written patient care instructions for a home health aide to follow. On 10/17/2025 at 12:40 PM the Administrator and the Director of Patient Service were interviewed and did not provide an explanation or additional documents for the finding.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (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) 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 paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on clinical record review, and staff interviews, the agency failed to ensure that home health aide receiving onsite supervision every 14 days. This was evident for six (6) of ten (10) clinical records reviewed (Patient: #1,#2, #6, #7, #8, and #10). Failure to ensure that home health aide receiving onsite supervision every 14 days, has the potential for negative patient outcomes. The Findings Are: The “HHA (Home Health Aide) Supervision Frequency for Patients Receiving Skilled and non-Skilled services” Policy (Effective 1/4/2008) documents the following procedure: “If a patient is receiving skilled services from any professional discipline, the Home Health Aide (HHA) must be supervised on-site by the same discipline providing skilled care, at a minimum of once every two weeks. This supervision must be clearly documented in the patient’s medical record;” and “Clinical Managers will monitor compliance.” Patient #2 has a Start of Care date of 1/31/2024 with the diagnoses Autistic Disorder, Developmental Disorder of Scholastic Skills Unspecified, Unspecified Speech Disturbances, Unspecified Intellectual Disabilities documented in the Home Health Certification and Plan of Care for the Certification Period 9/22/2025 to 11/20/2025. The Home Health Certification and Plan of Care for Certification Period 7/24/2025 to 9/21/2025 documents orders for skilled services to include Skilled Nurse, Physical Therapist, Occupation Therapist, and Speech Therapist, and the following orders for Home Health Aide services: “for assistance with the child’s personal care and ADLS (Activities of Daily Living) secondary to functional limitations, Monday - Sunday 12 hours (daily).” The Home Health Certification and Plan(s) of Care for Certification Period 9/22/2025 to 11/20/2025 documents orders for skilled services to include Skilled Nurse, Physical Therapist, Occupation Therapist, and Speech Therapist, and the following orders for Home Health Aide services: “for assistance with the child’s personal care and ADLS (Activities of Daily Living) secondary to functional limitations, Monday - Friday 8 hours (daily), Saturday - Sunday 12 hours (daily).” The Registered Nurse Pediatric Recertification assessment(s) dated 7/22/2025 and 9/17/2025 document the following: “The patient (child) has poor safety awareness and unaware of danger. Patient’s (parent) reports patient has hx (history) of eloping;” “patient has tantrums and hits others when attempts made to go outside” “patient has difficulty staying asleep throughout the night and disturbs others while awake.” The clinical record documents that home health aide service was being provided from 07/24/2025 to 10/04/2025, during the two certification periods. The clinical record documents home health aide supervision was conducted on 7/22/2025 and then on 09/17/2025, fifty-seven (57) days later. The clinical record lacks documented evidence of three supervisory assessment of aide services after 7/22/2025 and of one supervisory assessment of after 09/17/2025, four missed supervisions. The clinical record lacks documented evidence of the aide(s) being supervised every 14 days to ensure services are safely being provided and in accordance with the aide plan of care. There is no documented evidence of the Clinical Manager monitoring the compliance of aide supervision, in accordance with the agency’s policy. On 10/14/2025 at 3:30 PM the Administrator, the Director of Patient Service, and the Director of Compliance and Quality Management were interviewed and did not provide an explanation or additional documents for the finding. Patient #7 has a Start of Care date of 9/4/2022 with the diagnoses Autistic Disorder, Muscle Weakness (Generalized), Abnormalities of Gait and Mobility documented in the Home Health Certification and Plan of Care for the Certification Period 8/19/2025 to 10/17/2025. The Home Health Certification and Plan of Care for Certification 8/19/2025 to 10/17/2025 documents orders for skilled services to include Skilled Nurse and Physical Therapist, and the following orders for Home Health Aide services: “for assistance with the child’s personal care and ADLS (Activities of Daily Living) secondary to functional limitations; “Monday - Wednesday 5 hours (daily), Thursday - Friday 7 hours (daily), Saturday - Sunday 12 hours (daily), increase (home health aide) up to 12 hours (daily) for school closure due to federal holidays, school administrative needs, medical appointments, sick day(s);” “patient to be under CG (caregiver/parent) care from August 17, 2025 to August 25, 2025.” The Registered Nurse Pediatric Recertification assessment dated 8/14/2025 documents the following: Patient “is minimal verbal, uses simple phases and gestures to communicate. (Patient) has fine motor delay, mild abnormal walking/gait. Requires prompting and support with ADLS (Activities of Daily Living); “primary focus on (patient’s) safety and assist with ADLS (Activities of Daily Living).” The clinical record documents the home health aide was supervised during the skilled nurse visit on 08/14/2025. The clinical record documents that home health aide service was being provided from 8/26/2025 to 9/11/2025. The clinical record documents the next aide supervision was on 9/12/2025 during the Physical Therapist visit, 29 days after the supervision on 8/14/2025. The clinical record lacks documented evidence of the aide(s) being supervised every 14 days to ensure services are safely being provided and in accordance with the aide plan of care. There is no documented evidence of the Clinical Manager monitoring the compliance of aide supervision, in accordance with the agency’s policy. On 10/16/2025 at 10:50 AM the Administrator and the Director of Patient Service were interviewed, and the Director of Patient Services stated “I have nothing else” to provide for the finding. Patient #8 has a Start of Care date of 8/22/2025 with the diagnoses Autistic Disorder, Unspecified Intellectual Disabilities, Attention Deficit Hyperactivity Disorder Unspecified Type, Developmental Disorder of Speech and Language Unspecified, Other Forms of Scoliosis documented in the Home Health Certification and Plan of Care for the Certification Period 8/22/2025 to 10/20/2025. The Home Health Certification and Plan of Care for Certification Period 8/22/2025 to 10/20/2025 documents orders for skilled services to include Skilled Nurse, Physical Therapist, Speech Therapist, and Occupational Therapist and the following orders for Home Health Aide services: “for assistance with the child’s personal care and ADLS (Activities of Daily Living) secondary to functional limitations,” “Monday - Friday 11 hours (daily), Saturday - Sunday 12 hours (daily), increase (home health aide) up to 12 hours (daily) for school closure due to federal holidays, school administrative needs, medical appointments, sick day(s).” The Physician Order Dated 09/18/2025 documents the following changes to home health aide visit frequency: Effective 9/15/2025, Monday – Wednesday 3 hours (daily), Thursday 7 hours, Saturday and Sunday 12 hours (daily), Friday discontinued.” The Registered Nurse Pediatric Admission assessment dated 8/22/2025 documents the following: patient is “mostly nonverbal, very few words. Ambulates independently with unsteady gait and balance due to Scoliosis;” at “risk for elopement; requires constant supervision." The Speech Therapy evaluation note dated 9/12/2025 documents: parent “reports that pt (patient) can speak in sentences, but only when (patient) wants to/requesting (e.g. ‘I want a snack’). Pt (Patient) will repeatedly request until (patient) needs or met or (patient) will be aggressive (i.e. scratch or hit) people. Pt (Patient) will walk around the house in circles and mumble/make nonspeech sound to (self).” The clinical record documents that home health aide service was being provided from 8/27/2025 to 10/13/2025. The clinical record lacks documented evidence to the aide being supervised since the start of aide service on 8/27/2025. The clinical record lacks documented evidence of the aide(s) being supervised every 14 days to ensure services are safely being provided and in accordance with the aide plan of care. There is no documented evidence of the Clinical Manager monitoring the compliance of aide supervision, in accordance with the agency’s policy. On 10/16/2025 at 10:50 AM the Administrator and the Director of Patient Service were interviewed, and the Director of Patient Services stated “I have nothing else” to provide for the finding. Patient #10 has a Start of Care date of 8/28/2023 with the diagnoses Autistic Disorder, Unspecified Lack of Expected Normal Physiological Development in Childhood, Bronchopulmonary Dysplasia Origin in the Prenatal Period documented in the Home Health Certification and Plan of Care for the Certification Period 8/17/2025 to 10/15/2025. The Home Health Certification and Plan of Care for Certification Period 8/17/2025 to 10/15/2025 documents orders for skilled services to include Skilled Nurse, Physical Therapist, and Speech Therapist, and the following orders for Home Health Aide services: “for assistance with the child’s personal care and ADLS (Activities of Daily Living) secondary to functional limitations,” “Monday - Friday 5 Hours (daily), Saturday - Sunday 10 Hours (daily), increase (home health aide) up to 12 hours (daily) for school closure due to federal holidays, school administrative needs, medical appointments, sick day(s).” The Registered Nurse Pediatric Recertification assessment dated 8/13/2025 documents the following: “Patient is nonverbal. Caregiver reports ongoing difficulty with daily living activities, including hygiene, dressing and behavior management;” “primary focus on patient’s safety.” The clinical record documents the skilled nurse conducted a supervision of aide services on 8/13/2025 and the Speech Therapist conducted a subsequent supervision on 9/2/2025, twenty (20) days later. The clinical record lacks documented evidence of the aide(s) being supervised every 14 days to ensure services are safely being provided and in accordance with the aide plan of care. There is no documented evidence of the Clinical Manager monitoring the compliance of aide supervision, in accordance with the agency’s policy. On 10/16/2025 at 10:50 AM the Administrator and the Director of Patient Service were interviewed, and the Director of Patient Services stated “I have nothing else” to provide for the finding. Patient #1 has a Start of Care date of 10/09/2025 with the following diagnoses Autistic Disorder, Unspecified Intellectual Disabilities, Other Abnormalities of Gait and Mobility, Congenital Hypotonia documented in the Home Health Certification and Plan of Care for the Certification Period 8/19/2025 to 10/17/2025. The Home Health Certification and Plan of Care for Certification Period 8/19/2025 to 10/17/2025 documents the following orders for Home Health Aide services: “Monday – Friday 6 hours, Saturday -Sunday 8 hours, increase HHA (Home Health Aide) to 12 hours for school closer due to federal holidays, school administrative needs, medical appointments, sick day(s). Home Health Aide for assistance with the child’s personal care ADL(Activity of Daily Living)’s secondary to functional limitations.” The clinical record documents that home health aide service was being provided from 08/31/2025 to 09/18/2025. The clinical record lacks documented evidence to the aide being supervised from 08/31/2025 to 09/18/2025. The clinical record lacks documented evidence of the aide(s) being supervised every 14 days to ensure services are safely being provided and in accordance with the aide plan of care. On 10/16/2025 at 10:50 AM the Administrator and the Director of Patient Service were interviewed and did not provide an explanation for the findings. Patient #6 has a Start of Care date of 08/21/2025 with the following diagnoses Autistic Disorder, Unspecified Intellectual Disabilities, Down Syndrome, Unspecified Speech Disturbances, Thyrotoxicosis documented in the Home Health Certification and Plan of Care for the Certification Period 8/21/2025 to 10/19/2025. The Home Health Certification and Plan of Care for Certification Period 8/19/2025 to 10/17/2025 documents the following orders for Home Health Aide services: “ HHA(Home Health Aide) effective 08/24/2025 6wk8 (six times a week for eight weeks); Monday –Saturday 7 hours, increase HHA (Home Health Aide) to 12 hours for school closer due to federal holidays, school administrative needs, medical appointments, sick day(s). Home Health Aide for assistance with the child’s personal care ADL (Activity of Daily Living)’s secondary to functional limitations.” The clinical record documents that home health aide service was being provided from 8/25/2025 to 10/08/2025. The clinical record lacks documented evidence to the aide being supervised since the start of aide service on 8/25/2025. The clinical record lacks documented evidence of the aide(s) being supervised every 14 days to ensure services are safely being provided and in accordance with the aide plan of care. On 10/16/2025 at 10:50 AM the Administrator and the Director of Patient Service were interviewed and did not provide an explanation for the findings. The “HHA (Home Health Aide) Supervision Frequency for Patients Receiving Skilled and non-Skilled services” Policy (Effective 1/4/2008) documents the following procedure: “If a patient is receiving skilled services from any professional discipline, the Home Health Aide (HHA) must be supervised on-site by the same discipline providing skilled care, at a minimum of once every two weeks. This supervision must be clearly documented in the patient’s medical record;” and “Clinical Managers will monitor compliance.” 1. Patient #1 has a Start of Care date of 10/09/2025 with the following diagnoses Autistic Disorder, Unspecified Intellectual Disabilities, Other Abnormalities of Gait and Mobility, Congenital Hypotonia documented in the Home Health Certification and Plan of Care for the Certification Period 8/19/2025 to 10/17/2025. The Home Health Certification and Plan of Care for Certification Period 8/19/2025 to 10/17/2025 documents the following orders for Home Health Aide services: “Monday – Friday 6 hours, Saturday -Sunday 8 hours, increase HHA (Home Health Aide) to 12 hours for school closer due to federal holidays, school administrative needs, medical appointments, sick day(s). Home Health Aide for assistance with the child’s personal care ADL(Activity of Daily Living)’s secondary to functional limitations.” The clinical record documents home health aide service being provided from 08/31/2025 to 09/18/2025. The clinical record lacks documented evidence of the aide being supervised from 08/31/2025 to 09/18/2025. The clinical record lacks documented evidence of the aide(s) being supervised every 14 days to ensure services are safely being provided and in accordance with the aide plan of care. On 10/16/2025 at 10:50 AM the Administrator and the Director of Patient Service were interviewed and did not provide an explanation for the findings. 2. Patient #6 has a Start of Care date of 08/21/2025 with the following diagnoses Autistic Disorder, Unspecified Intellectual Disabilities, Down Syndrome, Unspecified Speech Disturbances, Thyrotoxicosis documented in the Home Health Certification and Plan of Care for the Certification Period 8/21/2025 to 10/19/2025. The Home Health Certification and Plan of Care for Certification Period 8/21/2025 to 10/19/2025 documents the following orders for Home Health Aide services: “ HHA(Home Health Aide) effective 08/24/2025 6wk8 (six times a week for eight weeks); Monday –Saturday 7 hours, increase HHA (Home Health Aide) to 12 hours for school closer due to federal holidays, school administrative needs, medical appointments, sick day(s). Home Health Aide for assistance with the child’s personal care ADL (Activity of Daily Living)’s secondary to functional limitations.” The clinical record documents the home health aide providing service from 8/25/2025 to 10/08/2025. The clinical record lacks documented evidence of the aide being supervised since the start of aide service on 8/25/2025 to 10/08/2025. The clinical record lacks documented evidence of the aide(s) being supervised every 14 days to ensure services are safely being provided and in accordance with the aide plan of care. On 10/16/2025 at 10:50 AM the Administrator and the Director of Patient Service were interviewed and did not provide an explanation for the findings. 3. Patient #2 has a Start of Care date of 1/31/2024 with the diagnoses Autistic Disorder, Developmental Disorder of Scholastic Skills Unspecified, Unspecified Speech Disturbances, Unspecified Intellectual Disabilities documented in the Home Health Certification and Plan of Care for the Certification Period 9/22/2025 to 11/20/2025. The Home Health Certification and Plan of Care for Certification Period 7/24/2025 to 9/21/2025 documents orders for skilled services to include Skilled Nurse, Physical Therapist, Occupation Therapist, and Speech Therapist, and the following orders for Home Health Aide services: “for assistance with the child’s personal care and ADLS (Activities of Daily Living) secondary to functional limitations, Monday - Sunday 12 hours (daily).” The Home Health Certification and Plan(s) of Care for Certification Period 9/22/2025 to 11/20/2025 documents orders for skilled services to include Skilled Nurse, Physical Therapist, Occupation Therapist, and Speech Therapist, and the following orders for Home Health Aide services: “for assistance with the child’s personal care and ADLS (Activities of Daily Living) secondary to functional limitations, Monday - Friday 8 hours (daily), Saturday - Sunday 12 hours (daily).” The Registered Nurse Pediatric Recertification assessment(s) dated 7/22/2025 and 9/17/2025 documents the following: “The patient (child) has poor safety awareness and unaware of danger. Patient’s (parent) reports patient has hx (history) of eloping;” “patient has tantrums and hits others when attempts made to go outside” “patient has difficulty staying asleep throughout the night and disturbs others while awake.” The clinical record documents home health aide service being provided from 07/24/2025 to 10/04/2025, during the two certification periods. The clinical record documents home health aide supervision was conducted on 7/22/2025 and then on 09/17/2025, fifty-seven (57) days later. The clinical record lacks documented evidence of three supervisory assessment of aide services after 7/22/2025 and of one supervisory assessment of after 09/17/2025, four missed supervisions. The clinical record lacks documented evidence of the aide(s) being supervised every 14 days to ensure services are safely being provided and in accordance with the aide plan of care. There is no documented evidence of the Clinical Manager monitoring the compliance of aide supervision, in accordance with the agency’s policy. On 10/14/2025 at 3:30 PM the Administrator, the Director of Patient Service, and the Director of Compliance and Quality Management were interviewed and did not provide an explanation or additional documents for the finding. 4. Patient #7 has a Start of Care date of 9/4/2022 with the diagnoses Autistic Disorder, Muscle Weakness (Generalized), Abnormalities of Gait and Mobility documented in the Home Health Certification and Plan of Care for the Certification Period 8/19/2025 to 10/17/2025. The Home Health Certification and Plan of Care for Certification 8/19/2025 to 10/17/2025 documents orders for skilled services to include Skilled Nurse and Physical Therapist, and the following orders for Home Health Aide services: “for assistance with the child’s personal care and ADLS (Activities of Daily Living) secondary to functional limitations; “Monday - Wednesday 5 hours (daily), Thursday - Friday 7 hours (daily), Saturday - Sunday 12 hours (daily), increase (home health aide) up to 12 hours (daily) for school closure due to federal holidays, school administrative needs, medical appointments, sick day(s);” “patient to be under CG (caregiver/parent) care from August 17, 2025 to August 25, 2025.” The Registered Nurse Pediatric Recertification assessment dated 8/14/2025 documents the following: Patient “is minimal verbal, uses simple phases and gestures to communicate. (Patient) has fine motor delay, mild abnormal walking/gait. Requires prompting and support with ADLS (Activities of Daily Living); “primary focus on (patient’s) safety and assist with ADLS (Activities of Daily Living).” The clinical record documents the home health aide was supervised during the skilled nurse visit on 08/14/2025. The clinical record documents that home health aide service was being provided from 8/26/2025 to 9/11/2025. The clinical record documents the next aide supervision was on 9/12/2025 during the Physical Therapist visit, 29 days after the supervision on 8/14/2025. The clinical record lacks documented evidence of the aide(s) being supervised every 14 days to ensure services are safely being provided and in accordance with the aide plan of care. There is no documented evidence of the Clinical Manager monitoring the compliance of aide supervision, in accordance with the agency’s policy. On 10/16/2025 at 10:50 AM the Administrator and the Director of Patient Service were interviewed, and the Director of Patient Services stated “I have nothing else” to provide for the finding. 5. Patient #8 has a Start of Care date of 8/22/2025 with the diagnoses Autistic Disorder, Unspecified Intellectual Disabilities, Attention Deficit Hyperactivity Disorder Unspecified Type, Developmental Disorder of Speech and Language Unspecified, Other Forms of Scoliosis documented in the Home Health Certification and Plan of Care for the Certification Period 8/22/2025 to 10/20/2025. The Home Health Certification and Plan of Care for Certification Period 8/22/2025 to 10/20/2025 documents orders for skilled services to include Skilled Nurse, Physical Therapist, Speech Therapist, and Occupational Therapist and the following orders for Home Health Aide services: “for assistance with the child’s personal care and ADLS (Activities of Daily Living) secondary to functional limitations,” “Monday - Friday 11 hours (daily), Saturday - Sunday 12 hours (daily), increase (home health aide) up to 12 hours (daily) for school closure due to federal holidays, school administrative needs, medical appointments, sick day(s).” The Physician Order Dated 09/18/2025 documents the following changes to home health aide visit frequency: Effective 9/15/2025, Monday – Wednesday 3 hours (daily), Thursday 7 hours, Saturday and Sunday 12 hours (daily), Friday discontinued.” The Registered Nurse Pediatric Admission assessment dated 8/22/2025 documents the following: patient is “mostly nonverbal, very few words. Ambulates independently with unsteady gait and balance due to Scoliosis;” at “risk for elopement; requires constant supervision." The Speech Therapy evaluation note dated 9/12/2025 documents: parent “reports that pt (patient) can speak in sentences, but only when (patient) wants to/requesting (e.g. ‘I want a snack’). Pt (Patient) will repeatedly request until (patient) needs or met or (patient) will be aggressive (i.e. scratch or hit) people. Pt (Patient) will walk around the house in circles and mumble/make nonspeech sound to (self).” The clinical record documents that home health aide service was being provided from 8/27/2025 to 10/13/2025. The clinical record lacks documented evidence to the aide being supervised since the start of aide service on 8/27/2025. The clinical record lacks documented evidence of the aide(s) being supervised every 14 days to ensure services are safely being provided and in accordance with the aide plan of care. There is no documented evidence of the Clinical Manager monitoring the compliance of aide supervision, in accordance with the agency’s policy. On 10/16/2025 at 10:50 AM the Administrator and the Director of Patient Service were interviewed, and the Director of Patient Services stated “I have nothing else” to provide for the finding. 6. Patient #10 has a Start of Care date of 8/28/2023 with the diagnoses Autistic Disorder, Unspecified Lack of Expected Normal Physiological Development in Childhood, Bronchopulmonary Dysplasia Origin in the Prenatal Period documented in the Home Health Certification and Plan of Care for the Certification Period 8/17/2025 to 10/15/2025. The Home Health Certification and Plan of Care for Certification Period 8/17/2025 to 10/15/2025 documents orders for skilled services to include Skilled Nurse, Physical Therapist, and Speech Therapist, and the following orders for Home Health Aide services: “for assistance with the child’s personal care and ADLS (Activities of Daily Living) secondary to functional limitations,” “Monday - Friday 5 Hours (daily), Saturday - Sunday 10 Hours (daily), increase (home health aide) up to 12 hours (daily) for school closure due to federal holidays, school administrative needs, medical appointments, sick day(s).” The Registered Nurse Pediatric Recertification assessment dated 8/13/2025 documents the following: “Patient is nonverbal. Caregiver reports ongoing difficulty with daily living activities, including hygiene, dressing and behavior management;” “primary focus on patient’s safety.” The clinical record documents the skilled nurse conducted a supervision of aide services on 8/13/2025 and the Speech Therapist conducted a subsequent supervision on 9/2/2025, twenty (20) days later. The clinical record lacks documented evidence of the aide(s) being supervised every 14 days to ensure services are safely being provided and in accordance with the aide plan of care. There is no documented evidence of the Clinical Manager monitoring the compliance of aide supervision, in accordance with the agency’s policy. On 10/16/2025 at 10:50 AM the Administrator and the Director of Patient Service were interviewed, and the Director of Patient Services stated “I have nothing else” to provide for the finding.

An on-site investigation of complaint #2583085 and complaint #2612245 were conducted at Americare Certified Special Services, Inc., located at 5923 Strickland Avenue, Brooklyn, NY 11234 on 09/15/2025 to 09/16/2025. The survey consisted of a review of (6) clinical records identified as (Patients #1, #2, #3, #4, #5 and #6), two (2) personnel records identified as (Employees #1 and #2), complaint logs for the period from June 2025 to August 2025, active patient census, and pertinent policies and procedures. The active patient census at the time of the survey was 8,561. The agency's Director of Compliance was interviewed. Findings were reviewed at the exit conference on 09/16/2025. The allegations in complaint #2583085 were determined to be substantiated. The allegations in complaint #2612245 were determined to be substantiated. The following deficiencies are identified as a result of the survey: G0598 Discharge Plans Communication G0608 Coordinate Care Delivery

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 clinical record reviews and staff interview, the agency failed to ensure any revision to the patient’s discharge is communicated to the patient and physician. This was evident for one (1) of six (6) clinical records reviewed (Patient #2). Failure to ensure that any revision to the patient’s discharge is communicated to the patient and physician has the potential for negative patient outcomes. The findings are: The agency "Criteria of Discharge - Transfer Discharge Summary" policy and procedure with a reviewed date of 08/04/2025 documents, "A patient is discharged from agency after notification of the authorized practitioner and consultation with the patient and any other professional staff involved in coordinating the plan of care no less than 48 hours prior to patient discharge." 1. Patient #2 has a Start of Care date of 07/15/2025 and discharge date of 08/28/2025 with diagnoses of Essential (Primary) Hypertension, Type 2 Diabetes Mellitus without Complications and Chronic Ischemic Heart Disease, Unspecified documented on the Home Health Certification and Plan of Care with a Certification Period from 07/15/2025 to 09/12/2025. The clinical record documents the last skilled Physical Therapy visit was on 08/26/2025. The patient was discharged from the agency on 08/28/2025. A medical order dated 08/28/2025 documents, "Order Type: Discharge From Agency." There is no documented evidence of the agency informing the patient and the physician no less than 48 hours prior to discharge that the patient would be discharged from the agency on 08/28/2025. On 09/16/2025 at 1:35 PM, the Director of Compliance was interviewed and did not provide an explanation.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on clinical record reviews and staff interview, the agency failed to coordinate care delivery and to involve the patient or representative in coordination of care activities. This was evident for two (2) of six (6) clinical records reviewed (Patients #1 and #2). Failure to ensure patient care delivery is coordinated and involves the patient or representative in the coordination of care activities has the potential for negative patient outcomes. The findings are: 1. Patient #1 has a Start of Care Date of 06/13/2025 and discharge date of 08/11/2025 with diagnoses of Acute Cystitis without Hematuria, Orthostatic Hypotension, and Unspecified Dementia documented on the Home Health Certification and Plan of Care with a Certification Period from 06/13/2025 to 08/11/2025. The patient's home health aide services were provided by a Licensed Home Care Services (LHCSA) vendor agency. A "Member Note" in HHA Exchange with a created date of 08/01/2025 by the LHCSA vendor documents, "Call patient's son (name of son) and apologized due to aide didn't show up. I inform him we looking for someone. Patient's son very upset he said he don't care we need to send some someone asap (as soon as possible). He also want to talk to director." HHA Exchange is a software program that allows communication and data exchange between providers (Certified Home Health Agencies and Licensed Home Care Agencies). There is no documented evidence of the agency coordinating with the vendor agency for any schedule changes or issues that could impact the quality of the home health aide services. On 09/16/2025 at 11:35 AM, the Director of Compliance was interviewed and stated, "there is no alert" (sent to the Americare CSS when a note is entered in HHA Exchange by the vendor) and "someone would have to be actively reviewing (HHA Exchange)." An Occupational Therapy "Visit Note Report" dated 08/08/2025 documents, "Was the NOMNC (Notice of Medicare Non-Coverage) delivered to the patient? No. Specify reason why NOMNC was not delivered to patient: Patient's son (primary caregiver) was unavailable during visit and patient was unable to understand NOMNC due to cognitive impairments." The clinical record documents the last skilled Occupational Therapy visit was on 08/11/2025. The patient was discharged from the agency on 08/11/2025. There is no documented evidence of the agency coordinating with the patient's caregiver to provide the Notice of Medical Care Non-Coverage within two days of terminating the patient's services on 08/11/2025. On 09/16/2025 at 1:35 PM, the Director of Compliance was interviewed and did not provide an explanation. 2. Patient #2 has a Start of Care date of 07/15/2025 and discharge date of 08/26/2025 with diagnoses of Essential (Primary) Hypertension, Type 2 Diabetes Mellitus without Complications and Chronic Ischemic Heart Disease, Unspecified documented on the Home Health Certification and Plan of Care with a Certification Period from 07/15/2025 to 09/12/2025. The Home Health Certification and Plan of Care with a Certification Period from 07/15/2025 to 09/12/2025 (medical orders) documents orders for "HHA 2WK1, 5WK7, 2WK1" (Home Health Aide, 2 times a week for 1 week, 5 times a week for 7 weeks, and 2 times a week for 1 week). The agency's work week is Sunday to Saturday. The home health aide (hha) services for 2 times a week for 1 week should have started the work week of 07/13/2025. The Patient Calendar documents hha services did not start until the following work week of 07/20/2025. The first day the hha provided services was on 07/23/2025. There is no documented evidence the patient was informed of the delay in starting hha services. On 09/16/2025 at 9:40 AM, the Director of Compliance was interviewed and stated, "there should have been a communication" (to the patient about the delay in starting hha services). For the week of 08/17/2025, the patient calendar lacks documented evidence hha services were provided on 08/18/2025 and 08/19/2025. Home Health Aide services resumed on 08/20/2025. On 09/16/2025 at 1:35 PM, the Director of Compliance was interviewed and stated the authorizations (for home health aide services) are provided in two-week intervals and there were no authorizations for 8/18 and 8/19. There is no documented evidence of the agency communicating with the patient the reasons for not providing hha services on 08/18/2025 and 08/19/2025, and when hha services would resume. On 09/16/2025 at 1:35 PM, the Director of Compliance stated it should have been communicated to the patient.

An on-site investigation of Complaint #116513 was conducted at Americare Certified Special Services, Inc, located at 5923 Strickland Avenue, Brooklyn, NY 11234 on 07/21/2025 - 07/22/2025. Three (3) clinical records were reviewed and are identified as (Patient #1, #2 and #3) and three (3) Personnel records were reviewed and are identified as (Employee #1, #2 and #3). The Complaint and Incident Log for the period 02/01/2025 to 07/01/2025, active census, Agency's Policies and Procedure were reviewed. The active patient census is 8341. Interviews were conducted throughout the survey with the Administrator, the Director of Patient Services and the Director of Quality Management/Compliance. The allegations in complaint # 116513 was 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 clinical records review and staff interview the agency failed to complete an investigation of all complaints. This was evident for one (1) of three (3) clinical records reviewed (Patient #1). Failure to complete an investigation of all complaints, has the potential for negative patient outcomes. The Finding Are: 1.Patient #1 has a Start of Care date of 02/14/2023 with the following diagnosis “Autistic Disorder” documented on the Home Health Certification and Plan of Care for Certification Period 02/14/2023 to 04/14/2023, 10/06/2024 to 12/04/2024, 12/05/2024 to 02/02/2025, 02/03/2025 to 04/03/2025, 04/04/2025 to 06/02/2025, and 06/03/205 to 08/01/2025. The Complaint dated 04/03/2025 documents: "Additionally, there were issues with timeliness, and OT (Occupational Therapy) frequently complained about the distance to the patient's house." The email (from mother to the agency) dated 06/10/2025 documents: "This provider was often late to sessions, would no show at times and would often "complain" about the distance of my home as well as location. I reported this to her supervisor and my daughter's coordinator to ensure they were aware." There is no documented evidence of the allegation regarding late sessions being addressed in the complaint investigation on 04/03/2025. On 07/22/2025 at 3:30 PM, the Director of Quality Management/Compliance was interviewed and did not provide an explanation for the findings.

This Statement of Deficiencies is a result of an on-site investigation of Complaints 113864 and 115601 conducted at Americare Certified Special Services, Inc, located at 5923 Strickland Ave., Brooklyn, NY 11234 on 06/25/2025 to 06/26/2025, to evaluate the agency's compliance with Federal and State regulations. The active patient census is 8426. Investigation consisted of a review of six (6) clinical records (identified as Patients #1, #2, #3, #4, #5 and #6), six (6) personnel records (Employees #1, #2, #3, #4, #5 and #6), complaint and incident logs from June 2024 to present, discharges and active patient census, and interviews with the Director of Patient Services and the Director of Quality Management. The allegations in Complaint 113864 and 115601 were determined to be Substantiated. A Statement of Deficiencies will be issued. The following deficiencies are being cited as result of the survey: G0572 – Plan of care G0509 – Promptly alert relevant physician of changes G0598 – Discharge plans communication G0608 – Coordinate care delivery J0508 – Patient Referral and Admission J0544 – Patient Discharge

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 interviews, the agency failed to ensure that each patient receives the services that are documented in the individualized plan of care. This was evident for six (6) of six (6) clinical records reviewed (Patients #1, #2, #3, #4, #5 and #6). Failure to ensure each patient receives the services that are documented in the plan of care has the potential for negative patient outcomes. The findings are: 4. Patient #2 has a Start of Care date of 05/16/2025 with the following diagnoses "Bilateral Primary Osteoarthritis of Knee, History of Falling" documented in the Home Health Certification and Plan of Care for the Certification Period 05/16/2025 to 07/14/2025. The Home Health Certification and Plan of Care for the Certification Period 05/16/2025 to 07/14/2025 documents: “SN (Skilled Nurse) 1WK4, 1EVERY2WK2,1WK1 (once a week for four weeks, once every two weeks two times, once a week for one week); PT (Physical Therapy) effective 5/18/2025 2WK5 (twice a week for five weeks); OT (Occupational Therapy) effective 5/18/2025 2WK1, 1EVERY2WK2 (twice a week for one week, once every two weeks two times).” The clinical record lacks documented evidence of the Skilled Nurse service being provided for the week of 05/18/2025 to 05/24/2025, missed one visit; and the Occupation Therapy being provided for the week of 05/18/2025 to 05/24/2025 missed two visits and for the week of 06/08/2025 to 06/21/2025 missed one visit. There is no documented evidence that the patient receiving the Skilled Nurse and Occupation Therapy services as documented in the individualized plan of care. On 06/26/2025 at 11:10AM, the Director of Quality Management was interviewed and did not provide an explanation for the findings. 5. Patient #5 has a Start of Care date of 04/25/2025 with the following diagnoses “Alzheimer’s Disease, Essential Hypertension” documented in the Home Health Certification and Plan of Care for the Certification Period 04/25/2025 to 06/23/2025. The Home Health Certification and Plan of Care for the Certification Period 04/25/2025 to 06/23/2025 documents: “SN (Skilled Nurse) 1WK2, 1EVERY2WK4, and 1WK1 (once a week for two weeks, once every two weeks four times, once a week for one week); PT (Physical Therapy) effective 04/27/2025 1WK1, 2WK7 (once a week for one week and twice a week for seven weeks). The clinical record lacks documented evidence of the Physical Therapy service being provided for the week of 05/11/2025 to 05/17/2025, missed one visit. There is no documented evidence of the patient receiving the Physical Therapy services as documented in the individualized plan of care. On 06/26/2025 at 11:10AM, the Director of Quality Management was interviewed and did not provide an explanation for the findings. 6. Patient #6 has a Start of Care date of 03/27/2025 with the following diagnoses “Unspecified Dementia, Anxiety Disorder, Essential Hypertension” documented in the Home Health Certification and Plan of Care for the Certification Period 03/27/2025 to 05/25/2025. The Home Health Certification and Plan of Care for the Certification Period 03/27/2025 to 05/25/2025 documents: “SN (Skilled Nurse) 1WK4, 1EVERY2WK4 (once a week for four weeks, once every two weeks four times), and effective 04/20/2025 SN (Skilled Nurse) 1WK2, 1EVERY2WK4 (once a week for two weeks, once every two weeks four twice); PT (Physical Therapy) 1WK1 (once a week for one week), and effective 4/20/2025 1WK1, 2WK4 (once a week for one week, twice a week for four weeks). The clinical record lacks documented evidence of the Skilled Nurse service being provided for the week of 03/30/2025 to 04/05/2025, missed one visit, the week of 04/13/2025 to 04/19/2025, missed one visit, the week of 04/27/2025 to 05/03/2025, missed one visit. The clinical record lacks documented evidence of the Physical Therapy service being provided for the week of 03/23/2025 to 03/29/2025, missed one visit, the week of 04/27/2025 to 05/03/2025, missed one visit, and the week of 05/18/2025 to 05/24/2025, missed one visit. There is no documented evidence that the patient receiving the Skilled Nurse and Physical Therapy services as documented in the individualized plan of care. On 06/26/2025 at 11:10AM, the Director of Quality Management was interviewed and did not provide an explanation for the findings. 1. Patient #1 has a Start of Care date of 08/16/2024 and Discharge Date of 02/11/2025 with the following diagnoses "Traumatic Subdural Hemorrhage Without Loss of Consciousness, Pneumonitis due to Inhalation of Food and Vomit, Unspecified Nondisplaced Fracture of Fifth Cervical Vertebra, Fracture of Orbit, unspecified, Maxillary fracture, unspecified side, Fracture of nasal bones” documented in the Home Health Certification and Plan of Care for the Certification Period (s) 08/16/2024 to 10/14/2024; 10/15/2024 to 12/13/2024; 12/14/2024 to 02/11/2025. The Home Health Certification and Plan of Care for the Certification Period(s) 08/16/2024 to 10/14/2024; 10/15/2024 to 12/13/2024; 12/14/2024 to 02/11/2025 documents “Licensed Professional to report Vital Signs falling outside the following established parameters: Temperature. 99.6 (less than 95, greater than 99.6); Pulse 100 (less than 60, greater than 100); Respiration 20 (less than 12, greater than 20); Systolic BP (Blood Pressure) 40 (less than 90, greater than 140); Diastolic BP (Blood Pressure) 90 ( less than 60 ,greater than 90) and RBS (Random Blood Sugar) 240 (less than 60, greater than 240)." Interim / Supplemental Order No. 345417, Order Date 09/03/2024 documents “Service Changes: Calendar Frequency; OT (occupational Therapy) Effective 09/01/2024: 2WK6 (two times a week for six weeks).” Interim / Supplemental Order No. 345417, Order Date 09/10/2024 documents “Service Changes: Calendar Frequency; PT (Physical Therapy) Effective 09/08/2024: 3WK1 (three times a week for one week); 4WK2 (four times a week for two weeks), 3WK2 (three times a week for 2 weeks) and 1WK1 (once for one week).” The (Occupational Therapy) Evaluation and Visits documents “Vitals: Temp (Temperature): N/A (Not Applicable); Pulse: N/A (Not Applicable); BP (Blood Pressure): N/A (Not Applicable); Resp (Respiration): N/A (Not Applicable)” on the following dates: 08/29/2024, 09/11/2024, 09/12/2024, 09/17/2024, 09/24/2024, 09/26/2024, 10/01/2024, 10/03/2024, 10/08/2024, 10/10/2024, 10/24/2024, 10/31/2024, 11/01/2024, 11/05/2024, 11/12/2024, 11/14/2024, 11/19/2024, 11/21/2024,11/26/2024, 11/28/2024, 12/03/2024, 12/05/2024, 12/10/2024, 12/17/2024, 01/13/2025, 01/22/2025, 01/25/2025, 01/26/2025, 01/28/2025, 02/04/2025, 02/05/2025, and 02/09/2025. The clinical record lacks documented evidence of the patient's vital signs being completed by licensed Occupational Therapist to report if falling outside the established parameters as ordered in the plan of care. The clinical record lacks documented evidence of the Occupational Therapy service being provided as ordered for the week of 09/01/2024 to 09/07/2024, missed two visits, and the week of 09/15/2024 to 09/21/2024 missed one visit. The clinical record lacks documented evidence of the Physical Therapy service being provided as ordered for the week of 09/08/2024 to 09/14/2024, missed two visits, the week of 09/15/2024 to 09/21/2024, missed two visits, and the week of 09/22/2004 to 09/28/2025, missed one visit. There is no documented evidence that the patient received the Occupational Therapy and Physical Therapy services as documented in the individualized plan of care. On 06/26//2025 at 11:10AM, the Director of Quality Management was interviewed and did not provide an explanation for the findings. 2. Patient #3 has a Start of Care date of 02/20/2025 and Discharge Date of 04/10/2025 with the following diagnoses "Hypertensive Chronic Kidney Disease with Stage 1 through Stage 4 chronic kidney disease, or unspecified chronic kidney disease, Chronic Kidney Disease Unspecified, Anxiety Disorder, Unspecified” documented in the Home Health Certification and Plan of Care for the Certification Period 02/20/2025 to 04/20/2025. The Home Health Certification and Plan of Care for the Certification Period 02/20/2025 to 04/20/2025 documents HHA (Home Health Aide) Effective 03/09/2025:4WK1 (four times a week for one week); and 5WK5 (five times a week for five weeks).” Interim / Supplemental Order No. 431754, Order Date 03/06/2025 documents “Service Changes: Calendar Frequency; SN (Skilled Nursing) Effective 03/09/2025: 4WK1 (four times a week for one week); and 1WK5 (once a week for five weeks).” Interim / Supplemental Order No. 452069, Order Date 04/14/2025 documents “Service Changes: Calendar Frequency: HHA (Home Health Aide) Effective 04/06/2025: 3WK1 (three times a week for one week); HHA (Home Health Aide) removed as of 04/10/2025.” The Aide Duty Sheets documents aide services started on 03/25/2025. The clinical record lacks documented evidence of the HHA (Home Health Aide) being provided as ordered for the week of 03/09/2025 to 03/15/2025, missed four visits, the week of 03/16/2025 to 03/22/2025 missed five visits, and the week of 03/23/2025 to 03/29/2025 missed two visits. The clinical record lacks documented evidence of the Skilled Nursing being provided as ordered for the week of 02/23/2025 to 03/01/2025, missed two visits, and the week of 03/09/2025 to 03/15/2025 missed two visits. There is no documented evidence that the patient received the HHA (Home Health Aide) and Skilled Nursing services as written in the individualized plan of care. On 06/26//2025 at 11:10AM, the Director of Quality Management was interviewed and did not provide an explanation for the findings. 3. Patient #4 has a Start of Care date of 04/14/2025 and Resumption of Care date of 06/04/2025 with the following diagnoses: "Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Urinary Tract Infection, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease" documented in the Home Health Certification and Plan of Care for the Certification Period 04/14/2025 to 06/12/2025. The Home Health Certification and Plan of Care for the Certification Period 04/14/2025 to 06/12/2025 documents "PT (Physical Therapy) 2WK2 (two times a week for two weeks); and 1WK5 (once a week for five weeks).” The clinical record lacks documented evidence of the Physical Therapy being provided as ordered for the week of 04/20/2025 to 04/26/2025, missed one visit. There is no documented evidence that the patient received the Physical Therapy services as documented in the individualized plan of care. On 06/26//2025 at 11:10AM, the Director of Quality Management was interviewed and did not provide an explanation for the findings.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on clinical records review and staff interview, the agency failed to promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This was evident for five (5) of six (6) clinical records reviewed (Patients #1, #2, #4, #5 and #6). Failure to ensure the relevant physician(s) or allowed practitioner(s) promptly alerted of any changes in the patient's condition has the potential for negative patient outcomes. The findings are: 3. Patient #2 has a Start of Care date of 05/16/2025 with the following diagnoses "Bilateral Primary Osteoarthritis of Knee, History of Falling" documented in the Home Health Certification and Plan of Care for the Certification Period 05/16/2025 to 07/14/2025. The Home Health Certification and Plan of Care for the Certification Period 05/16/2025 to 07/14/2025 documents: “SN (Skilled Nurse) 1WK4, 1EVERY2WK2,1WK1 (once a week for four weeks, once every two weeks two times, once a week for one week); PT (Physical Therapy) effective 5/18/2025 2WK5 (twice a week for five weeks); OT (Occupational Therapy) effective 5/18/2025 2WK1, 1EVERY2WK2 (twice a week for one week, once every two weeks two times).” The clinical record lacks documented evidence of the Skilled Nurse services being provided for the week of 05/18/2025 to 05/24/2025, missed one visit; and the Occupation Therapy being provided for the week of 05/18/2025 to 05/24/2025 missed two visits, and the week of 06/08/2025 to 06/21/2025 missed one visit. The Client Scheduling Calendar Report documents the following: Monday 05/19/2025; Entered by OT (Occupational Therapist): “No need visit – Schedule change.” Thursday 05/22/2025; Entered by RN (Registered Nurse): “No need visit – Schedule change.” There is no documented evidence of the physician or allowed practitioner being promptly notified of the missed visits and schedule changes. On 06/26//2025 at 11:10AM, the Director of Quality Management was interviewed and stated, “It’s the communication piece that is very important, we planning to have a new department that will put things in place.” 4. Patient #5 has a Start of Care date of 04/25/2025 with the following diagnoses “Alzheimer’s Disease, Essential Hypertension” documented in the Home Health Certification and Plan of Care for the Certification Period 04/25/2025 to 06/23/2025. The Home Health Certification and Plan of Care for the Certification Period 04/25/2025 to 06/23/2025 documents: “SN (Skilled Nurse) 1WK2, 1EVERY2WK4, and 1WK1 (once a week for two weeks, once every two weeks four times, once a week for one week); PT (Physical Therapy) effective 04/27/2025 1WK1, 2WK7 (once a week for one week and twice a week for seven weeks). The clinical record lacks documented evidence of Physical Therapy services being provided for the week of 05/11/2025 to 05/17/2025, missed one visit. The Client Coordination Note Report documents the following: Note Date 05/16/2025: “Date of Missed Visit: 5/16/2025; Discipline: PT (Physical Therapy); Treatment not provided for the following reason: Medical Appointments.; Name of MD Notified: Blank.” The Client Scheduling Calendar Report documents the following: Friday 05/16/2025; Entered by PT (Physical Therapist): “No need visit – Patient had Physician appointment.” There is no documented evidence of the physician or allowed practitioner being promptly notified of the missed visits and schedule changes. On 06/26//2025 at 11:10AM, the Director of Quality Management was interviewed and stated, “It’s the communication piece that is very important, we planning to have a new department that will put things in place.” . Patient #6 has a Start of Care date of 03/27/2025 with the following diagnoses “Unspecified Dementia, Anxiety Disorder, Essential Hypertension” documented in the Home Health Certification and Plan of Care for the Certification Period 03/27/2025 to 05/25/2025. The Home Health Certification and Plan of Care for the Certification Period 03/27/2025 to 05/25/2025 documents: “SN (Skilled Nurse) 1WK4, 1EVERY2WK4 (once a week for four weeks, once every two weeks four times), and effective 04/20/2025 SN (Skilled Nurse) 1WK2, 1EVERY2WK4 (once a week for two weeks, once every two weeks four twice); PT (Physical Therapy) 1WK1 (once a week for one week), and effective 4/20/2025 1WK1, 2WK4 (once a week for one week, twice a week for four weeks). The clinical record lacks documented evidence of the Skilled Nurse services being provided for the week of 03/30/2025 to 04/05/2025, missed one visit, the week of 04/13/2025 to 04/19/2025, missed one visit, and the week of 04/27/2025 to 05/03/2025, missed one visit; and Physical Therapy services being provided for the week of 03/23/2025 to 03/29/2025, missed one visit, the week of 04/27/2025 to 05/03/2025, missed one visit, and the week of 05/18/2025 to 05/24/2025, missed one visit. The Client Coordination Note Reports dated 04/04/2025, 04/17/2025, 04/18/2025, 05/01/2025, and 05/16/2025 documents various Missed Visit Notifications with "Name of MD Notified: None.” There is no documented evidence of the physician or allowed practitioner being promptly notified of the missed visits and schedule changes. On 06/26//2025 at 11:10AM, the Director of Quality Management was interviewed and stated, “It’s the communication piece that is very important, we planning to have a new department that will put things in place.” The Policies and Procedures Title: Coordination of Services, reviewed 09/01/2024 documents on page 1, No. 5 “Americare staff promptly contacts the physician/contact: 5.2 When there are changes in the patient’s expected response to treatment and/or medications. “ 1. Patient #1 has a Start of Care date of 08/16/2024 and Discharge Date of 02/11/2025 with the following diagnoses "Traumatic Subdural Hemorrhage Without Loss of Consciousness, Pneumonitis due to Inhalation of Food and Vomit, Unspecified Nondisplaced Fracture of Fifth Cervical Vertebra, Fracture of Orbit, unspecified, Maxillary fracture, unspecified side, Fracture of nasal bones” documented in the Home Health Certification and Plan of Care for the Certification Period 08/16/2024 to 10/14/2024. The Home Health Certification and Plan of Care for the Certification Period 08/16/2024 to 10/14/2024 documents “PT (Physical Therapy) Effective 08/18/2024: 1WK1 (once for one week); 2WK2 (two times a week for two weeks); 1WK4 (once a week for four weeks).” Interim / Supplemental Order No. 345417, Order Date 09/10/2024 documents “Service Changes: Calendar Frequency; PT (Physical Therapy) Effective 09/08/2024: 3WK1 (three times a week for one week); 4WK2 (four times a week for two weeks), 3WK2 (three times a week for 2 weeks) and 1WK1 (once for one week).” The Client Coordination Note Report documents the following: Note Date 08/20/2024; Entered By (“Name, PT”); “Patient could not be seen yesterday as Scheduler could not confirm if case has been opened due to her computer problems. Visit is being moved to 8/20/2024.” Note Date 08/21/2024: Entered By (“Name, PT”); “Made call to patient’s home yesterday but there was no response. I called back this morning and the call was answered; we agreed to make the visit tomorrow on 8/22/2024.Scheduler (“Name”) accordingly.” Note Date 08/22/2024: Entered By (“Name, PT”); “Patient was seen on 8/22/2024 for PT (Physical Therapy) Evaluation Visit). Patient will benefit from Restorative PT program tentatively 2X2 Weeks (two times a week for two weeks), 1X4 weeks (once a week for four weeks). Received a call from the Doctor 30 (thirty minutes later and received verbal orders from him for continuation of care for the patient.” The Notes dated 09/14/2024, 09/17/2024, 09/19/2024, and 09/24/2024 documents various Missed Visit Notifications with "Name of MD Notified: Blank.” The Client Scheduling Calendar Report documents on 09/06/2024 and 09/13/2024 “PT (Physical Therapy.)-No Need Visit-Schedule Change.” The Client Scheduling Calendar Report dated 09/05/2024, 09/06/2024 and 09/13/2024 documents “OT (Occupational Therapy), No Need Visit-No answer door/phone”, and the Client Scheduling Calendar Report dated 10/29/2024, 11/09/2024, 11/12/2024, 12/12/2024 and 01/15/2025 documents "OT (Occupational Therapy), No Need Visit-Caregiver refused.” The Omit/ Missed Visit dated 01/15/2025 documents’ “Cancellation Details; Therapy Type: OT (Occupational Therapy); Reason for missed visit: Therapist had to cancel session due to inability to attend session in result of acute illness.; Was the Physician notified: No; Was the agency notified: No; Did you try to reschedule: No; Did you drive out to the patient: No.” There is no documented evidence of the physician or allowed practitioner being promptly notified of the missed visits and schedule changes affecting the patient’s expected outcome to the physical and occupational therapy treatment. On 06/26//2025 at 11:10AM, the Director of Quality Management was interviewed and did not provide an explanation for the findings. 2. Patient #4 has a Start of Care date of 04/14/2025 and Resumption of Care date of 06/04/2025 with the following diagnoses: "Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Urinary Tract Infection, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease" documented in the Home Health Certification and Plan of Care for the Certification Period 04/14/2025 to 06/12/2025. The Home Health Certification and Plan of Care for the Certification Period 04/14/2025 to 06/12/2025 documents SN (Skilled Nursing) 1WK2 (once a week for two weeks); and 1EVERY2WK6 (once every two weeks for six weeks).” The Client Coordination Note Report documents the following: Note Date 06/04/2025; Note Type: Medication Interaction; Entered By (“Name, RN”); “Cefpodoxime 100mg (milligram) tablet interacts with Pantoprazole 40mg (milligram) tablet delayed release; Severity Level 2- Severe Interaction; Action is required to reduce the risk of severe adverse interaction.” There is no documented evidence of the physician or allowed practitioner being promptly notified of the medication interaction or needs that suggest that the plan of care should be altered. On 06/26//2025 at 11:10AM, the Director of Quality Management was interviewed and did not provide an explanation for the 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 clinical record review and staff interviews, the governing authority failed to ensure any revision for the patient’s discharges is communicated to the patient, caregivers, and physicians. This was evident for two (2) of six (6) clinical records reviewed (Patients #1and #3). Failure to ensure that any revision for the patient’s discharges is communicated to the patient, caregivers, and physicians has the potential for negative patient outcomes. The findings are: 1. Patient #1 has a Start of Care date of 08/16/2024 and Discharge Date of 02/11/2025 with the following diagnoses "Traumatic Subdural Hemorrhage Without Loss of Consciousness, Pneumonitis due to Inhalation of Food and Vomit, Unspecified Nondisplaced Fracture of Fifth Cervical Vertebra, Fracture of Orbit, unspecified, Maxillary fracture, unspecified side, Fracture of nasal bones” documented in the Home Health Certification and Plan of Care for the Certification Period 12/14/2024 to 02/11/2025. The Policies and Procedures Title: Criteria of Discharge- Transfer Discharge Summary, reviewed 09/07/2024 documents: “A patient is discharged from agency after notification of the authorized practitioner and consultation with the patient and any other professional staff involved in coordinating the plan of care no less than 48 (forty-eight) hours prior to patient discharge. The Patient Welcome Package documents “Admission, Transfer, and Discharge Criteria: Additional Discharge and Transfer Information: Specific Discharge plans are discussed by the Registered Nurse / Therapist with you or your patient representative (if any) at least one (1) week prior to the expected discharge.” The Notice of Medicare Non-Coverage documents " The effective date coverage of your current OT (Occupational Therapy) services will end: 2025-02-10 (February 10, 2025).”, signed by patient’s authorized representative dated 02/09/2025; same day of the patient’s last OT (Occupational Therapy) service on 02/09/2025. The PT (Physical Therapy) Visit Date 02/10/2025, documents “Patient and Spouse notified about planned discharged. Patient will be discharged from Skilled PT (Physical Therapy)", same day of the patient's last PT (physical Therapy) services on 02/10/2025." The Client Coordination Note Report documents the following: Note Date 02/11/2025; Entered By (“Name, PT”); “Patient and spouse notified about planned discharge. Patient discharged from Skilled PT (Physical Therapy) services due to reached maximum rehab potential", same day of the patient’s discharge from the agency on 02/11/2025. Interim / Supplemental Order No. 419623, Order Date: 02/11/2025 documents “Order Type: Discharge from Agency; Order Description: Client no longer requires skill.” The clinical record lacks documented evidence of patient’s discharge plan communication, or any revisions related to the plan with the authorized practitioner and the patient or family prior to the patient’s discharge. On 06/26//2025 at 11:10AM, the Director of Quality Management was interviewed and stated, “Discharge and Transfer procedure is included in the admission welcome packet, “Patient’s name (Patient#1) received the admission packet.” 2. Patient #3 has a Start of Care date of 02/20/2025 and Discharge Date of 04/10/2025 with the following diagnoses "Hypertensive Chronic Kidney Disease with Stage 1 through Stage 4 chronic kidney disease, or unspecified chronic kidney disease, Chronic Kidney Disease Unspecified, Anxiety Disorder, Unspecified” documented in the Home Health Certification and Plan of Care for the Certification Period 02/20/2025 to 04/20/2025. The Client Coordination Note Report documents the following: Note Date 04/07/2025; Note Type: Case Conference: Entered By (“Name, RN”); “Recertifi (Recertification) due to continue wound care.” The clinical record lacks documented evidence of discharge communication or any revisions to the patient’s discharge plan with the authorized practitioner and the patient or family prior to the patient’s discharge on 04/10/2025. On 06/26//2025 at 11:10AM, the Director of Quality Management was interviewed and did not provide an explanation for the findings.

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 and staff interview, the agency failed to coordinate care delivery and to involve the patient in coordination of care activities. This was evident for three (3) of six (6) clinical records reviewed. (Patients #1, #2 and #6). Failure to ensure patient care delivery is coordinated and involves the patient in the coordination of care activities, has the potential for negative patient outcome. The findings are: 2. Patient #2 has a Start of Care date of 05/16/2025 with the following diagnoses "Bilateral Primary Osteoarthritis of Knee, History of Falling" documented in the Home Health Certification and Plan of Care for the Certification Period 05/16/2025 to 07/14/2025. The Home Health Certification and Plan of Care for the Certification Period 05/16/2025 to 07/14/2025 documents: “OT (Occupational Therapy) effective 5/18/2025 2WK1, 1EVERY2WK2 (twice a week for one week, once every two weeks two times).” The clinical record lacks documented evidence of Occupational Therapy being provided week the week of 05/18/2025 to 05/24/2025, two missed visits and the weeks 06/08/2025 to 06/21/2025 one missed visit. The “Occupation Therapy add-on evaluation” dated 06/06/2025 documents the Occupational Therapy evaluation was conducted on 06/06/2025, more than two weeks after the effective date of 05/18/2025. The clinical record lacks documented evidence of the agency informing the patient of the delay in providing Occupational Therapy services. There is no documented evidence of the agency coordinating care delivery and involving the patient in changes in services to be furnished. On 06/26/2025 at 11:10AM, the Director of Quality Management were interviewed and did not provide an explanation for the findings. 3. Patient #6 has a Start of Care date of 03/27/2025 with the following diagnoses “Unspecified Dementia, Anxiety Disorder, Essential Hypertension” documented in the Home Health Certification and Plan of Care for the Certification Period 03/27/2025 to 05/25/2025. The Home Health Certification and Plan of Care for the Certification Period 03/27/2025 to 05/25/2025 documents: “PT (Physical Therapy) 1WK1 (once a week for one week), and effective 4/20/2025 1WK1, 2WK4 (once a week for one week, twice a week for four weeks). The clinical record lacks documented evidence of physical therapy service being provided the week of 03/23/2025 to 03/29/2025, one missed visit. The Client Coordination Note Report dated 04/04/2025 documented a note by (GA), Physical Therapist: “Please be informed that patient was unreachable despite several attempts.” On 06/26/2025 the agency’s Complaint and Incident logs were reviewed. The Complaint and Incident logs documents Patient’s #6 complaint/incident on 04/22/2025: “The patient has not received any phone calls from the Rehab Department. She is in need of physical therapy services and is very disappointed with the lack of follow up.” QM (Quality Manager) investigation documented: “04/04/2025, it has been reported by Physical Therapist (GA), that patient declined PT (Physical Therapy) services. 04/22/2025 QM service call made, and patient confirmed of needing the PT services. The clinical record lacks documented evidence of the agency informing the patient of the delay in providing physical therapy services. There is no documented evidence of the agency coordinating care delivery and involving the patient in changes in services to be furnished, as specified in the agency's coordination policies. On 06/26/2025 at 11:10AM, the Director of Quality Management were interviewed and did not provide an explanation for the findings. The agency's "Coordination of Patient Care" Policy documents: "Coordination of Agency's internal resources includes Notifying the patient in a timely manner about schedule changes." The agency's "Coordination of Services" Policy documents: "Coordination of services activities is documented in the patient's home care record. Each record shall contain up-to-date information regarding: Communication between involved parties." 1.Patient #1 has a Start of Care date of 08/16/2024 and Discharge Date of 02/11/2025 with the following diagnoses "Traumatic Subdural Hemorrhage Without Loss of Consciousness, Pneumonitis due to Inhalation of Food and Vomit, Unspecified Nondisplaced Fracture of Fifth Cervical Vertebra, Fracture of Orbit, unspecified, Maxillary fracture, unspecified side, Fracture of nasal bones” documented in the Home Health Certification and Plan of Care for the Certification Period (s) 08/16/2024 to 10/14/2024; 10/15/2024 to 12/13/2024; 12/14/2024 and 02/11/2025. The Client Coordination Note Report documents the following: Note Date 08/22/2024: Entered By (“Name, PT”); “Patient was seen on 8/22/2024 for PT (Physical Therapy) Evaluation Visit). Patient will benefit from Restorative PT program tentatively 2X2 Weeks (two times a week for two weeks), 1X4 weeks (once a week for four weeks). Received a call from the Doctor 30 (thirty minutes later and received verbal orders from him for continuation of care for the patient.” The Notes dated 09/14/2024, 09/17/2024, 09/19/2024, and 09/24/2024 documents various Missed Visit Notifications with "Name of MD Notified: Blank.” The Client Scheduling Calendar Report documents on 09/06/2024 and 09/13/2024 “No Need Visit-Schedule Change PT (Physical Therapy.)” Interim / Supplemental Order No. 341668, Order Date: 09/03/2024 documents “Order Description OT (Occupational Therapy) 1WK1 (once for one week)-Service Delay due to no available OT (Occupational Therapy) to service area/ referred to outside vendor; Service Changes: Calendar Frequency: OT (Occupational Therapy) Effective 08/25/2024, 1WK1 (once for one week)” Interim / Supplemental Order No. 367338, Order Date: 10/28/2024 documents “Order Description OT (Occupational Therapy) 1WK1 (once for one week) for Eval (Evaluation)-Service Delay due to no available OT (Occupational Therapy) to service area/ referred to outside vendor; Service Changes: Calendar Frequency: OT (Occupational Therapy) Effective 08/25/2024, 1WK1 (once for one week).” Interim / Supplemental Order No. 400041, Order Date: 01/06/202 documents “Order Description OT (Occupational Therapy) 1WK1 (once for one week) for Eval (Evaluation)-Service Delay due to no available OT (Occupational Therapy) to service area/ referred to outside vendor; Service Changes: Calendar Frequency: OT (Occupational Therapy) Effective 01/05/2025, 1WK1 (once for one week).” The Client Scheduling Calendar Report dated 09/05/2024, 09/06/2024 and 09/13/2024 documents “OT (Occupational Therapy), No Need Visit-No answer door/phone”, and the Client Scheduling Calendar Report dated 10/29/2024, 11/09/2024, 11/12/2024, 12/12/2024 and 01/15/2025 documents "OT (Occupational Therapy), No Need Visit-Caregiver refused.” The Omit/ Missed Visit dated 01/15/2025 documents’ “Cancellation Details; Therapy Type: OT (Occupational Therapy); Reason for missed visit: Therapist had to cancel session due to inability to attend session in result of acute illness.; Was the Physician notified: No; Was the agency notified: No; Did you try to reschedule: No; Did you drive out to the patient: No.” There is no documented evidence of the coordination of care with the patient or family for the delay in services, schedule changes and missed visits. On 06/26//2025 at 11:10AM, the Director of Quality Management was interviewed and stated, “It’s the communication piece that is very important, as we plan to put a new department in place.”

This Statement of Deficiencies is a result of an on-site investigation of Complaints 111788, 112084, 112091, 112448 conducted at Americare Certified Special Services, Inc, located at 5923 Strickland Ave., Brooklyn, NY 11234 on 01/23/2025 to 01/24/2025, to evaluate the agency's compliance with Federal and State regulations. The active patient census is 7,174. Investigation consisted of a review of eight (8) clinical records (identified as Patients #1, #2, #3, #4, #5, #6, #7, and #8), seven (7) personnel records (Employees #1, #2, #3, #4, #5, #6, and #7), complaint and incident logs from October to present, discharges, and active patient census, and interviews with the Director of Patient Services and the Director of Quality Management. The allegations in Complaint 111788, 112084, 112091, and 112448 were determined to be Substantiated. A Statement of Deficiencies will be issued. The following deficiencies are being cited as result of the survey: G - 0514 – RN performs assessment G - 0528 – Health, psychosocial, functional, cognition G - 0548 - Within 48 hours of the patient's return G - 0550 - At discharge G - 0572 - Plan of care G - 0574 - Plan of care must include the following G - 0598 - Discharge plans communication G - 0608 - Coordinate care delivery G - 0610 - Patients receive education and training G - 0962 - Coordinate patient care

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 clinical record review and staff interviews, the governing authority failed to ensure an initial assessment was conducted within 48 hours of referral, or within 48 hours of the patient’s return home. This was evident for two (2) of eight (8) clinical records reviewed (Patients #3 and #6). Failure to ensure an initial assessment is held either within 48 hours of referral, or within 48 hours of the patient’s return home has the potential for negative patient outcomes. The findings are: 1. Patient #3 has a Start of Care date of 12/27/2024 with the following diagnoses "Unspecified Open Wound Left Foot, Type 2 Diabetes Mellitus" documented in the Home Health Certification and Plan of Care for the Certification Period 12/27/2024 to 02/24/2025. The Client Coordination Note Report documents: 12/20/2024 “SOC (start of care) date 12/23.” 12/23/2024 “I have been trying to reach this patient since 7am, but the phone numbers on file were completely different. Finally the patient answered and said that he was expecting a nurse tomorrow.” 12/24/2024 “Called patient several times in the morning. Left a vm (voice mail) for a call back.” “Patient called me back at 7:21PM asking why I didn’t go, told him that we have tried several times and he didn’t respond. He will wait for a nurse to go over tomorrow.” 12/25/2024 “no answer left VML (voicemail).” The Policy and Procedure for Delayed in Services Process documents: “If the delayed service is critical to the patient’s health (e.g., wound care, medication administration, injections), the situation should be escalated immediately to ensure no further impact on the patient’s condition.” “The Clinical Manger should be notified for further guidance, particularly if the delay involves high-priority care.” The clinical record lacks documented evidence of the initial assessment visit within 48 hours of referral. There is no documented evidence of the follow up and the escalation to the clinical managers. On 01/23/2025 at 3:30PM, the Director of Patient Services and the Director of Quality Management were interviewed and stated, “Our policy is if the patient did not answer the phone, we have to go in the home”, no further explanation for the findings. 2. Patient #6 has a Start of Care date of 12/02/2024 with the following diagnoses "Ventricular Flutter, Unspecified Atrial Fibrillation" documented in the Home Health Certification and Plan of Care for the Certification Period 12/02/2024 to 01/30/2025. The Referral Information documents: Discharge Date 11/28/2024. The Client Coordination Note Report documents: 11/29/2024 "SOC (start of care) date change; Reason: confirmed with patient; New Date: 12/2." There is no documented evidence of the reason for the change in the start of care and the notification to the physician. The clinical record lacks documented evidence of the initial assessment visit within 48 hours of referral. On 01/23/2025 at 3:30PM, the Director of Patient Services and the Director of Quality Management were interviewed and confirmed findings.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: (1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interviews, the governing authority failed to ensure an accurate reflection of the patient’s current status. This was evident for two (2) of eight (8) clinical records reviewed (Patients #3 and #4). Failure to ensure an accurate reflection of the patient’s current status has the potential for negative patient outcomes. The findings are: 1. Patient #3 has a Start of Care date of 12/27/2024 with the following diagnoses "Unspecified Open wound Left Foot, Type 2 Diabetes Mellitus" documented in the Home Health Certification and Plan of Care for the Certification Period 12/27/2024 to 02/24/2025. The Home Health Certification and Plan of Care for the Certification Period 12/27/2024 to 02/24/2025 documents: “Wound care cleanse with Vashe Solution, apply Aquacel AG dressing, cover with gauze, Kling, secure with paper tape.” “Skilled nurse to perform/teach wound care, Cleanse with Vashe Solution, apply Aquacel AG Dressing, cover with gauze, Kling, secure with paper tape, using clean/aseptic technique. Change dressing every day and PRN.” The Visit Note Report documents: 12/27/2024 “#1 Lat Lt Prox (Lateral Left Proximal) Great Toe; Indicate Type: Closed Surg (surgical); Epithelialization: 50-25%; Epithelialization: 50-<75%; Necrotic Tissue Type: Sft Bl ( soft blister); Necrotic Tissue Amount: None.” The comprehensive assessment lacks documented evidence of an accurate description of the wound: #1 with yellow necrosis and no amount; #2 missing location of wound – which part of dorsum and with soft blister but with granulation and epithelialization. There is no documented evidence of an accurate reflection of the patient’s current status. On 01/23/2025 at 3:30PM, the Director of Patient Services and the Director of Quality Management were interviewed and did not provide an explanation for the findings. 2. Patient #4 has a Start of Care date of 11/29/2024 with the following diagnoses "Pain due to Internal Orthopedic Prosthesis, Type 2 Diabetes Mellitus, Hyperlipidemia" documented in the Home Health Certification and Plan of Care for the Certification Period 11/29/2024 to 01/27/2025. The Visit Note Report documents Rt (right) – Prox (proximal) Thigh on: 11/29/2024 “Indicate Type: Closed Surg (surgical); Epithelialization: 75-<100%.” 12/11/2024 “Indicate Type: Susp (suspected) DTI (deep tissue injury); Epithelialization: 100%; Necrotic Tissue Type and Amount: None.” The comprehensive assessment lacks documented evidence of an accurate description of the wound: suspected deep tissue injury but the description is closed (100% epithelialization) and no signs of deep tissue injury. There is no documented evidence of an accurate reflection of the patient’s current status. On 01/23/2025 at 3:30PM, the Director of Patient Services and the Director of Quality Management were interviewed and did not provide an explanation for the findings.

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interviews, the governing authority failed to ensure an update of the comprehensive assessment within 48 hours of the patient’s return to the home from a hospital admission. This was evident for one (1) of eight (8) clinical records reviewed (Patient #8). Failure to ensure an update of the comprehensive assessment within 48 hours of the patient’s return to the home from a hospital admission has the potential for negative patient outcomes. The findings are: 1. Patient #8 has a Start of Care date of 11/19/2024 with the following diagnoses "ST Elevation Myocardial Infarction, Paroxysmal Atrial Fibrillation" documented in the Home Health Certification and Plan of Care for the Certification Period 11/19/2024 to 01/17/2025. The Printable Discharge Form dated 12/23/2024 documents: “Referral, Date First Sent: 12/23/2024, Referral Type: Home Health Care Services; Admission Date: 12/18/2024." Th Client Coordination Note Report documents: 01/02/2025 “Date of missed visit: 1/2/25; Discipline: SN (skilled nurse); Treatment not provided for the following reason: patient has a medical appointment today.” 01/04/2025 “Date of missed visit: 1/4/25; Discipline: SN (skilled nurse); Treatment not provided for the following reason: Called main number and (name) contact, but no answer. Voicemail left, but no call back received.” 01/07/2025 “Date of missed visit: 1/6/25; Discipline: SN (skilled nurse); Treatment not provided for the following reason: schedule change.” 01/09/2025 “Hospitalized (12/18/24 – 12/31/24) for sepsis”. The Medical Order dated 1/8/2025 documents: "Resumption of Care." There is no documented evidence of the resumption OASIS was completed within 48 hours of the patient’s return to the home. On 01/24/2025 at 12:00PM, the Director of Patient Services and the Director of Quality Management were interviewed and did not provide an explanation for the findings.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interviews, the governing authority failed to ensure an update of the comprehensive assessment at discharge. This was evident for four (4) of eight (8) clinical records reviewed (Patients #1, #2, #7 and #8). Failure to ensure an update of the comprehensive assessment at discharge has the potential for negative patient outcomes. The findings are: 2. Patient #1 has a Start of Care date of 09/30/2024 with the following diagnoses "Atrial Fibrillation, Sepsis due to Enterococcus" documented in the Home Health Certification and Plan of Care for the Certification Period 09/30/2024 to 11/28/2024. The Home Health Certification and Plan of Care for the Certification Period 09/30/2024 to 11/28/2024 documents: “PT (physical therapy) effective 10/06/2024 1WK2 (once a week for 2 weeks), 2WK4 (twice a week for 4 weeks), 1WK2 (once a week for 2 weeks.” The clinical record documents physical therapy was provided on 11/21/2024 and a missed visit on 11/28/2024, no answer at the door. There is no documented evidence of an update of the comprehensive assessment at discharge (no discharge OASIS) for Certification Period ending on 11/28/2024. On 01/23/2025 at 3:30PM, the Director of Patient Services and the Director of Quality Management were interviewed and did not provide an explanation for the findings. 3. Patient #2 has a Start of Care date of 11/12/2024 with the following diagnoses "Spondylosis with Radiculopathy Lumbar Region, Type 2 Diabetes Mellitus" documented in the Home Health Certification and Plan of Care for the Certification Period 11/16/2024 to 01/14/2025. The Visit Note Report – PT (physical therapy Discharge Data Collection Only – no visit made dated 11/25/2024 documents: “This Assessment is currently being completed for the following reason: Discharge from agency; Date completed with physical therapy signature 01/05/2025.” The Medical Order dated 12/30/2024 documents: "Patient unable to be contacted by clinicians after multiple attempts. Case DC (discharge) from Americare Certified Special Services a/o (as of) last visit 11/25/24.” The clinical record documents visit with skilled nurse on 11/16/2024 and 11/21/2024, occupational therapy on 11/22/2024, and physical therapy on 11/25/2024. There is no documented evidence that the discharge OASIS was completed within two days. There is no documented evidence of an update of the comprehensive assessment at discharge in a timely manner On 01/23/2025 at 3:30PM, the Director of Patient Services and the Director of Quality Management were interviewed and did not provide an explanation for the findings. 4. Patient #8 has a Start of Care date of 11/19/2024 with the following diagnoses "ST Elevation Myocardial Infarction, Paroxysmal Atrial Fibrillation" documented in the Home Health Certification and Plan of Care for the Certification Period 11/19/2024 to 01/17/2025. The Medical Order dated 12/19/2024 documents: “Patient admitted at NYP (New York Presbyterian) lower Manhattan Hospital on12/18/24.” There is no documented evidence of the transfer OASIS being completed within 2 days after the knowledge of patient’s hospitalization on 12/19/2024. There is no documented evidence of an update of the comprehensive assessment at discharge to hospital – transfer to an inpatient facility (OASIS assessment timeframe: within 2 calendar days of transfer date to inpatient facility). On 01/24/2025 at 12:00PM, the Director of Patient Services and the Director of Quality Management were interviewed and did not provide an explanation for the findings. 1. Patient #7 has a Start of Care date of 11/11/2024 with the following diagnoses "Parkinson’s Disorder, Essential Hypertension" documented in the Home Health Certification and Plan of Care for the Certification Period 11/11/2024 to 01/09/2025. The clinical record documents occupational therapy was provided on 12/16/2024, and patient decline services with physical therapy on 12/28/2024 and 12/31/2024, no other services provided from 12/17/2024 to the present. There is no documented evidence of an update of the comprehensive assessment at discharge (no discharge OASIS) for Certification Period ending on 01/09/2025. On 01/24/2025 at 12:00PM, the Director of Patient Services and the Director of Quality Management 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 interviews, the governing authority failed to ensure that each patient must receive the services that are written in the individualized plan of care. This was evident for seven (7) of eight (8) clinical records reviewed (Patients #1, #2, #4, #5, #6, #7, and #8). Failure to ensure each patient must receive the services that are written in the plan of care has the potential for negative patient outcomes. The findings are: 5. Patient #1 has a Start of Care date of 09/30/2024 with the following diagnoses "Atrial Fibrillation, Sepsis due to Enterococcus" documented in the Home Health Certification and Plan of Care for the Certification Period 09/30/2024 to 11/28/2024. The Home Health Certification and Plan of Care for the Certification Period 09/30/2024 to 11/28/2024 documents: “SN (skilled nurse) 1WK1 (once for one week), 1 every 3WK3 (once every three weeks for three weeks), 1 every 2WK2 (once every two weeks for two weeks).” “HHA (home health aide) 2WK1 (twice a week for one week), 5WK7 (five times a week for seven weeks), 2WK1 (twice a week for one week).” The Client Coordination Note Report dated 10/02/2024 documents: “Pt (patient) eval (evaluation) SN (skilled nurse) 1W3 (once a week for three weeks) cardiac assessment safety at home Dementia care education.” The plan of care lacks documented evidence of the skilled nurse services frequency change from the initial orders. The clinical record lacks documented evidence of aide services being provided 09/30/2024 to 10/05/2024, missed two visits; and 10/06/2024 to 10/12/2024, missed five visits. There is no documented evidence that the patient received the services that are written in the individualized plan of care. On 01/23/2025 at 3:30PM, the Director of Patient Services and the Director of Quality Management were interviewed and did not provide an explanation for the findings. 6. Patient #2 has a Start of Care date of 11/12/2024 with the following diagnoses "Spondylosis with Radiculopathy Lumbar Region, Type 2 Diabetes Mellitus" documented in the Home Health Certification and Plan of Care for the Certification Period 11/16/2024 to 01/14/2025. The Home Health Certification and Plan of Care for the Certification Period 11/16/2024 to 01/14/2025 documents: “SN (skilled nurse) 1WK2 (once a week for two weeks), 1 every 2WK4 (once every two weeks for four weeks).” The Medical Order dated 12/30/2024 documents: "Patient unable to be contacted by clinicians after multiple attempts. Case DC (discharge) from (Americare Certified Special Services) a/o (as of) last visit 11/25/24.” The clinical record lacks documented evidence of the skilled nurse visit for the once every two weeks for four weeks on 11/24/2024 to 12/07/2024, missed one visit; and 12/08/2024 to 12/21/2024, missed one visit. The clinical record lacks documented evidence of the multiple attempts of the clinician visits being documented. There is no documented evidence that the patient received the services that are written in the individualized plan of care. On 01/23/2025 at 3:30PM, the Director of Patient Services and the Director of Quality Management were interviewed and did not provide an explanation for the findings. 7. Patient #8 has a Start of Care date of 11/19/2024 with the following diagnoses "ST Elevation Myocardial Infarction, Paroxysmal Atrial Fibrillation" documented in the Home Health Certification and Plan of Care for the Certification Period 11/19/2024 to 01/17/2025. The Home Health Certification and Plan of Care for the Certification Period 11/19/2024 to 01/17/2025 documents: “SN (skilled nurse) 1WK2 (once a week for two weeks), 1 every 2WK6 (once every 2 weeks for 6 weeks); HHA (home health aide) 1WK1 (once a week for one week), 3WK7 (three times a week for seven weeks).” The Medical Order – Resumption of Care dated 01/08/2025 documents: “HHA (home health aide) effective 01/05/2025 1WK1 (once a week for one week).” The Duty Sheets lacks documented evidence of aide services being provided on 11/19/2024 to 11/23/2024, missed one visit; 11/24/2024 to 11/30/2024, missed three visits; and 01/05/2025 to 01/11/2025, missed one visit. On 01/24/2025 at 12:00PM, the Director of Patient Services and the Director of Quality Management were interviewed and did not provide an explanation for the findings. 1. Patient #4 has a Start of Care date of 11/29/2024 with the following diagnoses "Pain due to Internal Orthopedic Prosthesis, Type 2 Diabetes Mellitus, Hyperlipidemia" documented in the Home Health Certification and Plan of Care for the Certification Period 11/29/2024 to 01/27/2025. The Home Health Certification and Plan of Care for the Certification Period 11/29/2024 to 01/27/2025 documents: “PT (physical therapy) effective 12/01/2024 2WK7 (twice a week for seven weeks).” The clinical record lacks documented evidence of the Physical therapy being provided between 01/05/2025 to 01/11/2025, missed two visits. There is no documented evidence that the patient received the services that are written in the individualized plan of care. On 01/23/2025 at 3:30PM, the Director of Patient Services and the Director of Quality Management were interviewed and did not provide an explanation for the findings. 2. Patient #5 has a Start of Care date of 12/20/2024 with the following diagnoses "Mitral Valve Insufficiency, Chronic Atrial Fibrillation" documented in the Home Health Certification and Plan of Care for the Certification Period 12/20/2024 to 02/17/2024. The Client Coordination Note Report documents: 12/20/2024 “We have received your case for PT (physical therapy) and are currently working on placement. When a therapist has been assigned to your case you should receive a call directly from them to schedule the evaluation.” 12/23/2024 “PT (physical therapy) for eval (evaluation) and assessment.” 12/30/2024 “Date of missed visit: 12/27; Discipline: Physical Therapy; Treatment not provided for the following reason: Schedule change.” There is no documented evidence of the order for the physical therapy missed visit on 12/27/2024. The Medical Order documents: 12/26/2024 “hha (home health aide) effective 12/22/2024 2WK1 (twice a week for one week).” 01/10/2025 “Hha (home health aide) effective 01/12/2025 5WK3, 4WK1 (five times a week for three weeks, four times a week for one week).” The clinical record lacks documented evidence of aide services being provided from 12/22/2024 to 12/28/2024, missed two visits and 01/12/2025 to 01/18/2025, missed five visits. There is no documented evidence that the patient received the services that are written in the individualized plan of care. On 01/24/2025 at 12:00PM, the Director of Patient Services and the Director of Quality Management were interviewed and did not provide an explanation for the findings. 3. Patient #6 has a Start of Care date of 12/02/2024 with the following diagnoses "Ventricular Flutter, Unspecified Atrial Fibrillation" documented in the Home Health Certification and Plan of Care for the Certification Period 12/02/2024 to 01/30/2025. The Home Health Certification and Plan of Care for the Certification Period 12/02/2024 to 01/30/2025 documents: “OT (occupational therapy) effective 12/22/2024 1WK1 (once a week for one week); hha (home health aide) effective 12/08/2024 4WK1, 5WK1, 1WK1, 5WK4 (four times a week for one week, five times a week for one week, once a week for one week, five times a week for four weeks).” The clinical record lacks documented evidence of occupation therapy being provided week 12/22/2024 to 12/28/2024, missed one visit; 12/29/2024 to 01/04/2025, missed one visit; and aide services week 12/15/2024 to 12/21/2024, missed one visit; 01/05/2025 to 01/11/2025, missed four visits; and 1/12/2025 to 01/18/2025, missed five visits. There is no documented evidence that the patient received the services that are written in the individualized plan of care. On 01/23/2025 at 3:30PM, the Director of Patient Services and the Director of Quality Management were interviewed and did not provide an explanation for the findings. 4. Patient #7 has a Start of Care date of 11/11/2024 with the following diagnoses "Parkinson’s Disorder, Essential Hypertension" documented in the Home Health Certification and Plan of Care for the Certification Period 11/11/2024 to 01/09/2025. The Home Health Certification and Plan of Care for the Certification Period 11/11/2024 to 01/09/2025 documents: “SN (skilled nurse) 1WK4 (once a week for four weeks); PT (physical therapy) 2WK8, 1WK1 (twice a week for eight weeks, once a week for one week).” The clinical record lacks documented evidence of skilled nurse services being provided week 11/17/2024 to 11/23/2024, missed one visit; 11/24/2024 to 11/30/2024; missed one visit; 12/01/2024 to 12/07/2024; missed one visit; and physical therapy week 12/15/2024 to 12/21/2024, missed two visits; 12/22/2024 to 12/28/2024, missed one visit; 12/29/2024 to 01/04/2025, missed one visit; and 01/05/2025 to 01/09/2025, missed one visit. There is no documented evidence that the patient received the services that are written in the individualized plan of care. On 01/23/2025 at 3:30PM, the Director of Patient Services and the Director of Quality Management 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 interviews, the governing authority failed to ensure that the individualized plan of care must include all medications and treatments. This was evident for two (2) of eight (8) clinical records reviewed (Patients #3 and #4). Failure to ensure that the individualized plan of care includes all medications and treatments has the potential for negative patient outcomes. The findings are: 1. Patient #3 has a Start of Care date of 12/27/2024 with the following diagnoses "Unspecified Open Wound Left Foot, Type 2 Diabetes Mellitus" documented in the Home Health Certification and Plan of Care for the Certification Period 12/27/2024 to 02/24/2025. The Home Health Certification and Plan of Care for the Certification Period 12/27/2024 to 02/24/2025 documents: “SN (skilled nurse) 1WK1, 2WK1, 1WK1, 3WK6, 1WK1 (once a week for one week, twice a week for one week, once a week for one week, three times a week for six weeks, once a week for one week).” “Wound care cleanse with Vashe Solution, apply Aquacel AG dressing, cover with gauze, Kling, secure with paper tape.” “Skilled nurse to perform/teach wound care, Cleanse with Vashe Solution, apply Aquacel AG Dressing, cover with gauze, Kling, secure with paper tape, using clean/aseptic technique. Change dressing every day and PRN (as needed).” The Visit Note Report dated 12/27/2024 documents: “#1 Lat Lt Prox (Lateral Left Proximal) Great Toe; Indicate Type: Closed Surg (surgical)” “#2 Med (medial) Dorsum, Mid. Lt (middle left)”. The plan of care lacks documented evidence of the site (for the first order) and the frequency for the wound treatment. There is no documented evidence of a complete individualized plan of care. On 01/23/2025 at 3:30PM, the Director of Patient Services and the Director of Quality Management were interviewed and did not provide an explanation for the findings. 2. Patient #4 has a Start of Care date of 11/29/2024 with the following diagnoses "Pain due to Internal Orthopedic Prosthesis, Type 2 Diabetes Mellitus, Hyperlipidemia" documented in the Home Health Certification and Plan of Care for the Certification Period 11/29/2024 to 01/27/2025. The Home Health Certification and Plan of Care for the Certification Period 11/29/2024 to 01/27/2025 documents: “Skilled Nurse to observe and assess integumentary status to identify changes and intervene to minimize complications. Skilled Nurse to provide skilled teaching related to altered skin integrity including pathophysiology, nutrition, medication regimen. Skilled nurse to report significant changes in status to physician for early intervention.” The Visit Note Report documents: 11/29/2024 “On the Right Leg, the outer side of the thigh, there is a surgical incision of about 20 intimators. The incision has no visible symptoms of infection. No any other wound observed. There is no order from the doctor to treat the wound. According to patients daughter they treated with warm water and soap.” 12/11/2024, 12/20/2024 “Wound care provided – awaiting wound care orders from MD (medical doctor).” The plan of care lacks documented evidence of the treatment for the wound and monitoring for signs and symptoms of infection. There is no documented evidence that the nurse clarified with the physician the wound care treatment of warm water and soap used by the daughter. There is no documented evidence of a complete individualized plan of care. On 01/23/2025 at 3:30PM, the Director of Patient Services and the Director of Quality Management were interviewed and did not provide an explanation for the 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 clinical record review and staff interviews, the governing authority failed to ensure any revision for the patient’s discharges must be communicated to the patient, caregivers, and physicians. This was evident for three (3) of eight (8) clinical records reviewed (Patients #1, #2, and #7). Failure to ensure that any revision for the patient’s discharges must be communicated to the patient, caregivers, and physicians has the potential for negative patient outcomes. The findings are: 3. Patient #7 has a Start of Care date of 11/11/2024 with the following diagnoses "Parkinson’s Disorder, Essential Hypertension" documented in the Home Health Certification and Plan of Care for the Certification Period 11/11/2024 to 01/09/2025. The Home Health Certification and Plan of Care for the Certification Period 11/11/2024 to 01/09/2025 documents: “SN (skilled nurse) 1WK4 (once a week for four weeks) PT (physical therapy) 2WK8, 1WK1 (twice a week for eight weeks, once a week for one week).” The Client Coordination Note Report documents: 12/29/2024 “Date of Missed Visit: 12/28/24, Discipline: PT (Physical therapy); Treatment not provided for the following reason: Pt (patient) decline.” 01/02/2025 “Date of Missed Visit: 12/31/24, Discipline: PT (Physical therapy); Treatment not provided for the following reason: Pt (patient) decline.” The clinical record documents occupational therapy was provided on 12/16/2024, and patient decline services with physical therapy on 12/28/2024 and 12/31/2024, no other services provided from 12/17/2024 to the present. The clinical record lacks documented evidence of physical therapy services being provided week 12/15/2024 to 12/21/2024, missed two visits; 12/22/2024 to 12/28/2024, missed one visit; 12/29/2024 to 01/04/2025, missed one visit; and 01/05/2025 to 01/09/2025, missed one visit. The clinical record lacks documented evidence of the communication with the patient, family, and the physician related to the missed visits and the discharge. On 01/24/2025 at 12:00PM, the Director of Patient Services and the Director of Quality Management were interviewed and did not provide an explanation for the findings. 1. Patient #1 has a Start of Care date of 09/30/2024 with the following diagnoses "Atrial Fibrillation, Sepsis due to Enterococcus" documented in the Home Health Certification and Plan of Care for the Certification Period 09/30/2024 to 11/28/2024. The Home Health Certification and Plan of Care for the Certification Period 09/30/2024 to 11/28/2024 documents: “PT (physical therapy) effective 10/06/2024 1WK2 (once a week for two weeks), 2WK4 (twice a week for four weeks), 1WK2 (once a week for two weeks)." The clinical record documents physical therapy being provided on 11/21/2024 and a missed visit on 11/28/2024, no answer at the door. There is no documented evidence of an update of the comprehensive assessment at discharge for Certification Period ending on 11/28/2024. The clinical record lacks documented evidence of the communication with the patient, family, and the physician related to the discharge. On 01/23/2025 at 3:30PM, the Director of Patient Services and the Director of Quality Management were interviewed and did not provide an explanation for the findings. 2. Patient #2 has a Start of Care date of 11/12/2024 with the following diagnoses "Spondylosis with Radiculopathy Lumbar Region, Type 2 Diabetes Mellitus" documented in the Home Health Certification and Plan of Care for the Certification Period 11/16/2024 to 01/14/2025. The Visit Note Report – PT (physical therapy) Discharge Data Collection Only – no visit made dated 11/25/2024 documents: “This Assessment is currently being completed for the following reason: Discharge from agency; Date completed with physical therapy signature 01/05/2025.” The Medical Order dated 12/30/2024 documents: "Patient unable to be contacted by clinicians after multiple attempts. Case DC (discharge) from (Americare Certified Special Services) a/o (as of) last visit 11/25/24.” There is no documented evidence of an update of the comprehensive assessment at discharge in a timely manner. The clinical record lacks documented evidence of the communication with the patient and family related to the discharged. On 01/23/2025 at 3:30PM, the Director of Patient Services and the Director of Quality Management were interviewed and did not provide an explanation for the findings.

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 and staff interviews, the governing authority failed to coordinate care delivery with the patient and caregivers to meet the patient’s needs. This was evident for three (3) of eight (8) clinical records reviewed (Patients #4, #5, and #6). Failure to coordinate care delivery with the patient and caregivers to meet the patient’s needs has the potential for negative patient outcomes. The findings are: 1. Patient #4 has a Start of Care date of 11/29/2024 with the following diagnoses "Pain due to Internal Orthopedic Prosthesis, Type 2 Diabetes Mellitus, Hyperlipidemia" documented in the Home Health Certification and Plan of Care for the Certification Period 11/29/2024 to 01/27/2025. The Home Health Certification and Plan of Care for the Certification Period 11/29/2024 to 01/27/2025 documents: “PT (physical therapy) effective 12/01/2024 2WK7 (twice a week for seven weeks).” The clinical record lacks documented evidence of physical therapy being provided between 01/05/2025 to 01/11/2025, missed two visits. There is no documented evidence of the coordination with the patient or family of the missed visits. On 01/23/2025 at 3:30PM, the Director of Patient Services and the Director of Quality Management were interviewed and did not provide an explanation for the findings. 2. Patient #5 has a Start of Care date of 12/20/2024 with the following diagnoses "Mitral Valve Insufficiency, Chronic Atrial Fibrillation" documented in the Home Health Certification and Plan of Care for the Certification Period 12/20/2024 to 02/17/2024. The Client Coordination Note Report documents: 12/20/2024 “We have received your case for PT (physical therapy) and are currently working on placement. When a therapist has been assigned to your case you should receive a call directly from them to schedule the evaluation.” 12/23/2024 “PT (physical therapy) for eval (evaluation) and assessment.” 12/30/2024 “Date of missed visit: 12/27; Discipline: Physical Therapy; Treatment not provided for the following reason: Schedule change.” There is no documented evidence of the coordination with the patient or family of the delay in services from 12/21/2024 to 01/08/2025. The Admission Client Service Agreement documents: “At this point in time your physician has approved an initial plan of care that includes the following services (enter frequency, interval, and duration for each skill) Skilled nursing, physical therapy, home health aide.” “Home health aide - hha: 5days x 4 hours”. The Medical Order dated documents: 12/26/2024 “hha (home health aide) effective 12/22/2024 2WK1 (twice a week for one week).” 01/10/2025 “Hha (home health aide) effective 01/12/2025 5WK3, 4WK1 (five times a week for three weeks, four times a week for one week).” The Home Health Aide Plan of Care was completed on 12/20/2024. The Client Coordination Note Report dated 12/26/2024 documents: “Spoke to patient informed him we are waiting for hha (home health aide) approval from his health insurance. Once auth (authorization) is approved we will informed him.” There is no documented evidence of the coordination and notification to the family regarding aide services after the call on 12/26/2024 to 01/06/2025 and for the missed visits between 01/12/2025 to 01/18/2025. On 01/24/2025 at 12:00PM, the Director of Patient Services and the Director of Quality Management were interviewed and did not provide an explanation for the findings. 3. Patient #6 has a Start of Care date of 12/02/2024 with the following diagnoses "Ventricular Flutter, Unspecified Atrial Fibrillation" documented in the Home Health Certification and Plan of Care for the Certification Period 12/02/2024 to 01/30/2025. The Home Health Certification and Plan of Care for the Certification Period 12/02/2024 to 01/30/2025 documents: “PT (physical therapy) effective 12/08/2024 1WK1, 2WK1, 1WK1, 2WK1, 1WK1 (once a week for one week, twice a week for one week, once a week for one week, twice a week for one week, once a week for one week).” The Client Coordination Note Report documents: 12/07/2024 “Called and left voicemail to notify the patient that their PT (physical therapy) case has been received and therapist will be reaching out to schedule the evaluation visit”. “Patient was not seen for PT (physical therapy) eval (evaluation) today. Patient will be rescheduled on Tuesday Dec (December) 10. MD (medical doctor) notified.” 12/10/2024 “Called and left voicemail to notify the patient that their PT (physical therapy) case has been received and therapist will be reaching out to schedule the evaluation visit”. There is no documented evidence of the notification or coordination with the patient/family about rescheduling of the evaluation on 12/10/2024 and the reason of the change. The Home Health Certification and Plan of Care for the Certification Period 12/02/2024 to 01/30/2025 documents: “hha (home health aide) effective 12/08/2024 4WK1, 5WK1, 1WK1, 5WK4 (four times a week for one week, five times a week for one week, once a week for one week, five times a week for four weeks).” The clinical record lacks documented evidence of the aide services being provided on week 12/15/2024 to 12/21/2024 – missed one visit, 01/05/2025 to 01/11/2025 – missed four visits; and 1/12/2025 to 01/18/2025 – missed five visits. There is no documented evidence of the coordination and notification with the patient or family of the missed visits. On 01/24/2025 at 12:00PM, the Director of Patient Services and the Director of Quality Management were interviewed and did not provide an explanation for the findings.

Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interviews, the governing authority failed to ensure that each patient receive ongoing education and training regarding wound care. This was evident for one (1) of eight (8) clinical records reviewed (Patient #3). Failure to ensure that each patient receive ongoing education and training regarding the care has the potential for negative patient outcomes. The findings are: 1. Patient #3 has a Start of Care date of 12/27/2024 with the following diagnoses "Unspecified Open wound Left Foot, Type 2 Diabetes Mellitus" documented in the Home Health Certification and Plan of Care for the Certification Period 12/27/2024 to 02/24/2025. The Home Health Certification and Plan of Care for the Certification Period 12/27/2024 to 02/24/2025 documents: “SN (skilled nurse) 1WK1, 2WK1, 1WK1, 3WK6, 1WK1 (once a week for one week, twice a week for one week, once a week for one week, three times a week for six weeks, once a week for one week).” The Visit Note Report dated 12/27/2024 documents: “#1 Lat Lt Prox (Lateral Left Proximal) Great Toe; Indicate Type: Closed Surg (surgical)” “#2 Med (medial) Dorsum, Mid. Lt (middle left)”. “Patient lives alone” “Document caregiver’s willingness and/or ability to provide the care the patient needs: No caregiver available” “He had difficult caring for self at home, due to change/decline in functional/strength status need assistance in home to perform ADLS/IADLS (activity of daily living / instrumental activity of daily living).” The clinical record lacks documented evidence of the patient receiving education and training for wound care treatment. On 01/23/2025 at 3:30PM, the Director of Patient Services and the Director of Quality Management were interviewed and did not provide an explanation for the findings.

Coordinate patient care CFR(s): 484.105(c)(2) Coordinating patient care, This ELEMENT is not met as evidenced by: Based on clinical record review and staff interviews, the governing authority failed to ensure of the coordination of patient care with the clinical manager. This was evident for three (3) of eight (8) clinical records reviewed (Patients #1, #2, and #6). Failure to coordinate patient care with the clinical manager has the potential for negative patient outcomes. The findings are: 3. Patient #6 has a Start of Care date of 12/02/2024 with the following diagnoses "Ventricular Flutter, Unspecified Atrial Fibrillation" documented in the Home Health Certification and Plan of Care for the Certification Period 12/02/2024 to 01/30/2025. The Home Health Certification and Plan of Care for the Certification Period 12/02/2024 to 01/30/2025 documents: “PT (physical therapy) effective 12/08/2024 1WK1, 2WK1, 1WK1, 2WK1, 1WK1 (once a week for one week, twice a week for one week, once a week for one week, twice a week for one week, once a week for one week). OT (occupational therapy) effective 12/22/2024 1WK1 (once a week for one week).” The Medical Order documents: 01/02/2025 “OT (occupational therapy) effective 12/29/2024 1WK1 (once a week for one week).” 01/06/2025 “OT (occupational therapy) effective 01/05/2025 1WK1 (once a week for one week).” 01/14/2025 “OT (occupational therapy) effective 01/12/2025 1WK1 (once a week for one week).” 01/17/2025 “OT (occupational therapy) effective 01/12/2025 1WK1, 2WK1, 1WK1 (once a week for one week, twice a week for one week, once a week for one week).” The Client Coordination Note Report documents: 12/19/2024 (Occupational therapy) “PT (patient) was called, but (no) one answered. A message was left.” 12/27/2024 “Date of Missed Visit: Dec (December) 27 2024; Discipline: PT (physical therapy); Treatment not provided for the following reason: no answer on phone.” 12/31/2024 “Date of Missed Visit: Dec (December) 31 2024; Discipline: PT (physical therapy); Treatment not provided for the following reason: no answer on phone.” 01/02/2025 “Date of Missed Visit: Jan (January) 2 2025; Discipline: PT (physical therapy); Treatment not provided for the following reason: no answer on phone.” 01/08/2025 “Date of Missed Visit: Jan (January) 8 2025; Discipline: PT (physical therapy); Treatment not provided for the following reason: no answer on phone.” 01/09/2025 (Occupational therapy) “Phone call was made today on 01/09/2025, but no one answered.” 01/16/2025 (Occupational therapy) “Patient was called on 01/15/2025, but no one answered.” 01/07/2025 (Occupational therapy) “called on 01/16/2025, and again on 01/17/2025, but no one answered the phone.” The clinical record lacks documented evidence of the coordination of patient care with the Clinical Manager regarding multiple missed visits to identify patient’s needs and safety. On 01/24/2025 at 12:00PM, the Director of Patient Services and the Director of Quality Management were interviewed and did not provide an explanation for the findings. 1. Patient #1 has a Start of Care date of 09/30/2024 with the following diagnoses "Atrial Fibrillation, Sepsis due to Enterococcus" documented in the Home Health Certification and Plan of Care for the Certification Period 09/30/2024 to 11/28/2024. The Home Health Certification and Plan of Care for the Certification Period 09/30/2024 to 11/28/2024 documents: “PT (physical therapy) effective 10/06/2024 1WK2 (once for two weeks), 2WK4 (twice for four weeks), 1WK2 (once for two weeks)”. The Client Coordination Note Report documents: 10/07/2024 “Date of Missed Visit: 10-05-24; Discipline: PT (physical therapy); Treatment not provided for the following reason: Patient didn’t open the door, went to his house but no response. Requesting evaluation to be moved from 10-05-24 to 10-08-24.” 10/13/2024 “Date of Missed Visit: 10.11.24; Discipline: SN (skilled nurse); Treatment not provided for the following reasons: unable to reach, no one returns voice mail.” 10/20/2024 “Date of Missed Visit: 10.16.24; Discipline: SN (skilled nurse); Treatment not provided for the following reasons: unable to reach.” 10/21/2024 “Date of Missed Visit: 10-15-24; Discipline: PT (physical therapy); Treatment not provided for the following reason: Patient is not home.” 10/27/2024 “Date of Missed Visit: 10-17-24; Discipline: PT (physical therapy); Treatment not provided for the following reason: Patient is not available.” 11/09/2024 “Date of Missed Visit: 11.8.24; Discipline: SN (skilled nurse); Treatment not provided for the following reasons: unable to reach.” 11/11/2024 “Date of Missed Visit: 10-24-24; Discipline: PT (physical therapy); Treatment not provided for the following reason: Patient is not available.” 12/02/2024 “Date of Missed Visit: 11-07-24; Discipline: PT (physical therapy); Treatment not provided for the following reason: Patient is sick.” 12/02/2024 “Date of Missed Visit: 11-05-24; Discipline: PT (physical therapy); Treatment not provided for the following reason: No answer at door.” 12/10/2024 “Date of Missed Visit: 11-14-24; Discipline: PT (physical therapy); Treatment not provided for the following reason: No answer at door.” 12/10/2024 “Date of Missed Visit: 11-28-24; Discipline: PT (physical therapy); Treatment not provided for the following reason: No answer at door.” The clinical record lacks documented evidence of the coordination with the Clinical Manager regarding multiple missed visits to identify patient’s needs and safety. On 01/23/2025 at 3:30PM, the Director of Patient Services and the Director of Quality Management were interviewed and did not provide an explanation for the findings. 2. Patient #2 has a Start of Care date of 11/12/2024 with the following diagnoses "Spondylosis with Radiculopathy Lumbar Region, Type 2 Diabetes Mellitus" documented in the Home Health Certification and Plan of Care for the Certification Period 11/16/2024 to 01/14/2025. The Home Health Certification and Plan of Care for the Certification Period 11/16/2024 to 01/14/2025 documents: “1WK2 (once a week for two weeks), 1 every 2WK4 (once every two weeks for four weeks).” The Medical Order dated 12/30/2024 documents: "Patient unable to be contacted by clinicians after multiple attempts. Case DC (discharge) from Americare Certified Special Services a/o (as of) last visit 11/25/24.” The clinical record lacks documented evidence of the coordination of patient care with the Clinical Manager regarding multiple attempts visits to identify patient’s needs and safety. On 01/23/2025 at 3:30PM, the Director of Patient Services and the Director of Quality Management were interviewed and did not provide an explanation for the findings.

This Statement of Deficiencies is a result of an on-site investigation of complaint IQIES 110426 conducted on 11/13/24 – 11/14/24 at Americare Certified Special Services CHHA, ID# 337290, located at 5923 Strickland Avenue, Brooklyn, New York 11234. The agency reports an active patient census of 6954. The investigation consisted of a review of three (3) clinical records identified as (Patient #1, #2, and #3), two (2) personnel records identified as (Employee #1, and #2) the agency’s complaint/ Incident logs for the period 07/01/24 – 11/08/24, and pertinent policies and procedures. Interviews were conducted throughout the survey with the Director of Patient Services and the Director Quality Management/Compliance. The findings were reviewed at the Exit Conference on 11/14//24. The allegations for complaint # 110426 were determined to be substantiated. The following deficiencies are identified as a result of the survey. G0572: Plan of Care G0580: Only as ordered by a physician. G0590: Promptly alert relevant physician of changes G0606: Integrate Services: G0716: Preparing clinical notes

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 that the patient received the care that is written in the individualized Plan of Care. This was evident for one (1) of three (3) clinical records reviewed (Patient (#1). Failure to ensure that patients receive the care that is written in the individualized Plan of Care has the potential for negative patient outcome. The findings are: Patient #1 has a Start of Care date of 9/21/2024 with diagnoses: Encounter for Orthopedic after care following surgical Amputation, Type 2 Diabetes Mellitus with Foot Ulcer, Non-Prs Chronic Ulcer Oth Prt Left Foot with Oth Severity (Non-Pressure Chronic Other part left foot with other severity) Acquired Absence of Left Foot, Gas Gangrene, Muscle Weakness (Generalized) documented on the Home Health Certification and Plan of Care for Certification Period 9/21/24 – 11/19/24. The Home Health Certification and Plan of Care documents: Frequency/Duration of Visits: SN: 1WK 1, 4WK 1, 3WK7, 1Wk1 SN to perform/ teach wound care to left foot transmetarsal amputation. Remove vac dressing, ensure that the adaptive remains sutured to the wound bed. Cut black granufoam to the size of the wound, cover with provided Tegaderm. Cut a dime size hole to the Tegaderm and attach the suction apparatus , ensure no leaks present set wound vacuum to 125mmhg continuously, medium intensity , dressing left foot with drain sponge , abdominal pad, kerlix, and ace bandage ( ensure the tubing is not rubbing against the patient’s skin ) Skilled Nurse to perform/ teach wound care SN to perform wound care three times a week (Monday, Wednesday and Friday. The Visit Note Reports documents: On 9/29/24 (Sunday) a Skilled nurse visit was conducted. On 10/3 (Thursday) the skilled nurse documents wound care not provided refused care, wound care provided by the physician. The clinical record lacks documented evidence of the patient receiving three wound care treatment visits for the week 9/29/24 – 10/5/24. (one treatment not provided). The clinical record lacks documented evidence of the patient receiving wound care service on Monday, Wednesday and Friday as written in the patient’s individualized plan of care. On 11/13/24 at 2:45 PM the Director of Patient Services and the Director Quality Management/Compliance were interviewed and did not provide an explanation for the findings.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to ensure that treatments are administered as ordered by the physician. This was evident for one (1) of three (3) clinical records reviewed. (Patient #1). Failure to ensure all treatments are administered only as ordered by the physician has the potential for negative patient outcomes. The findings are: Patient #1 has a Start of Care date of 9/21/2024 with diagnoses: Encounter for Orthopedic After care following surgical Amputation , Type 2 Diabetes Mellitus with Foot Ulcer, Non-Prs Chronic Ulcer Oth Prt Left Foot with Oth Severity ( Non-Pressure Chronic Other part left Foot With Other Severity) Acquired Absence of Left Foot, Gas Gangrene, Muscle Weakness (Generalized) documented on the Home Health Certification and Plan of Care for Certification Period 9/21/24 – 11/19/24. The Home Health Certification and Plan of Care documents: Frequency/Duration of Visits: SN: 1WK 1, 4WK 1, 3WK7, 1Wk1 SN to perform/ teach wound care to left foot transmetarsal amputation. Remove vac dressing, ensure that the adaptive remains sutured to the wound bed. Cut black granufoam to the size of the wound, cover with provided Tegaderm. Cut a dime size hole to the Tegaderm and attach the suction apparatus , ensure no leaks present set wound vacuum to 125mmhg continuously, medium intensity , dressing left foot with drain sponge , abdominal pad, kerlix, and ace bandage ( ensure the tubing is not rubbing against the patient’s skin ) Skilled Nurse to perform/ teach wound care SN to perform wound care three times a week (Monday, Wednesday and Friday. Visit Note Reports documents: 09/25/2024: Narrative: Cleansed with NSS (Normal Saline Solution), patted dry, applied wound vac at 125mmhg. 09/27/2024: Wound Care Provided: Cleansed with NSS (Normal Saline Solution), patted dry, applied wound vac at 125mmhg. 09/29/2024: wound care provided. Cleansed with NSS (Normal Saline Solution), patted dry, applied wound vac at 125mmhg. The clinical record lacks documented evidence of the Registered Nurse providing wound care treatments only as ordered by the physician for the dates 9/25/, 9/27, and 9/29/24. On 11/13/24 at 2:45 PM the Director of Patient Services and the Director Quality Management/Compliance were interviewed and did not provide an explanation for the findings.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview the agency failed to promptly alert the physician of changes in the patient's wound care treatment that would potentially affect the outcome of the patient’s treatment goals. This was evident for one (1) of three (3) clinical records reviewed. (Patient #1). Failure to ensure the physician is promptly notified of changes that would affect the patient’s treatment regime has the potential for negative patient outcome. The findings are: Patient #1 has a Start of Care date of 9/21/2024 with diagnoses: Encounter for Orthopedic After care following surgical Amputation , Type 2 Diabetes Mellitus with Foot Ulcer, Non-Prs Chronic Ulcer Oth Prt Left Foot with Oth Severity ( Non-Pressure Chronic Other part left Foot With Other Severity) Acquired Absence of Left Foot, Gas Gangrene, Muscle Weakness (Generalized) documented on the Home Health Certification and Plan of Care for Certification Period 9/21/24 – 11/19/24. The Home Health Certification and Plan of Care for Certification Period 9/21/24 – 11/19/24 documents SN to perform/ teach wound care to left foot transmetarsal amputation: Remove vac dressing, ensure that the adaptive remains sutured to the wound bed. Cut black granufoam to the size of the wound, cover with provided Tegaderm. Cut a dime size hole to the Tegaderm and attach the suction apparatus, ensure no leaks present set wound vacuum to 125mmhg continuously, medium intensity, dressing left foot with drain sponge , abdominal pad, kerlix, and ace bandage ( ensure the tubing is not rubbing against the patient’s skin. The Visit Note Report documents: 09/27/2024: Wound Care Provided. Narrative: Patient requires drape and vac granufoam, and cannister for wound vac, the system does not show the supplies to request them. Please assist. 09/29/2024: wound care provided. Patient requires the supplies for wound vac. The clinical record lacks documented evidence of the Registered Nurse promptly alerting the physician of the absence of the patient’s wound care treatment supplies and that the plan of care may need to be altered. On 11/13/24 at 2:45 PM the Director of Patient Services and the Director Quality Management/Compliance were interviewed and did not provide an explanation for the findings.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview the agency failed to appropriately identify the needs of the patient, factors that could affect the effectiveness of the patient wound care treatment and coordinate the care being provided. This was evident for one (1) of three (3) clinical records reviewed. (Patient #1). Failure to identify the needs of the patient, factor that will affect the effectiveness of treatment and coordinate the care being provided has the potential for negative patient outcome. The findings are: Patient #1 has a Start of Care date of 9/21/2024 with diagnoses: Encounter for Orthopedic After care following surgical Amputation , Type 2 Diabetes Mellitus with Foot Ulcer, Non-Prs Chronic Ulcer Oth Prt Left Foot with Oth Severity ( Non-Pressure Chronic Other part left Foot With Other Severity) Acquired Absence of Left Foot, Gas Gangrene, Muscle Weakness (Generalized) documented on the Home Health Certification and Plan of Care for Certification Period 9/21/24 – 11/19/24. The Visit Note Report documents: 09/27/2024: Wound Care Provided: Cleansed with NSS (Normal Saline Solution), patted dry, applied wound vac at 125mmhg patient tolerated well. Narrative: Patient requires drape and vac granufoam, and cannister for wound vac, the system does not show the supplies to request them. Please assist. 09/29/2024: wound care provided. Cleansed with NSS (Normal Saline Solution), patted dry, applied wound vac at 125mmhg patient tolerated well. Patient requires the supplies for wound vac. The clinical record lacks documented evidence of coordination between the Registered Nurse, Supervisor/Case manager, and the patient’s physician regarding the absence of wound care treatment supplies, changes in wound care being provided by the Registered Nurse and to request physician’s input for new orders or for an alternate wound care treatment. On 11/13/24 at 2:45 PM the Director of Patient Services and the Director Quality Management/Compliance were interviewed and did not provide an explanation for the findings.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview the agency failed to ensure all Registered Nurses /(SN) (skilled nurses) clinical notes are complete and accurately documented. This was evident for one (1) of three (3) clinical records reviewed. (Patient #1). Failure to ensure that clinicians prepare, and document complete and accurate clinical/ progress notes has the potential for negative patient outcome. The findings are: The Client Coordination Notes Report documents: 10/3/24: Wound assessment: Wound care provided: wound care not provided refused care. Narrative: Wound care was provided by the physician. The Client Coordination Notes Report documents: Note Date: 10/03/2024: Nurse visit for wound care was provided. Patient requires the supplies for wound vac. The Client Coordination Notes Report documents: Note Date:10/06/2024: Date of missed visit 10/5/24. Treatment not provided for the following reason: Patient was seen by MD (Medical Doctor) day before. Name of Medical Doctor notified: No. The Client Coordination Notes Report documents: Note Date:10/06/2024: Wound care was provided by the physician. The clinical record lacks documented evidence of the Registered Nurses /(SN) (skilled nurses) clinical notes being clear, concise, complete and accurately documenting the dates the wound care treatment is being provided. On 11/13/24 at 2:45 PM the Director of Patient Services and the Director Quality Management/Compliance were interviewed and did not provide an explanation for the findings.

This Statement of Deficiencies is a result of on-site investigation of complaints #105862, #105696, #109981, and #109809 conducted at Americare Certified Special Services, INC located at 5923 Strickland Avenue, Brooklyn, NY 11234 on 09/23/2024 to 09/24/2024. Pre-survey activities consisted of review on 09/20/24 of the agency's Health Commerce System account. The active patient census is 6464. The investigation consisted of a review of seven (7) clinical records (identified as Patients #1, #2, #3, #4, #5, #6, and #7), and a review of four (4) employee records (identified as Employee #1, #2, #3 and #4), and interviews with The Administrator, the Director of Patient Services, and the Director Quality Management/Compliance. The allegations in complaints #105862, #105696, and #109809 were determined substantiated. The allegations in complaint # 109981 was determined unsubstantiated. The following deficiencies are identified as a result of the survey: G0436 – Receive all services in plan of care G0478 – Investigate complaints made by patient G0574 – Plan of care must include the following G0606 – Integrate all services G0608 Coordinate care delivery G0718 Communication with physicians

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on review of clinical record reviews, and staff interviews, the agency failed to ensure that all patients receive all services outlined in the plan of care. This was evident for two (2) of seven (7) clinical records reviewed (Patient #1, and #2). Failure to ensure all patients receive all services outlined in their plan of care, has the potential for negative patient outcomes. The Findings Are: 1.Patient #1 has a Start of Care date of 05/31/24 with the following diagnoses “Unilateral Primary Osteoarthritis of The First Carpometacarpal Joint In The Left Hand, Encounter For Other Orthopedic Aftercare, Other Chronic Pain” documented on the Home Health Certification and Plan of Care for Certification Period 07/30/24 to 09/27/24. The Home Health Certification and Plan of Care for Certification Period 07/30/24 to 09/27/24 documents: “HHA 3wk1,5wk8 three (3) times a week for one (1) week, five (5) times a week for eight (8) weeks)” The Complaint/Incident: Inquiry dated 09/19/2024 documents: “QM (Quality Management) Investigation: The case is unstable, lots of missed visits. As per HHA exchange no clock in for 09/17/24. Aide finished her shift an hour earlier 09/16/24. No notes located in HHAX (Home Health Aide Exchange) indicating the reason. Action taken: contacted HHA (Home Health Aide) Vendor (name) to confirm and request a assistance on stabilizing the case. As per HHA (Home Health Aide) vendor: Member has a lapsed in services back in July week of 07/29/24. Member had another lapse in services on week of 08/19 until 8/28. Services resume 8/29. Regarding aide services no replacement was sent on several occasions due to member refusing pm services. There was another lapse of services on 08/20 to 8/28. On the month of August, no replacement was sent on 09/02,09/03,09/04,09/05, 09/10,09/11, 09/12, 09/13, 09/17, 09/18. Member contacted to discuss the lapse of services and requested schedule adjustment. SC (Schedule Coordinator) was not able to restaff the case due to difficulties staffing. SC (Schedule Coordinator) informed client that they are unable fulfill their request. The agency lacks documented evidence of any case communication with patient regarding missed Home Health Aide Visits. There is no documented evidence of the patient being offered a transfer to an agency that could provide Home Health Aide services. On 09/24/2024 at 04:00PM , the Administrator, the Director of Patient Services, and the Director Quality Management/Compliance were interviewed and did not provide an explanation. 2.Patient #2 has a Start of Care date of 12/28/23 with the following diagnoses “Cerebral Infarction due to Unspecified Occlusion or Stenosis of Left Posterior Cerebral Artery, Localization-Related (focal) (partial) Symptomatic Epilepsy and Epileptic Syndromes with Simple Partial Seizures, Intractable, without Status Epilepticus” documented on the Home Health Certification and Plan of Care for Certification Period 12/28/23 to 02/25/24. The Physician order dated 02/5/2024 documents: “ST Eval (Speech Therapy Evaluation)” The Physician order dated 02/13/2024 documents: “ST (Speech Therapy) Evaluation and Treatment as of 02/13/24.” The clinical record lacks documented evidence of a Speech Therapy Evaluation. On 09/24/2024 at 04:00PM, the Administrator, the Director of Patient Services, and the Director Quality Management/Compliance were interviewed and did not provide an explanation.

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 review of clinical record reviews, and staff interviews, the agency failed to ensure all patient’s complaints are investigated. This was evident for one (1) of seven (7) clinical records reviewed (Patient #1). Failure to ensure all patient’s complaints are investigated has the potential for negative patient outcomes. The Findings Are: 1.Patient #4 has a Start of Care date of 11/30/2023 and discharge date of 01/25/2024 with the following diagnoses “Chronic Systolic (Congestive) Heart Failure, Ischemic Cardiomyopathy, Spinal Stenosis” documented on the Home Health Certification and Plan of Care for Certification Period 11/30/2023 to 01/28/2024. The SN (Skilled Nurse) Visit Note dated 01/08/2024 (Monday) documents: "Section: Supervisory Functions: Is the client satisfied with the current care being provided by the HHA (Home Health Aide)? NO Narrative: Patient reports an incident with her HHA (Home Health Aide). Patient said an aide who was scheduled previously stole multiple items from her including her shampoo, staples, and other items. Patient also reports that her aide damaged her rollator by pushing rollator into cracks in the sidewalk when walking with patient. Patient does not recall aide’s name but said she has already called ACSS (Americare Certified Special Services) multiple times reporting the incident." On 09/23/2024 the agency’s Complaint and Incident logs were reviewed. The Complaint and Incident logs lack documented evidence of Patient’s #4 complaint/incident in December 2023 and January 2024. The agency's "Patient Complaints" Policy documents: "6. After the investigation is concluded, the complainant will be sent a letter within 15 days of the complaint filed date (for any complaint received in writing-by letter, e-mail or facsimile) or contacted via phone by (if complainant has requested this mode of communication) to apprise of the investigation findings. Patient representative Department will call the complainant and confirm that resolution was taken place, and the complainant is satisfied with the outcome." There is no documented evidence of the investigation and resolution for the complaint within 15 days. There is no documented evidence of the patient being notified and satisfied with the investigation outcome. There is no documented evidence of the complaint on 01/08/2024 being documented in the complaint log. On 09/23/2024 at 03:30 pm, Director of Quality Management/ Compliance was interviewed and did not provide an explanation.

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 record review and interview this agency failed to ensure each patient's individualized plan of care included all the required information. This was evident for one (1) of seven (7) clinical records reviewed (Patient #1). Failure to ensure individualized plan of care is established for all patients has the potential risk for negative patient outcomes. The Findings Are: 1.Patient #1 has a Start of Care date of 05/31/24 with the following diagnoses “Unilateral Primary Osteoarthritis of The First Carpometacarpal Joint in The Left Hand, Encounter for Other Orthopedic Aftercare, Other Chronic Pain” documented on the Home Health Certification and Plan of Care for Certification Period 07/30/24 to 09/27/24. The Home Health Certification and Plan of Care for Certification Period 07/30/24 to 09/27/24 documents: “HHA (Home Health Aide) 3wk1,5wk8 (three (3) times a week for one (1) week, five (5) times a week for eight (8) weeks)” The clinical record lacks documented evidence of Home Health Aide visits duration. On 09/24/2024 at 04:00 pm, the Administrator, the Director of Patient Services, and the Director Quality Management/Compliance were interviewed and did not provide an explanation.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on review of clinical record reviews, and staff interviews, the agency failed to integrate services to assure the identification of patient needs. This was evident for one (1) of seven (7) clinical records reviewed (Patient #1). Failure to integrate services to assure the identification of patient needs. has the potential for negative patient outcomes. The Findings Are: 1.Patient #4 has a Start of Care date of 11/30/2023 and discharge date of 01/25/2024 with the following diagnoses “Chronic Systolic (Congestive) Heart Failure, Ischemic Cardiomyopathy, Spinal Stenosis” documented on the Home Health Certification and Plan of Care for Certification Period 11/30/2023 to 01/28/2024. The agency's "Patient Complaints" Policy documents: "How to route the Patient communication to their immediate supervisor. 1) If a complaint is received during normal business hours, it must be forward to the employee's immediate supervisor within one business day. ... 3) Regardless of the day received, an appropriate supervisor will be notified as soon as possible, but no later than 24 hours after receipt." The SN (Skilled Nurse) Visit Note dated 01/08/2024 documents: "Section: Supervisory Functions: Is the client satisfied with the current care being provided by the HHA (Home Health Aide)? NO Narrative: Patient reports an incident with her HHA (Home Health Aide). Patient said an aide who was scheduled previously stole multiple items from her including her shampoo, staples, and other items. Patient also reports that her aide damaged her rollator by pushing rollator into cracks in the sidewalk when walking with patient. Patient does not recall aide’s name but said she has already called ACSS (Americare Certified Special Services) multiple times reporting the incident." The Clinical Record lacks documented evidence of the nurse notifying the agency supervisory staff no later than 24 hours after receipt complaint/concerns on 01/08/2024. The agency's LHCSA (Licensed Home Care Service Agency) Investigator documents none of the aides have previous complaints filed against them for theft allegation or property damage. The Caregivers deny the allegations. The Complaint/Incident Form documents: "Date Initially Reported: 02-28-2024 Reported by: Americare INC Relationship to patient: HHA Vendor Complaint/Incident: Complaint Category: Theft Allegation Investigation: Note was placed by Supervisor on 12/22/2023 -"Spoke to patient regarding miss visits. Per patient, she had a bad experience with the aide and has not been sure if she wants to accept services at this time." The complaint/correspondence(e-mail) from the patient to the LHCSA dated 12/31/2023, 01/05/2024, 01/10/2024, 01/19/2024 and 02/26/2024 documents: "Subject: Invoice for list of items stolen from my house and walker damaged during walk to/from MD (Medical Doctor). " On 09/23/2024 the agency’s Complaint and Incident logs were reviewed. The Complaint and Incident logs lack documented evidence of Patient’s #4 complaint/incident in December 2023 and January 2024. The clinical record lacks documented evidence of communication between the HHA (Home Health Aide) vendor and agency regarding patient's complaint(s) before 02/28/2024. On 09/24/2024 at 04:30 pm, Director of Quality Management/ Compliance was interviewed and did not provide an explanation.

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 and staff interviews, the agency failed to ensure that all clinicians coordinate care delivery to meet the patient's needs. This was evident for one (1) of seven (7) patient care records reviewed (Patient #2). Failure to ensure that all clinicians coordinate to the patient or caregiver the delivery of care has the potential for negative patient outcomes. The Findings Are: 1.Patient #2 has a Start of Care date of 12/28/23 with the following diagnoses “Cerebral Infarction due to Unspecified Occlusion or Stenosis of Left Posterior Cerebral Artery, Localization-Related (focal) (partial) Symptomatic Epilepsy and Epileptic Syndromes with Simple Partial Seizures, Intractable, without Status Epilepticus” documented on the Home Health Certification and Plan of Care for Certification Period 12/28/23 to 02/25/24. The Physician order dated 02/5/2024 documents: “ST Eval (Speech Therapy Evaluation)” The Physician order dated 02/13/2024 documents: “ST (Speech Therapy) Evaluation and Treatment as of 02/13/24.” The Physician order dated 02/23/2024 documents: “Patient Discharged 2/23/24”. The clinical record lacks documented evidence of a Speech Therapy Evaluation. There is no documented evidence of communication with patient/family about discharging the patient without the patient receiving Speech Therapy Services. On 09/24/2024 at 04:00 pm, the Administrator, the Director of Patient Services, and the Director Quality Management/Compliance were interviewed and did not provide an explanation.

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 review of clinical record reviews, and staff interviews, the agency failed to ensure ongoing communication with the physician involved in the patient's plan of care is maintained. This was evident for two (2) of seven (7) clinical records reviewed (Patient #1, and #2). Failure to ensure ongoing communication with the physician involved in the patient's plan of care has the potential for negative patient outcomes. The Findings Are: 1.Patient #1 has a Start of Care date of 05/31/24 with the following diagnoses “ Unilateral Primary Osteoarthritis of The First Carpometacarpal Joint In The Left Hand, Encounter For Other Orthopedic Aftercare, Other Chronic Pain” documented on the Home Health Certification and Plan of Care for Certification Period 07/30/24 to 09/27/24. The Home Health Certification and Plan of Care for Certification Period 07/30/24 to 09/27/24 documents: “HHA 3wk1,5wk8 (three(3) times a week for one (1) week, five(5) times a week for eight (8) weeks)” The Complaint/Incident: Inquiry dated 09/19/2024 documents: “QM (Quality Management) Investigation: The case is unstable, lots of missed visits. As per HHA exchange no clock in for 09/17/24. Aide finished her shift an hour earlier 09/16/24. No notes located in HHAX (Home Health Aide Exchange) indicating the reason. Action taken: contacted HHA (Home Health Aide) Vendor (name) to confirm and request an assistance on stabilizing the case. As per HHA (Home Health Aide) vendor: Member has a lapsed in services back in July week of 07/29/24. Member had another lapse in services on week of 08/19 until 8/28. Services resume 8/29. Regarding aide services no replacement was sent on several occasions due to member refusing pm services. There was another lapse of services on 08/20 to 8/28. On the month of August, no replacement was sent on 09/02,09/03,09/04,09/05, 09/10,09/11, 09/12, 09/13, 09/17, 09/18. Member contacted to discuss the lapse of services and requested schedule adjustment. SC (Schedule Coordinator) was not able to restaff the case due to difficulties staffing. SC (Schedule Coordinator) informed client that they are unable fulfill their request. There is no documented evidence of the patient's physician being notified that the patient did not receive Home Health Aide services as ordered in Plan of Care. 2.Patient #2 has a Start of Care date of 12/28/23 with the following diagnoses “Cerebral Infarction due to Unspecified Occlusion or Stenosis of Left Posterior Cerebral Artery, Localization-Related (focal) (partial) Symptomatic Epilepsy and Epileptic Syndromes with Simple Partial Seizures, Intractable, without Status Epilepticus” documented on the Home Health Certification and Plan of Care for Certification Period 12/28/23 to 02/25/24. The Physician order dated 02/5/2024 documents: “ST Eval (Speech Therapy Evaluation)” The Physician order dated 02/13/2024 documents: “ST (Speech Therapy) Evaluation and Treatment as of 02/13/24.” The clinical record lacks documented evidence of a Speech Therapy Evaluation. There is no documented evidence of the physician being notified that the patient did not receive Speech Therapy as ordered in Plan of Care. On 09/24/2024 at 04:00 pm, the Administrator, the Director of Patient Services, and the Director Quality Management/Compliance were interviewed and did not provide an explanation.

The following Statement of Deficiencies represents the results of a partial extended re-certification survey of Americare Certified, Special Services, Certified Home Health Agency located at 5923 Strickland Ave, Brooklyn, NY 11234 conducted on 02/26/2024 through 03/01/2024 and included complaints investigations of # 104957, #104168, #103695, #102894, #100307, #99353, #98513, #94163, #71994, #61735, #61517, and #59001. The allegations in Complaints # 104957, #103695, #100307, #99353, #98513, #94163, #71994, #61517, and #59001 were determined to be substantiated. The allegations in Complaints #104168, #102894, and # 61735 were determined to be unsubstantiated. A Standard Initial Certification Survey was initiated on 02/26/2024. Deficient practices were identified within Level 1 standards in 484.55 Comprehensive Assessment of Patients, 484.60 Care planning, coordination of services, and quality of care, 484.75 Skilled professional services, and 484.80 Home Health Aide Services resulting in a partial extended survey. The survey consisted of a review of twenty-five (25) clinical records (identified as Patient #1, #2, #3, #4, #5, #6, #7, #8, #9 #10, #11, #12, #13, #14, #15, #16, #17. #18, #19, #20, #21, #22, #23, #24, and #25) including thirteen (13) discharge records, twelve (12) personnel records (identified as Employee#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, and #12) three (3) contracts, and seven (7) observational home visits. The survey included a review of pertinent policies and procedures, Quality Improvement Meeting Minutes for past 12 months, PIP (Performance Improvement Projects), Admission Packet, Emergency Preparedness Plan, Complaint Log, Three (3) contracts, and the agency's Infection Control and Flu policy and procedure. The active patient census is 5571 Pre-survey activities consisted of review on 02/22/2024 of the agency’s Health Commerce System account, and the Internet Quality Improvement Evaluation System (iQIES) account. The Administrator, the Director of Patient Services, and the Corporate Director Quality Management/Compliance were interviewed. Findings were reviewed at the exit conference on 03/01/2024. The following deficiencies are identified as a result of the survey: G0374 – Accuracy of encoded OASIS data G0434 – Participate in care G0464 – Advise the patient of discharge for cause G0476 – Investigation of complaints G0528 – Health, psychosocial, functional, cognition G0536 – A review of all current medications G0572 – Plan of care G0574 – Plan of care must include the following G0580 – Only as ordered by a physician G0616 – Patient medication schedule /instructions G0718 – Communication with physicians G0726 – Nursing services supervised by RN G1012 – Required items in clinical record J1444 – Personnel

Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient's status at the time of assessment. This STANDARD is not met as evidenced by: Based on clinical records review and staff interview the agency failed to ensure the encoded OASIS (The Outcome and Assessment Information Set) assessments accurately reflect each patient's status at the time of the assessment. This was evident for four (4) of twenty-five (25) clinical records reviewed (Patient: #1, #2, #5, and #21). Failure to ensure the encoded OASIS (The Outcome and Assessment Information Set) accurately reflect the patient's status at the time of the assessment, has the potential for negative patient outcomes. The Finding Are: 4. Patient #21 has a Start of Care of 2/10/2023 with the diagnoses ”Bilateral Primary Osteoarthritis of Knee, Colostomy Status, Hypertensive Heart Disease with Heart Failure, Heart Failure, Unspecified, Unspecified Atrial Fibrillation, Athscl (Arteriosclerosis) Heart Disease of Native Coronary Artery w/o Ang Pctrs (Angina Pectoris), Anemia, Unspecified, Hypothyroidism, Unspecified, Muscle Weakness (Generalized)" documented on the Home Health Certification and Plan of Care for Certification Period 2/5/24 to 4/4/2024. The agency’s “Referral Request for Home Care Services” documents: “Date: 1/24/23. The Registered Nurse Start of Care OASIS (Outcome and Assessment Information Set) Admission Comprehensive Assessment dated 02/10/2023 documents: “Assessment: Has the client received home health services from a different home health provider in the past 60 days? No.” On 2/29/24 at 3:45pm the Administrator, Director of Quality, and the Director of Patient Services were interviewed regarding the period between the referral date and the Start of Care date. On 3/1/24 at 2:20pm the following notes were provided: The Client Coordination Note Report documents: “Note Date: 02/08/2023 Note: As per Name (Name of Agency) PT (patient) was DC (discharge on 2/8/23. The Client Coordination Note Report documents: Note Date: 02/10/2023: As per Administrator, family called to schedule visit for today.” The Registered Nurse Start of Care OASIS lacks documented evidence of an accurate assessment of the patient receiving home health services from a different home health provider 60 days prior. No additional information was provided. 1. Patient #1 has a Start of Care date of 02/08/2023 and a discharge date of 04/14/2023 with the following diagnoses "Unstageable Pressure Ulcer of Right Heel, Chronic Obstructive Pulmonary Disease" documented in the Home Health Certification and Plan of Care dated 02/08/2023 to 04/08/2023 and 04/09/2023 to 08/07/2023. The Visit Note Report (Admission) dated 02/08/2023 documents: Does the patient have at least one unhealed pressure ulcer at Stage 2 or higher or designated as unstageable? NO The Visit Note Report (Subsequent visit) dated 04/14/2023 documents: Wound Assessment #1 Rt (right) heel, Rt (right) Unstage (unstageable); Granulation tissue 25%; Epithelialization 50-<75%; Necrotic Tissue Type: None. The Visit Note Report (Discharge Data Collection Only) dated 04/14/2023 documents: The Oldest Stage 2 pressure ulcer that is present at discharge: Was present at the most recent SOC/ROC (start of care / resumption of care) assessment. Current number of unhealed pressure ulcers at stage 2: 1 Number of these stage 2 pressure ulcers that were present at most recent SOC/ROC (start of care / resumption of care)? 1 Current number of unhealed pressure ulcers at unstageable: non-removable dressing: 0 Current number of unhealed pressure ulcers at unstageable: slough and/or eschar: 0 Current number of unhealed pressure ulcers at unstageable: deep tissue injury: 0 Stage of most problematic unhealed pressure ulcer that is stageable: Stage 2. The Discharge OASIS lacks documented evidence of an accurate reflection of patient’s status – with unstageable pressure ulcer and no stage 2 on start of care or on discharge. On 02/27/2024 at 01:50pm, the Directors of Patient Services and the Director of Education were interviewed and did not provide an explanation for the findings. 2. Patient #2 has a Start of Care date of 10/20/2022 and a discharge date of 10/10/2023 with the following diagnoses "Malignant Neoplasm of Unspecified Site of Left Female Breast; Type 2 Diabetes Mellitus without Complications" documented in the Home Health Certification and Plan of Care dated 08/16/2023 to 10/14/2023. The Visit Note Report (Discharge from Agency) dated 10/10/2023 documents: “Emergent Care: At the time of or at any time since the most recent SOC/ROC (start of care / resumption of care) assessment has the patient utilized a hospital emergency department? YES, used hospital emergency department without hospital admission.” “Reason for emergent care: for what reason(s) did the patient seek and/or receive emergent care (with or without hospitalization)? Improper medication administration, adverse drug reactions, medication side effects, toxicity, anaphylaxis; hypo/hyperglycemia, diabetes out of control.” The Discharge OASIS lacks documented evidence of an accurate reflection of patient’s status – no emergent care and no hypo/hyperglycemia. On 02/28/2024 at 12:41pm, the Director of Quality Measure/Compliance was interviewed and stated, “there was no ER (emergency room) visit, it was documentation error”, no further explanation for the findings provided. 3. Patient #5 has a Start of Care date of 08/09/2023 and a discharge date of 02/01/2024 with the following diagnoses "Type 2 Diabetes Mellitus with Mild Non-proliferative Diabetic Retinopathy without Macular Edema, Peripheral Vascular Disease" documented in the Home Health Certification and Plan of Care dated 12/07/2023 to 02/04/2024. The Visit Note Report (Resumption of Care) dated 09/06/2023 documents: Does the patient have at least one unhealed pressure ulcer at Stage 2 or higher or designated as unstageable? YES Current number of unhealed pressure ulcers at stage 3: 0 Current number of unhealed pressure ulcers at unstageable: non-removable dressing: 1 Stage of most problematic unhealed pressure ulcer that is stageable: Stage 3 Does this patient have a surgical wound? NO Wound Assessment: “#4 Med edge of Foot, Rt (right), Surgical.” The Resumption of Care OASIS lacks documented evidence of an accurate reflection of patient’s status – no pressure ulcers, with surgical wound. The Visit Note Report (Recertification with Skill) dated 12/05/2023 documents: “Does the patient have at least one unhealed pressure ulcer at stage 2 or higher or designated as unstageable? YES Wound Assessment: “#5 Ant (anterior) Great toe, LT (left) Diab (diabetic) Ulcer” “#4 Med edge of Foot, Rt (right), Surgical.” The Recertification OASIS lacks documented evidence of an accurate reflection of patient’s status – no pressure ulcers, with diabetic and surgical wound. The Visit Note Report (subsequent visit) dated 02/01/2024 documents: Wound Assessment: “#5 Ant (anterior) Great toe, LT (left) Diab (diabetic) Ulcer” “#4 Med edge of Foot, Rt (right), Surgical.” The Visit Note Report (Discharge Data Collection only) dated 02/01/2024 documents: “Does the patient have at least one unhealed pressure ulcer at stage 2 or higher or designated as unstageable? YES Number of stage 2 pressure ulcers that were present at most recent SOC/ROC (start of care/ resumption of care)? 1 Stage of most problematic unhealed pressure ulcer that is stageable: Stage 2 Does this patient have a surgical wound? NO The Discharge OASIS lacks documented evidence of an accurate reflection of patient’s status – no pressure ulcers, with diabetic and surgical wound. On 02/28/2024 at 12:41pm, the Director of Quality Management/Compliance was interviewed and did not provide an explanation for the findings.

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 clinical records review and staff interview the agency failed to ensure that all patients informed about changes in planned care. This was evident for three (3) of twenty-five (25) clinical records reviewed (Patient: #4, #7, and 13). Failure to ensure that all patients are informed about changes in planned care, has the potential for negative patient outcomes. The Finding Are: 3. Patient #13 has a Start of Care date of 03/15/2023 with diagnoses Encounter for Surgical Aftercare Following Surgery on the Genitourinary System, Malignant Neoplasm of Prostate, Presence of Urogenital Implants documented in the Home Health Certification and Plan of Care dated 03/15/2023 to 05/13/2023. The Home Health Certification and Plan of Care dated 03/15/2023 to 05/13/2023 documents: “hha (home health aide) effective (week of) 03/19/2023 5WK5 (five days (Monday-Friday) a week for five weeks)” for “4 Hours” a day. The aide Duty Sheet dated 03/22/0223 documents an initial aide service date of 03/22/2023 (Wednesday) for two hours during the week of 03/19/2023. The home health aide vendor communication notes document the following: 03/23/2023 - “Aide called out. Patient’s family stated replacement is needed.” 03/23/2023 - “I called Pt (Patient) (family) to inform (vendor) is still looking (for) coverage today. Pt (Patient) (family) is very upset because the repl (replacement) is not found in time.” 03/23/2023 - “We care currently looking for a replacement aide for Pt (Patient) because Pt (Patient) (family) requested to remove hha (home health aide) (assigned 03/22/2023) from the calendar because (aide) called out today on 03/23/2023 and yesterday (aide) arrive(d) late. (Patient’s family) is aware we are currently looking for a replacement aide that is able to take case permanently.” 03/24/2023 – “(Patient family) has called following up on status of aide; (family) was informed (initial aide assigned 03/22/2023) was scheduled for 9am. (Family) is upset bc (because) aide (name) was suppose to be removed; (family) was informed by coordinator (patient) would be getting a replacement. Case has been opened up.” 3/24/2024 – “(Vendor) unable to provide replacement (aide) coverage (no show, no replacement);” “Please be advised that Pt(Patient) (family) is aware that replacement aide was not found (family) is very upset (family) stated (family) no longer wants to keep waiting for an aide.” The clinical record lacks documented evidence of the patient/family being informed and agreeing to the initial aide returning on 03/24/2023. The clinical record documents the agency failed respect the patient/family’s request/choice on 03/23/2023 to remove and replace the aide initially assigned. There is no documented evidence the agency respecting the patient/family’s care choices and preferences regarding home health aide services. On 02/29/2024 at 2:30 PM, the Administrator. The Director of Patient Services, and the Director of Quality Management/Compliance were interviewed and did not provide an explanation for the finding. 2. Patient #7 has a Start of Care date of 12/09/2021 and discharge date of 12/21/2021 with the following diagnoses “Parkinson’s Disease, Essential (Primary) Hypertension, Hypothyroidism” documented on the Home Health Certification and Plan of Care for the Certification Period 12/09/2021 to 02/06/2021. The Home Health Certification and Plan of Care for the Certification Period 12/09/2021 to 02/06/2021 documents:” HHA (Home Health Aide) effective 12/12/2021 5WK 3 (five days a week for three week)” The Clinical Record lacks documented evidence of the patient receiving the Home Health Aide services. There is no documented evidence of the patient being informed of the hha (home health aide) services changes. On 02/29/2024 at 03:30 PM, the Administrator, the Director of Patient Services, and the Director of Quality Management/Compliance were interviewed and did not provide an explanation for the finding. 1. Patient #4 (not admitted to the agency). The Client Coordination Note Report dated 12/26/2023 documents: “Date of missed visit: 12/19/23. Visit was not completed due to NTUC (not taken under care) and DNTB (do not take back) upon initial assessment.” The Email Print-out dated 12/21/2023 documents: “Upon inspecting the home and status of the patient, (patient #4), I am deeming that it is unsafe to enroll this patient into homecare. Patient has multiple large dogs that has torn his catheter bag. The dogs are not well trained and has no barrier to separate from patient or trained professionals as they jump over a gate with ease. One of the dogs jumped on me preventing me from moving creating a hazard and barrier to continue my job. The home has a strong foul odor of what it seems to be dog urine. The hallway floors of the home are covered in clumps of wet dog hair. There are many sanitization hazards throughout the home with hoarding being a tremendous problem. The living space of where the patient stays is small, and he is chair bound. Patient #4 has admitted to lying about his clinical status to his family so he can get discharged home via ambulette. His daughter and SIL (son in law) was shocked when he arrived that he was not able to move on his own. His daughter and SIL (son in law) seems overwhelmed and unfit to care for the patient. I highly recommend that the patient be referred to a skilled nursing facility as he needs around the clock professional help in a safe environment.” The clinical record lacks documented evidence of patient being informed of non-acceptance during the initial assessment. On 02/28/2024 at 02:30pm, the Administrator, the Directors of Patient Services and the Director of Quality Management/Compliance were interviewed and did not provide an explanation for the findings.

Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health 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) that a discharge for cause is being considered; This ELEMENT is not met as evidenced by: Based on clinical records review and staff interview the agency failed to advise the patient that a discharge for cause is being considered. This was evident for one (1) of twenty-five (25) clinical records reviewed (Patient: #5). Failure to advise the patient that a discharge for cause is being considered, has the potential for negative patient outcomes. The Finding Are: 1. Patient #5 has a Start of Care date of 08/09/2023 and a discharge date of 02/01/2024 with the following diagnoses "Type 2 Diabetes Mellitus with Mild Non-proliferative Diabetic Retinopathy without Macular Edema, Peripheral Vascular Disease" documented in the Home Health Certification and Plan of Care dated 12/07/2023 to 02/04/2024. The Email Print-Out thread from Registered Nurse documents: 02/03/2024 “After he told me all the bad words that he possibly could, I decided to pick up my items and leave the bedroom in a rush. The patient started walking VERY WELL and followed me to the living room to keep yelling at me.” “He was very fast, but I managed to run faster and take the emergency door to the stairs. I jumped all the stairs until I got to the first floor before him. I got in my car and left him behind.” 02/06/2024 at 12:17pm “Pt (patient) calling, was pt (patient) and MD (medical doctor) informed case will be d/c (discharge). I have to call pt (patient) back please let us know.” 02/06/2024 at 2:03pm “I tried reaching pt (patient) no answer.” 02/09/2024 at 10:31am “(name) was pt (patient) and MD (medical doctor) told of d.c (discharge)” 02/09/2024 at 11:41am “Please be advised that I have already informed the doctor.” There is no documented evidence that the agency advised the patient of discharge for cause. On 02/28/2024 at 02:30pm, the Administrator, the Directors of Patient Services, and the Director of Quality Management/Compliance were interviewed and did not provide an explanation for the findings.

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 clinical records review and staff interview the agency failed to complete investigation of all complaints. This was evident for two (2) of twenty-five (25) clinical records reviewed (Patient: #18, and #19). Failure to complete investigation of all complaints, has the potential for negative patient outcomes. The Finding Are: 1. Patient #18 has a Start of Care date of 05/19/23 and discharge date of 7/13/23 with diagnoses “Essential (Primary) Hypertension, Unspecified Atrial Fibrillation, Unspecified Diastolic (Congestive) Heart Failure,” documented on the Home Health Certification and Plan of Care for Certification Period 5/19/23 to 7/17/23. The HHA eXchange Patient General Notes documents the following: “Created Date: 06/26/2023 12:21 Note: Received call from patient’s daughter stating aide did not show up on 6/23/23 (Friday) and just arrived at case after 12pm today. Aide clocked in out of range at 9am. 06/27/2023 15:20 Note: Client daughter stated she informed aide on 6/26 not to return to pt.(patient) 06/27/2023 14:47 Note: did aide work today we received a DOH (Department of Health) call. 06/27/2023 15:02 Note: Aide clock out but never service client.” There is no documented evidence of a complaint in the complaint log. The clinical record lacks documented evidence of a complaint investigation regarding the patient’s daughter reporting of the aide’s no show, no home health services being provided on 6/23, and the reason for the aide’s dismissal on 6/26. On 2/29/24 at 3:30pm, the Director of Quality Management/Compliance, the Administrator, and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 2. Patient # 19 has a Start of Care date of 9/24/22 and discharge date of 1/21/23 with diagnoses “Aftercare following Joint Replacement Surgery, Difficulty in Walking, not Elsewhere Classified, Repeated Falls, Muscle Weakness (Generalized)” documented on the Home Health Certification and Plan of Care for Certification Period 9/24/22 to 11/22/22. The HHA eXchange Patient General Notes documents the following: “Created Date: 09/28/2022 12:52 Note: As per a conversation with patient, aide did not show today, please call her back and let her know who will be going. 09/29/2022 15:21 Note: there was a miscommunication with aide, and she was unable to service the client. 10/17/2022 12:20 Note: Please call member as she said her case was closed but is supposed to receive an aide until 11/22/22. There is no documented evidence of a complaint in the complaint log. On 2/29/24 at 3:30PM the Director of Quality Management/Compliance, the Director of Patient Services, and the Administrator, were interviewed and did not provide an explanation for the findings.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on clinical records reviews and staff interview, the agency failed to ensure that all assessments documents an accurate reflection of the patient status. This was evident for two (2) of twenty-five (25) clinical records reviewed (Patient: #1, and #5). Failure to ensure that all assessments documents an accurate reflection of patient status, has the potential for negative patient outcomes. The Findings Are: 1. Patient #1 has a Start of Care date of 02/08/2023 and a discharge date of 04/14/2023 with the following diagnoses "Unstageable Pressure Ulcer of Right Heel, Chronic Obstructive Pulmonary Disease" documented in the Home Health Certification and Plan of Care dated 02/08/2023 to 04/08/2023 and 04/09/2023 to 06/07/2023. The Visit Note Report (Subsequent visit) dated 03/28/2023 and 04/14/2023 documents: "Wound Assessment #1 Rt (right) heel, Rt (right) Unstage (unstageable); Granulation tissue 25%; Epithelialization 50-<75%; Necrotic Tissue Type: None." The Visit Note Report (Discharge Data Collection Only) dated 04/14/2023 documents: "Current number of unhealed pressure ulcers at stage 2: 1 Current number of unhealed pressure ulcers at unstageable: non-removable dressing: 0 Current number of unhealed pressure ulcers at unstageable: slough and/or eschar: 0 Current number of unhealed pressure ulcers at unstageable: deep tissue injury: 0 Stage of most problematic unhealed pressure ulcer that is stageable: Stage 2." There is no documented evidence of an accurate staging of the pressure ulcer – unstageable without slough, eschar, or non-removable dressing; with unstageable and no stage 2 pressure ulcer. There is no documented evidence of an accurate reflection of patient status. On 02/27/2024 at 01:50pm, the Directors of Patient Services, and the Director of Education were interviewed and did not provide an explanation for the findings. 2. Patient #5 has a Start of Care date of 08/09/2023 and a discharge date of 02/01/2024 with the following diagnoses "Type 2 Diabetes Mellitus with Mild Non-proliferative Diabetic Retinopathy without Macular Edema, Peripheral Vascular Disease" documented in the Home Health Certification and Plan of Care dated 12/07/2023 to 02/04/2024. The Visit Note Report (Resumption of Care) dated 09/06/2023 documents: "Does the patient have at least one unhealed pressure ulcer at Stage 2 or higher or designated as unstageable? YES Current number of unhealed pressure ulcers at stage 3: 0 Current number of unhealed pressure ulcers at unstageable: non-removable dressing: 1 Stage of most problematic unhealed pressure ulcer that is stageable: Stage 3 Does this patient have a surgical wound? NO Wound Assessment: “#4 Med edge of Foot, Rt (right), Surgical.” The comprehensive assessment lacks documented evidence of an accurate reflection of patient’s status – no pressure ulcers, with surgical wound. The Visit Note Report (Recertification with Skill) dated 12/05/2023 documents: “Does the patient have at least one unhealed pressure ulcer at stage 2 or higher or designated as unstageable? YES Wound Assessment: “#5 Ant (anterior) Great toe, LT (left) Diab (diabetic) Ulcer” “#4 Med edge of Foot, Rt (right), Surgical.” The comprehensive assessment lacks documented evidence of an accurate reflection of patient’s status – no pressure ulcers, with diabetic and surgical wound. The Visit Note Report (subsequent visit) dated 02/01/2024 documents: Wound Assessment: “#5 Ant (anterior) Great toe, LT (left) Diab (diabetic) Ulcer, #4 Med edge of Foot, Rt (right), Surgical.” The Visit Note Report (Discharge Data Collection only) dated 02/01/2024 documents: “Does the patient have at least one unhealed pressure ulcer at stage 2 or higher or designated as unstageable? YES Number of stage 2 pressure ulcers that were present at most recent SOC/ROC (start of care/ resumption of care)? 1 Stage of most problematic unhealed pressure ulcer that is stageable: Stage 2 Does this patient have a surgical wound? NO" The Visit Note Report documents: "Indicate Integumentary Assessment Findings: no problems identified" on 12/07/2023, 12/09/2023, 12/12/2023, 12/14/2023, 12/16/2023, 12/19/2023, 12/21/2023, 12/23/2023, 12/26/2023, 12/28/2023, 12/30/2023, 01/02/2024, 01/09/2024, 01/11/2024, 01/16/2024, 01/18/2024, 01/20/2024, 01/23/2024, 01/25/2024, 01/27/2024, and 01/30/2024. The comprehensive assessment lacks documented evidence of an accurate reflection of patient’s status – no problems identified for integumentary, with diabetic and surgical wound from 12/05/2023 to 02/01/2024. On 02/28/2024 at 12:41pm, the Director of Quality Management/Compliance was interviewed and did not provide an explanation for the findings.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, record reviews and staff interview, the agency failed to ensure that all patient's medications were reviewed and accurately reflected in the patient's plan of care. This was evident for one (1) of twenty - five (25) clinical records reviewed (Patient: #14). Failure to ensure that all patient's medications are reviewed and accurately reflected in the patient's plan of care, has the potential for negative patient outcomes. The Findings Are: 1. Patient #14 has a Start of Care date of 02/11/2024 with diagnoses Type 2 Diabetes Mellitus without Complications, Dementia, Pleural Effusion, Atelectasis, Essential (Primary) Hypertension, Atrial Fibrillation documented on the Home Health Certification and Plan of Care dated 02/11/2024 to 04/10/2024. The Home Health Certification and Plan of Care dated 02/11/2024 to 04/10/2024 and the Client Medication Report printed 02/25/2024 document the following medication regimen: Hiprex 1 gram tablet (genitourinary/urinary antibacterial therapy), 1 tablet, 2 times daily oral; Lasix 40 mg tablet (diuretic), 1 tablet daily oral. The RN (Registered Nurse) Start of Care comprehensive assessment dated 02/11/2024 documents: Inpatient (Hospital) Discharge Date 02/09/2024; Drug regimen review – “No issues found during review.” On 02/26/2024 at 1:43 PM, an observational home visit with the Skilled Nurse/Registered Nurse was conducted and the patient’s medications were reviewed. The surveyor observed the following prescribed medication that was not listed in the plan of care and the Client medication Report: Docusate take 1 capsule (100mg) by mouth three times per day as needed – prescription “written date 1/2/2024 (prior to the start of care).” The medications Hiprex and Lasix were not observed in the home. The skilled nurse and the patient’s caregiver were interviewed. The caregiver stated the patient “has not taken Hiprex for at least one month,” and Lasix was only to be taken “for one week” after the hospital discharge (on 02/09/2024). The Skilled nurse was interviewed and was not aware of the medication discrepancies. The Skilled Nurse stated the hospital discharge medication list was used to list medications in the plan of care. The Skilled Nurse did not review the medications the patient is currently taking in the home at the start of care. The clinical record lacks documented evidence of the Registered Nurse accurately identifying, reviewing and reconciling all medications the patient is currently taking in the home, as part of the comprehensive assessment. On 02/28/2024 at 2:30 PM, the Administrator, the Director of Patient Services, and the Director of Quality Management/Compliance were interviewed and did not provide an explanation for the finding.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on clinical records review and staff interview the agency failed to ensure that all patients receive services as documented in their individualized plan of care. This was evident for eight (8) of twenty-five (25) clinical records reviewed (Patient: #7, #13, #18, #19, #20, #16, #22, and #24). Failure to ensure that all patients receive services as documented in their individualized plan of care has the potential for negative patient outcomes. The Findings Are: 8. Patient #24 has a Start of Care date of 10/20/2022 with the following diagnoses "Dysphagia Following Cerebral Infarction; Hypertensive Heart and Chronic Kidney Disease with Heart Failure and with Stage 5 Chronic Kidney Disease, or End Stage Renal Disease" documented in the Home Health Certification and Plan of Care dated 10/20/2022 to 12/18/2022. The Home Health Certification and Plan of Care dated 10/20/2022 to 12/18/2022 documents: hha (home health aide) effective 10/23/2022 5WK8 (five times a week for eight weeks). The Client Coordination Note Report dated 10/27/2022 documents: “Spoke to Pt (patient) daughter updating her the aide did a no call no show and coordinator was unaware of that, but will follow up with her with new aide info.” The Client Calendar Report aide providing services on: 10/28/2022, 10/31/2022 to 11/04/2022. There is no documented evidence of the follow up and notification of missed visit on 10/27/2022. There is no documented evidence of the patient receiving aide services as ordered on the plan of care, missing four visits between 10/23/2022 to 10/29/2022. On 02/28/2024 at 02:30pm, the Administrator, the Directors of Patient Services and the Director of Quality Management/Compliance were interviewed and did not provide an explanation for the findings. 1.Patient#7 has a Start of Care date of 12/09/2021 and discharge date of 12/21/2021 with the following diagnoses “Parkinson’s Disease, Essential (Primary) Hypertension, Hypothyroidism” documented on the Home Health Certification and Plan of Care for the Certification Period 12/09/2021 to 02/06/2021. The Home Health Certification and Plan of Care for the Certification Period 12/09/2021 to 02/06/2021 documents:” SN (Skilled Nurse) 1WK4 (one time per week for four weeks), PT (Physical Therapy) Eval. (Evaluation), HHA (Home Health Aide) effective 12/12/2021 5WK 3 (five days a week for three week)” The Supplemental Orders dated 12/14/2021 documents: “Physical Therapist to evaluate/assess and develop Physical Therapy Plan of Care to be signed by the Physician. PT (Physical Therapy) eval. treat as of 12/15/21.” The Clinical Record lacks documented evidence of the PT (Physical Therapy) evaluation the week of 12/09/2021, 12/12/2021 and no documented evidence of the patient receiving PT (Physical Therapy) services. The Clinical Record lacks documented evidence of the patient receiving Home Health Aide services. On 02/29/2024 at 03:30 pm, the Administrator, the Directors of Patient Services and the Director of Quality Management/Compliance were interviewed and did not provide an explanation. 2. Patient #13 has a Start of Care date of 03/15/2023 with diagnoses Encounter for Surgical Aftercare Following Surgery on the Genitourinary System, Malignant Neoplasm of Prostate, Presence of Urogenital Implants documented in the Home Health Certification and Plan of Care dated 03/15/2023 to 05/13/2023. The Home Health Certification and Plan of Care dated 03/15/2023 to 05/13/2023 documents: “hha (home health aide) effective (week of) 03/19/2023 5WK5 (five days a week (Monday-Friday) for five weeks)” for “4 Hours” a day. The aide Duty Sheet documents one aide visit on 03/22/2023 (Wednesday) for two hours during the week of 03/19/2023. The clinical record lacks documented evidence of aide service being provided prior to 03/22/2023. The clinical record documents four missed visits during the week of 03/19/2023 and a delay in initiating aide services. The aide Duty sheet dated 03/22/2023 lacks documented evidence of the patient receiving aide service for four hours as ordered in the plan of care. The aide vendor communication notes document the following regarding missed visits: 03/23/2023 - “Aide called out. Patient’s family stated replacement is needed;” 03/23/2023 - “I called Pt (Patient) (family) to inform (vendor) is still looking (for) coverage today. Pt (Patient) (family) is very upset because the repl (replacement) is not found in time;” “coordinator please f/u (follow-up).” 03/23/2023 - “We care currently looking for a replacement aide for Pt (Patient) because Pt (Patient) (family) requested to remove hha (home health aide) (assigned 03/22/2023) from the calendar because (aide) called out today on 03/23/2023 and yesterday (03/22/2023) (aide) arrive(d) late. (Patient’s family) is aware we are currently looking for a replacement aide that is able to take case permanently.” 03/23/2023 – “Please be advised that an aide was found today but Pt (Patient) (family) stated (family) no longer needs the aide because Pt (Patient) has a medical appointment at 1pm.” 03/24/2023 – “(Patient family) has called following up on status of aide; was informed (aide assigned 03/22/2023) was scheduled for 9am. (Family) is upset bc(because) aide (name) was suppose(d) to be removed; (family) was informed by coordinator (patient) would be getting a replacement. Case has been opened up.” 03/24/2024 – “(Vendor) unable to provide replacement (aide) coverage (no show, no replacement);” “Please be advised that Pt(Patient) (family) is aware that replacement aide was not found (family) is very upset (family) stated (family) no longer wants to keep waiting for an aide.” The agency failed to timely remove the aide from the case as requested on 03/23/2023 and find and assign a replacement aide to provide services on 03/24/2023. The Clinical Record lacks documented evidence of the patient receiving home health aide services five days a week as ordered in the plan of care. On 02/29/2024 at 2:30 PM, the Administrator, the Director of Patient Services, and the Director of Quality Management/Compliance were interviewed and did not provide an explanation for the finding. 3. Patient #18 has a Start of Care date of 05/19/23 and discharge date of 7/13/23 with diagnoses “Essential (Primary) Hypertension, Unspecified Atrial Fibrillation, Unspecified Diastolic (Congestive) Heart Failure,” documented on the Home Health Certification and Plan of Care for Certification Period 5/19/23 to 7/17/23. The Home Health Certification and Plan of Care for Certification Period 5/19/23 to 7/17/23 documents “HHA (Home Health Aide) Effective 05/21/2023: 4WK1, 5WK6 5 DX4H: Effective: 7/9/23: 4WK 1 (Four times for one week, five times a week for six weeks – five days a week for four hours). The HHA eXchange Duty Sheet documents: Monday 6/26/23: TimeIn: 12:00 TimeOut13:00 Total Hours: 01:00 The clinical record lacks documented evidence of the patient receiving the number of service hours as ordered in the Plan of Care. The Client Calendar Report documents “Visit Date: Begin Time: End Time: Service Code: The Client Calendar Report lacked documented evidence of four home health aide visits for the week 5/21/2023 (and five documented visits for the week 6/18/23 (missed visit 6/22). The Aides Care Plan Report documents “Care Plan Category/ Service: Frequency: Daily: Bathing-Shower with Chair: Dressing: Stand-By Assistance with ambulation: Assist to toilet: Provide Medication Reminders: Prepare Meal: Home Exercise Program: Shampoo: Frequency: 3XWeekly (three times a week) The HHA eXchange Duty Sheet lacks documented evidence of all daily services being provided as ordered for the following dates:/6/1,6/2, 6/6, 6/8, 6/21, 6/26, 6/29, 6/30, 7/3, 7/4, 7/5, 7/6, 7/7, 7/10,7/11, 7/12, 7/13, The HHA eXchange Duty Sheet lacks documented evidence of the following services being provided three times a week as ordered in the Plan of Care for the following dates: Weeks ending of 6/30, 7/7,7/14, The clinical record lacks documented evidence of home health services being provided as ordered in the Plan of Care. On 2/30/24 at 3:00pm, the Administrator, the director of Patient Services and the Director of Quality Management/compliance were interviewed and did not provide an explanation. 4.Patient # 19 has a Start of Care date of 9/24/22 and discharge date of 1/21/23 with diagnoses “Aftercare following Joint Replacement Surgery, Difficulty in Walking, not Elsewhere Classified, Repeated Falls, Muscle Weakness (Generalized)” documented on the Home Health Certification and Plan of Care for Certification Period 9/24/22 to 11/22/22. The Home Health Certification and Plan of Care for Certification Period 9/24/22 to 11/22/22 documents: HHA (Home Health Aide) 5 Day/4 hrs/Per Day- Mon to Fri (Five days for four hours per day- Monday through Friday). The Client Calendar Report lacks documented evidence of home health aide services being provided on 9/28, 9/29, and 10/17/22 as ordered in the Plan of Care. The Aide Care of Plan Report documents: “Care Plan Category/ Service: Assist to Toilet: Assist TO Bedside Commode Shower with Chair: Prepare Meal: Offer Fluids: Apply Lotion: Every Visit.” There is no documented evidence of all services being provided on every visit as ordered in the Plan of Care for the following dates: 9/27, 9/30, 10/3, 10/4, 10/5, 10/6, 10/7, 10/10, 10/11, 10/12, 10/13,10/14, 10/19, 10/20, 10/21, 10/26, 10/27, 10/28, 10/31. The clinical record lacks documented evidence of home health services being provided as ordered in the Plan of Care. On 2/29/24 at 3:30PM the Administrator, the director of Patient Services and the Director of Quality Management/ Compliance were interviewed and did not provide an explanation. 5. Patient #20 has a Start of Care date of 11/28/2023 with diagnosis Non- Pressure Chronic Ulcer Other Part Right Lower Leg with Unspecified Severity, Type 2 Diabetes Mellitus Without Complications, Hyperglycemia, Unspecified, Morbid (Severe) Obesity due to Excess Calories, Anxiety Disorder, Unspecified, Difficulty walking, Not Elsewhere Classified” on the Home Health Certification and Plan of Care for Certification Period 1/27/24 to 3/26/24. The Home Health Certification and Plan of Care for Certification Period 1/27/24 to 3/26/24 documents: Frequency/ Duration of Visits: SN (Skilled Nurse) Effective 01/28/2024 1WK8 ( one time a week for eight weeks). Physician Orders: Order Date: 2/15/24 10:06AM Service Changes: Calendar Frequency: SN (Skilled Nurse) Effective 02/11/2024 2WK1, 3WK5, 1WK1 ( two times a week for one week, three times a week for five weeks, one time for one week). The Client Calendar Report Documents: Skilled Nurse visit for visit date 2/1, 2/15 and 2/17. The clinical record lacks documented evidence of the patient receiving a Skilled Nurse visit for the week of 2/4/24 as written in the plan of care. On 2/29/24 at 3:30PM the Director of Quality Management/ Compliance, the Director of Patient Services, and the Administrator were interviewed and did not provide and explanation for the finding. 6. Patient#16 has a Start of Care date of 07/18/23 with the following diagnoses “Chronic Respiratory Failure With Hypoxia, Chronic Obstructive Pulmonary Disease, and Heart Failure” documented on the Home Health Certification and Plan of Care for the Certification Period 07/18/23 to 09/15/23. The Home Health Certification and Plan of Care for the Certification Period 07/18/23 to 09/15/23 documents: “HHA (Home Health Aide) 3wk1 (three days a week for one week), 5wk 7 (five days a week for seven weeks).” The Clinical Record lacks documented evidence of the patient receiving Home Health Aide services in week one (07/18 – 7/22), and week two (07/23-7/29). On 02/29/2024 at 03:30 pm, the Administrator, the Directors of Patient Services and the Director of Quality Management/Compliance were interviewed and did not provide an explanation. 7. Patient#22 has a Start of Care date of 01/23/23 with the following diagnoses “Autistic Disorder, and Other Abnormalities of Gait and Mobility” documented on the Home Health Certification and Plan of Care for the Certification Period 01/18/24 to 03/17/24. The Home Health Certification and Plan of Care for the Certification Period 01/18/24 to 03/17/24documents: “HHA (Home Health Aide) Friday 2 hours, Saturday 12 hours, Sunday 5 hours” The Clinical Record lacks documented evidence of the patient receiving Home Health Aide services on 01/19, 01/20, 01/21, 01/26, 2/2, 2/9, 2/18, 02/23, 02/24, and 02/25. On 02/29/2024 at 03:30 pm, the Administrator, the Directors of Patient Services and the Director of Quality Management/Compliance were interviewed and did not provide an explanation.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical records review and staff interview the agency failed to ensure each individualized plan of care includes all the required information. This was evident for eight (8) of twenty-five (25) clinical records reviewed (Patient: #1, #2, #5, #12, #14, #15, #19, and #20). Failure to ensure each individualized plan of care includes all the required information, has the potential for negative patient outcomes. The Findings Are: 1. Patient #1 has a Start of Care date of 02/08/2023 and a discharge date of 04/14/2023 with the following diagnoses "Unstageable Pressure Ulcer of Right Heel, Chronic Obstructive Pulmonary Disease" documented in the Home Health Certification and Plan of Care dated 02/08/2023 to 04/08/2023 and 04/09/2023 to 08/07/2023. The Visit Note Report dated 02/08/2023, 03/15/2023, 03/17/2023, 03/28/2023, and 04/14/2023 documents: “How frequent are blood sugars checked? 3X (three times) daily.” The plan of care lacks documented evidence of the frequency of blood sugar monitoring. On 02/27/2024 at 01:50pm, the Directors of Patient Services and the Director of Education were interviewed and did not provide an explanation for the findings. 2. Patient #2 has a Start of Care date of 10/20/2022 and a discharge date of 10/10/2023 with the following diagnoses "Malignant Neoplasm of Unspecified Site of Left Female Breast; Type 2 Diabetes Mellitus without Complications" documented in the Home Health Certification and Plan of Care dated 08/16/2023 to 10/14/2023. The Visit Note Report dated 08/11/2023, 08/14/2023, and 10/10/2023 documents: “How frequent are blood sugars checked? BID (twice a day).” The plan of care lacks documented evidence of the frequency of blood sugar monitoring. On 02/27/2024 at 01:50pm, the Directors of Patient Services and the Director of Education were interviewed and did not provide an explanation for the findings. 3. Patient #5 has a Start of Care date of 08/09/2023 and a discharge date of 02/01/2024 with the following diagnoses "Type 2 Diabetes Mellitus with Mild Non-proliferative Diabetic Retinopathy without Macular Edema, Peripheral Vascular Disease" documented in the Home Health Certification and Plan of Care dated 12/07/2023 to 02/04/2024. The Visit Note Report dated 12/05/2023 documents: “How frequent are blood sugars checked? daily.” The Visit Note Report dated 12/07/2023, 12/12/2023, 12/19/2023, 01/30/2024 and 02/01/2024 documents: “How frequent are blood sugars checked? BID (twice a day).” The plan of care lacks documented evidence of the frequency of blood sugar monitoring. On 02/27/2024 at 01:50pm, the Directors of Patient Services and the Director of Education were interviewed and did not provide an explanation for the findings. Patient #12 has a Start of Care date of 01/17/2024 with diagnoses Encounter for Surgical Aftercare Following Surgery on the Genitourinary System, Malignant Neoplasm of Prostate, Presence of Urogenital Implants documented in the Home Health Certification and Plan of Care dated 01/17/2024 to 03/16/2024. The Home Health Certification and Plan of Care dated 01/17/2024 to 03/16/2024 documents: Skilled Nurse for instructions/reinforcement of “blood glucose (sugar) testing.” The RN (Registered Nurse) Start of Care assessment dated 01/17/2024 documents: Endocrine hematopoietic assessment – Diabetes; blood sugar checked “daily.” The Skilled Nurse Visit Note dated 02/09/2024 documents the patient blood sugar is checked “2 time(s) daily.” The Home Health Certification and Plan of Care lacks documented evidence of a diabetes diagnosis and the frequency to monitor/test blood glucose levels. On 02/28/2024 at 2:30 PM, the Administrator. The Director of Patient Services, and the Director of Quality Management/Compliance were interviewed and did not provide an explanation for the finding. Patient #14 has a Start of Care date of 02/11/2024 with diagnoses Type 2 Diabetes Mellitus without Complications, Dementia, Pleural Effusion, Atelectasis, Essential (Primary) Hypertension, Atrial Fibrillation documented on the Home Health Certification and Plan of Care dated 02/11/2024 to 04/10/2024. The Home Health Certification and Plan of Care dated 02/11/2024 to 04/10/2024 documents: Skilled Nurse for instructions/reinforcement of “blood glucose (sugar) testing.” The RN (Registered Nurse) Start of Care assessment dated 02/11/2024 documents: Blood sugar checked “daily.” The Home Health Certification and Plan of Care lacks documented evidence of the frequency to monitor/test blood glucose levels. On 02/28/2024 at 2:30 PM, the Administrator. The Director of Patient Services, and the Director of Quality Management/Compliance were interviewed and did not provide an explanation for the finding. Patient #15 has a Start of Care date of 12/14/2019 with diagnoses Essential (Primary) Hypertension, Type 2 Diabetes Mellitus without Complications documented on the Home Health Certification and Plan of Care dated 01/22/2024 to 03/21/2024. The Home Health Certification and Plan of Care dated 01/22/2024 to 03/21/2024 documents: Skilled Nurse for instructions/reinforcement of “blood glucose (sugar) testing.” The RN (Registered Nurse) Recertification assessment dated 01/17/2024 documents: “BS (Blood Sugar) monitored by MD (Medical Doctor).” The subsequent Skilled Nurse Visit Notes dated 01/31/2024 and 02/14/2024 documents the patient blood sugar is checked “PRN (as needed),” and the patient’s usual blood sugar reading is “130 (on 1/31/2024)” and “121 (on 2/14/2024).” During an observational home visit on 02/27/2024 at 11:00 AM, the Skilled Nurse was interviewed. The Skilled Nurse stated the "patient’s doctor monitors" the patient's blood sugar level, and the patient does not perform blood sugar testing. The Home Health Certification and Plan of Care lacks documented evidence of how the patient’s blood sugar level is monitor and the frequency blood sugar is monitored. On 02/28/2024 at 2:30 PM, the Administrator. The Director of Patient Services, and the Director of Quality Management/Compliance were interviewed and did not provide an explanation for the finding. Patient # 19 has a Start of Care date of 9/24/22 and discharge date of 1/21/23 with diagnoses “Aftercare following Joint Replacement Surgery, Difficulty in Walking, not Elsewhere Classified, Repeated Falls, Muscle Weakness (Generalized)” documented on the Home Health Certification and Plan of Care for Certification Period 9/24/22 to 11/22/22. The Home Health Certification and Plan of Care for Certification Period 9/24/22 to 11/22/22 documents: Frequency / Duration of Visits: “SN (Skilled Nurse) For Post Op Care: HHA (Home Health Aide) 5 Day/4 hrs/Per Day- Mon to Fri (Five days for four hours per day- Monday through Friday).” The Plan of Care lacks documented evidence of the frequency and duration for the Skilled Nurse visits. The Plan of Care lacks documented evidence of the duration for the Home health aide visits. On 2/30/24 at 3:30PM the Director of Quality Measures, the Director of Patient Services, and the Administrator were interviewed and did not provide an explanation for the findings. Patient #20 has a Start of Care date of 11/28/2023 with diagnosis Non- Pressure Chronic Ulcer Other Part Right Lower Leg with Unspecified Severity, Type 2 Diabetes Mellitus Without Complications, Hyperglycemia, Unspecified, Morbid (Severe) Obesity due to Excess Calories, Anxiety Disorder, Unspecified, Difficulty walking, Not Elsewhere Classified” on the Home Health Certification and Plan of Care for Certification Period 1/27/24 to 3/26/24. The Home Health Certification and Plan of Care for Certification Period 1/27/24 to 3/26/24 documents: Skilled Nurse to assess/evaluate co-morbid conditions, report BS (Blood Sugar) 240. The Plan of Care lacks documented evidence for patient diabetic education, frequency for monitoring, reporting, and appropriate instructions for elevated blood glucose levels. The clinical lacks documented evidence that the Plan of Care is complete. On 2/29/24 at 3:30PM the Director of Quality Measures, the Director of Patient Services, and the Administrator were interviewed and did not provide an explanation for the findings. 1. Patient # 19 has a Start of Care date of 9/24/22 and discharge date of 1/21/23 with diagnoses “Aftercare following Joint Replacement Surgery, Difficulty in Walking, not Elsewhere Classified, Repeated Falls, Muscle Weakness (Generalized)” documented on the Home Health Certification and Plan of Care for Certification Period 9/24/22 to 11/22/22. The Home Health Certification and Plan of Care for Certification Period 9/24/22 to 11/22/22 documents: "Frequency / Duration of Visits: SN (Skilled Nurse) For Post Op Care: HHA (Home Health Aide) 5 Day/4 hrs/Per Day- Mon to Fri (Five days for four hours per day- Monday through Friday).” The Plan of Care lacks documented evidence of the frequency and duration for the Skilled Nurse visits. The Plan of Care lacks documented evidence of the duration for the Home health aide visits. On 2/30/24 at 3:30PM the Director of Quality Management/Compliance, the Director of Patient Services, and the Administrator were interviewed and did not provide an explanation for the findings. 2. Patient #20 has a Start of Care date of 11/28/2023 with diagnosis Non- Pressure Chronic Ulcer Other Part Right Lower Leg with Unspecified Severity, Type 2 Diabetes Mellitus Without Complications, Hyperglycemia, Unspecified, Morbid (Severe) Obesity due to Excess Calories, Anxiety Disorder, Unspecified, Difficulty walking, Not Elsewhere Classified” on the Home Health Certification and Plan of Care for Certification Period 1/27/24 to 3/26/24. The Home Health Certification and Plan of Care for Certification Period 1/27/24 to 3/26/24 documents: "Skilled Nurse to assess/evaluate co-morbid conditions, report BS (Blood Sugar) 240." The Plan of Care lacks documented evidence for patient diabetic education, and frequency for monitoring BS(Blood Sugar). The clinical lacks documented evidence that the Plan of Care is complete. On 2/29/24 at 3:30PM the Director of Quality Management/Compliance, the Director of Patient Services, and the Administrator were interviewed and did not provide an explanation for the findings. 3. Patient #12 has a Start of Care date of 01/17/2024 with diagnoses Encounter for Surgical Aftercare Following Surgery on the Genitourinary System, Malignant Neoplasm of Prostate, Presence of Urogenital Implants documented in the Home Health Certification and Plan of Care dated 01/17/2024 to 03/16/2024. The Home Health Certification and Plan of Care dated 01/17/2024 to 03/16/2024 documents: "Skilled Nurse for instructions/reinforcement of “blood glucose (sugar) testing.” The Home Health Certification and Plan of Care lacks documented evidence of a diabetes diagnosis and the frequency to monitor/test blood glucose levels. On 02/28/2024 at 2:30 PM, the Administrator. The Director of Patient Services, and the Director of Quality Management/Compliance were interviewed and did not provide an explanation for the finding. 4. Patient #14 has a Start of Care date of 02/11/2024 with diagnoses Type 2 Diabetes Mellitus without Complications, Dementia, Pleural Effusion, Atelectasis, Essential (Primary) Hypertension, Atrial Fibrillation documented on the Home Health Certification and Plan of Care dated 02/11/2024 to 04/10/2024. The Home Health Certification and Plan of Care dated 02/11/2024 to 04/10/2024 documents: Skilled Nurse for instructions/reinforcement of “blood glucose (sugar) testing.” The Home Health Certification and Plan of Care lacks documented evidence of the frequency to monitor/test blood glucose levels. On 02/28/2024 at 2:30 PM, the Administrator. The Director of Patient Services, and the Director of Quality Management/Compliance were interviewed and did not provide an explanation for the finding. 5. Patient #15 has a Start of Care date of 12/14/2019 with diagnoses Essential (Primary) Hypertension, Type 2 Diabetes Mellitus without Complications documented on the Home Health Certification and Plan of Care dated 01/22/2024 to 03/21/2024. The Home Health Certification and Plan of Care dated 01/22/2024 to 03/21/2024 documents: Skilled Nurse for instructions/reinforcement of “blood glucose (sugar) testing.” The RN (Registered Nurse) Recertification assessment dated 01/17/2024 documents: “BS (Blood Sugar) monitored by MD (Medical Doctor).” The subsequent Skilled Nurse Visit Notes dated 01/31/2024 and 02/14/2024 documents the patient blood sugar is checked “PRN (as needed),” and the patient’s usual blood sugar reading is “130 (on 1/31/2024)” and “121 (on 2/14/2024).” During an observational home visit on 02/27/2024 at 11:00 AM, the Skilled Nurse was interviewed. The Skilled Nurse stated the "patient’s doctor monitors" the patient's blood sugar level, and the patient does not perform blood sugar testing. The Home Health Certification and Plan of Care lacks documented evidence of how the patient’s blood sugar level is monitor and the frequency blood sugar is monitored. On 02/28/2024 at 2:30 PM, the Administrator. The Director of Patient Services, and the Director of Quality Management/Compliance were interviewed and did not provide an explanation for the finding. 6. Patient #1 has a Start of Care date of 02/08/2023 and a discharge date of 04/14/2023 with the following diagnoses "Unstageable Pressure Ulcer of Right Heel, Chronic Obstructive Pulmonary Disease" documented in the Home Health Certification and Plan of Care dated 02/08/2023 to 04/08/2023 and 04/09/2023 to 08/07/2023. The Visit Note Report dated 02/08/2023, 03/15/2023, 03/17/2023, 03/28/2023, and 04/14/2023 documents: “How frequent are blood sugars checked? 3X (three times) daily.” The plan of care lacks documented evidence of the frequency of blood sugar monitoring. On 02/27/2024 at 01:50pm, the Directors of Patient Services and the Director of Education were interviewed and did not provide an explanation for the findings. 7. Patient #2 has a Start of Care date of 10/20/2022 and a discharge date of 10/10/2023 with the following diagnoses "Malignant Neoplasm of Unspecified Site of Left Female Breast; Type 2 Diabetes Mellitus without Complications" documented in the Home Health Certification and Plan of Care dated 08/16/2023 to 10/14/2023. The Visit Note Report dated 08/11/2023, 08/14/2023, and 10/10/2023 documents: “How frequent are blood sugars checked? BID (twice a day).” The plan of care lacks documented evidence of the frequency of blood sugar monitoring. On 02/27/2024 at 01:50pm, the Directors of Patient Services and the Director of Education were interviewed and did not provide an explanation for the findings. 8. Patient #5 has a Start of Care date of 08/09/2023 and a discharge date of 02/01/2024 with the following diagnoses "Type 2 Diabetes Mellitus with Mild Non-proliferative Diabetic Retinopathy without Macular Edema, Peripheral Vascular Disease" documented in the Home Health Certification and Plan of Care dated 12/07/2023 to 02/04/2024. The Visit Note Report dated 12/05/2023 documents: “How frequent are blood sugars checked? daily.” The Visit Note Report dated 12/07/2023, 12/12/2023, 12/19/2023, 01/30/2024 and 02/01/2024 documents: “How frequent are blood sugars checked? BID (twice a day).” The plan of care lacks documented evidence of the frequency of blood sugar monitoring. On 02/27/2024 at 01:50pm, the Directors of Patient Services, and the Director of Education were interviewed and did not provide an explanation for the findings.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on clinical records review and staff interview, the agency failed to ensure that treatments are administered in accordance with physician orders. This was evident for four (4) of twenty-five (25) clinical records reviewed (Patient: #1, #2, #3, and #5). Failure to ensure that treatments are administered in accordance with physician orders, has the potential for negative patient outcomes. The Findings Are: 1. Patient #1 has a Start of Care date of 02/08/2023 and a discharge date of 04/14/2023 with the following diagnoses "Unstageable Pressure Ulcer of Right Heel, Chronic Obstructive Pulmonary Disease" documented in the Home Health Certification and Plan of Care dated 02/08/2023 to 04/08/2023 and 04/09/2023 to 08/07/2023. The Order dated 03/15/2023 documents: “I am told by the patient’s caregiver that they were instructed to clean the ulcer with NS (normal saline), apply Triple Antibiotic ointment, and then cover with dressing.” There is no documented evidence of the site and frequency for the wound treatment. The Home Health Certification and Plan of Care dated 04/09/2023 to 08/07/2023 documents: “Skilled nurse to perform/teach pressure ulcer care to Right heel. Clean with NS (normal saline), apply triple Antibiotic Ointment, and then cover with dressing.” There is no documented evidence of a complete treatment order. On 02/27/2024 at 01:50pm, the Directors of Patient Services and the Director of Education were interviewed and did not provide an explanation for the findings. 2. Patient #2 has a Start of Care date of 10/20/2022 and a discharge date of 10/10/2023 with the following diagnoses "Malignant Neoplasm of Unspecified Site of Left Female Breast; Type 2 Diabetes Mellitus without Complications" documented in the Home Health Certification and Plan of Care dated 08/16/2023 to 10/14/2023. The Home Health Certification and Plan of Care dated 08/16/2023 to 10/14/2023 documents: “Skilled Nurse to perform/teach wound care to – cleanse with NSS (normal saline solution), apply Puracol, cover with DSD (dry sterile dressing), and secure with border gauze, using clean/aseptic technique. Change dressing 3 X (times) week, and PRN (as needed).” There is no documented evidence of the site for the wound treatment. There is no documented evidence of a complete treatment order. On 02/27/2024 at 01:50pm, the Directors of Patient Services and the Director of Education were interviewed and did not provide an explanation for the findings. 3. Patient #3 has a Start of Care date of 10/25/2023 and a discharge date of 12/04/2023 with the following diagnoses "Displaced Intertrochanteric Fractur Left Femur, Acute Respiratory Failure with Hypoxia, Bilateral Primary Osteoarthritis of Hip" documented in the Home Health Certification and Plan of Care dated 10/25/2023 to 12/23/2023. The Order dated 11/9/2023 documents: Skin tear Right Lower Leg. Calcium Alginate dressing. There is no documented evidence of the frequency of dressing change. There is no documented evidence of a complete treatment order. On 02/27/2024 at 01:50pm, the Directors of Patient Services and the Director of Education were interviewed and did not provide an explanation for the findings. 4. Patient #5 has a Start of Care date of 08/09/2023 and a discharge date of 02/01/2024 with the following diagnoses "Type 2 Diabetes Mellitus with Mild Non-proliferative Diabetic Retinopathy without Macular Edema, Peripheral Vascular Disease" documented in the Home Health Certification and Plan of Care dated 12/07/2023 to 02/04/2024. The Visit Note Report (Recertification with Skill) dated 12/05/2023 documents: “#5 Ant (anterior) Great toe, LT (left) Diab (diabetic) Ulcer - SN (skilled nurse) to perform wound care R. (right) foot, with NS (normal saline), pat dry, apply Santyl, cover with DSD (dry sterile dressing), wrap with Kerlix 2.” “#4 Med edge of Foot, Rt (right), Surgical - SN (skilled nurse) to perform wound care R. (right) foot, with NS (normal saline), pat dry, apply Santyl, cover with DSD (dry sterile dressing), wrap with Kerlix 2.” The Home Health Certification and Plan of Care dated 12/07/2023 to 02/04/2024 lacks documented evidence of the order for wound care to left great toe and right edge of foot. On 02/27/2024 at 01:50pm, the Directors of Patient Services and the Director of Education were interviewed and did not provide an explanation for the findings.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on clinical records review and staff interview, the agency failed to ensure all patients received information regarding the patient’s medication regimen. This was evident for one (1) of twenty-five (25) clinical records reviewed (Patient: #14). Failure to ensure all patients received information regarding the patient’s medication regimen, has the potential for negative patient outcomes. The Findings Are: 1. Patient #14 has a Start of Care date of 02/11/2024 with diagnoses Type 2 Diabetes Mellitus without Complications, Dementia, Pleural Effusion, Atelectasis, Essential (Primary) Hypertension, Atrial Fibrillation documented on the Home Health Certification and Plan of Care dated 02/11/2024 to 04/10/2024. The Home Health Certification and Plan of Care dated 02/11/2024 to 04/10/2024 documents: "Skilled Nurse for Administration of Tresiba (long-acting insulin) 12 Units SQ (Subcutaneous) Injection Daily." On 02/26/2024 at 1:43 PM, an observational home visit with the Skilled Nurse was conducted and the admission booklet provided by the agency was reviewed. The section of the booklet for listing the patient’s medication was not filled in. The Skilled Nurse was interviewed and stated the patient has the hospital discharge summary (prior to the start of care) with a list of discharge medications. The Skilled nurse stated there is “no” medications list from the agency in the home. The hospital “Medication List at Discharge” dated 02/09/2024 lacks documented evidence of reconciling with the medications listed in the agency’s the Home Health Certification and Plan of Care dated 02/11/2024 to 04/10/2024 and Client Medication Report/medication profile at the start of care. The hospital “Medication List at Discharge” does not document the long-acting insulin used to control the patient's blood sugar level. There is no documented evidence of the agency preparing and providing to the patient written information regarding the patient’s medication regimen based on the medication review conducted at start of care. On 02/28/2024 at 2:30 PM, the Administrator, the Director of Patient Services, and the Director of Quality Management/Compliance were interviewed and did not provide an explanation for the finding.

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 physician is maintained. This was evident for two (2) of twenty-five (25) clinical records reviewed (Patient: #6, and #18). Failure to ensure ongoing communication with physician is maintained, has the potential for negative patient outcomes. The Findings Are: Patient #18 has a Start of Care date of 05/19/23 and discharge date of 7/13/23 with diagnoses “Essential (Primary) Hypertension, Unspecified Atrial Fibrillation, Unspecified Diastolic (Congestive) Heart Failure,” documented on the Home Health Certification and Plan of Care for Certification Period 5/19/23 to 7/17/23. The Home Health Certification and Plan of Care for Certification Period 5/19/23 to 7/17/23 documents “HHA (Home Health Aide) Effective 05/21/2023: 4WK1, 5WK6 (Four times for one week, five times a week for six weeks). There is no documented evidence of the Home Health Aide providing services four times for the week starting 4/21 and no visit for 6/22/23. There is no documented evidence of the physician being notified of the missed visits. On 2/29/24 at 3:30pm the Administrator, the Director of Patient Services and the Director of Quality Measures/ Compliance were interviewed and did not provide an explanation. 1.Patient#6 has a Start of Care date of 07/05/2021 and discharge date of 08/31/2021 with the following diagnoses “Spinal stenosis, cervical Region, Essential (Primary) Hypertension, Hyperlipidemia” documented on the Home Health Certification and Plan of Care for the Certification Period 07/05/2021 to 09/02/2021. The Home Health Certification and Plan of Care for the Certification Period 07/05/2021 to 09/02/2021 documents: “Increased pain or ineffective pain control measures will be identified and promptly reported to the Physician.” The SN (Skilled Nurse) Visit dated 07/12/2021 documents:” Indicate Client’s Current pain Scale Rating: 8 Indicate Client’s Pain Scale Rating for Best/Least Intensity of Pain:2 Indicate Client’s Pain Scale Rating for Worst/Most Intensity of Pain:9” The OT (Occupational Therapy) Visit dated 07/30/2021 documents:” Indicate Client’s Current pain Scale Rating: 5 Indicate Client’s Pain Scale Rating for Best/Least Intensity of Pain:3 Indicate Client’s Pain Scale Rating for Worst/Most Intensity of Pain:7” The OT (Occupational Therapy) Visit dated 08/04/2021 documents:” Indicate Client’s Current pain Scale Rating:7 Indicate Client’s Pain Scale Rating for Best/Least Intensity of Pain:6 Indicate Client’s Pain Scale Rating for Worst/Most Intensity of Pain:9” The OT (Occupational Therapy) Visit dated 08/11/2021 documents:” Indicate Client’s Current pain Scale Rating:5 Indicate Client’s Pain Scale Rating for Best/Least Intensity of Pain:2 Indicate Client’s Pain Scale Rating for Worst/Most Intensity of Pain:7” The OT (Occupational Therapy) Visit dated 08/13/2021 documents:” Indicate Client’s Current pain Scale Rating:6 Indicate Client’s Pain Scale Rating for Best/Least Intensity of Pain:3 Indicate Client’s Pain Scale Rating for Worst/Most Intensity of Pain:7” The OT (Occupational Therapy) Visit dated 08/18/2021 documents:” Indicate Client’s Current pain Scale Rating:6 Indicate Client’s Pain Scale Rating for Best/Least Intensity of Pain:4 Indicate Client’s Pain Scale Rating for Worst/Most Intensity of Pain:8” The Clinical Record lacks documented evidence of the communication with the Physician regarding the patient’s pain. On 02/29/2024 at 03:30 pm, the Administrator, the Directors of Patient Services and the Director of Quality Management/Compliance were interviewed and did not provide an explanation.

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on clinical records review and staff interview the agency failed to ensure of an adequate supervision of the Licensed Practical Nurse. This was evident for one (1) of twenty-five (25) clinical records reviewed (Patient: #5). Failure to ensure of an adequate supervision of the Licensed Practical Nurse, has the potential for negative patient outcomes. The Finding Are: 1. Patient #5 has a Start of Care date of 08/09/2023 and a discharge date of 02/01/2024 with the following diagnoses "Type 2 Diabetes Mellitus with Mild Non-proliferative Diabetic Retinopathy without Macular Edema, Peripheral Vascular Disease" documented in the Home Health Certification and Plan of Care dated 12/07/2023 to 02/04/2024. The Home Health Certification and Plan of Care dated 12/07/2023 to 02/04/2024 documents: “12/5/23 Frequency: 3 times week SN (skilled nurse) to assess wound.” The clinical record documents LPN (licensed practical nurse) visits on 12/07/2023, 12/09/2023, 12/12/2023, 12/14/2023, 12/16/2023, 12/19/2023, 12/21/2023, 12/23/2023, 12/26/2023, 12/28/2023, 12/30/2023, 01/02/2024, 01/04/2024, 01/09/2024, 01/11/2024, 01/16/2024, 01/18/2024, 01/20/2024, 01/23/2024, 01/25/2024, 01/27/2024, 01/30/2024, and 02/01/2024. There is no documented evidence that the wound was assessed by the Registered Nurse from 12/07/2023 to 02/01/2024. There is no documented evidence of the licensed practical nurse being supervised by the Registered Nurse from 12/07/2023 to 02/01/2024. On 02/28/2024 at 02:30pm, the Administrator, the Directors of Patient Services, and the Director of Quality Management/Compliance were interviewed and did not provide an explanation for the findings.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on clinical records review and staff interview the agency failed to document the patient’s consistent non-compliance including behavior issues, and refusal of the registered nurse assessment and wound care. This was evident for one (1) of twenty-five (25) clinical records reviewed (Patient: #5). Failure to document the patient’s consistent non-compliance including behavior issues, and refusal of the registered nurse assessment and wound care, has the potential for negative patient outcomes. The Finding Are: 1. Patient #5 has a Start of Care date of 08/09/2023 and a discharge date of 02/01/2024 with the following diagnoses "Type 2 Diabetes Mellitus with Mild Non-proliferative Diabetic Retinopathy without Macular Edema, Peripheral Vascular Disease" documented in the Home Health Certification and Plan of Care dated 12/07/2023 to 02/04/2024. The Email Print-out documents: 05/03/2023 “So this pt (patient) will not allow my nurse to come to do the recert (recertification) he was cursing me” “I told the Pt (patient) if we do not do a recert (recertification) all services will end and he CURSED ME. 11/07/2023 “Patient #5 is a very difficult case, no RN’S (registered nurse) in Bronx want to see him as he threw objects at them, cursed me and other nurses out multiple times on the phone, he only accepts the lpn (licensed practical nurse name) and these missed visits happen to be during his vacation.” 11/08/2023 “we are exhausted all our RNs (registered nurses) in Bronx who can see this pt (patient) for the wound assessments and recerts (recertification).” “patient is rude, aggressive and exhibits racial comments to our staff. Everyone is afraid of this patient!!!” The Email Print-Out thread documents: 02/03/2024 “I was unable to finish the visit.” “Everything was fine until the patient started saying that “(name) of nurse” would go today to his apartment for wound care. I stated that (name) would not go today because I was there to complete the recertification, and I was able to perform the wound care as always. On speakerphone, (name) told the patient that he would go to his apartment when I leave. (Shortly after, I called (name) to find out WHY he was COMING TO VISIT THE PATIENT WITHOUT authorization OR BEING ON THE SCHEDULE?). The conversation between (name) and the patient triggered the patient even more because I was against (name) going to the apartment if I was the nurse assigned to the case already. The patient started to yell at me, very loudly. Coursing (cursing) out, etc. I tried to explain the situation politely, trying to keep it professional.” “After he told me all the bad words that he possibly could, I decided to pick up my items and leave the bedroom in a rush. The patient started walking VERY WELL and followed me to the living room to keep yelling at me.” “HE WANTED TO HURT ME. This patient is a safety issue for Americare’s nurses.” The clinical record lacks documented evidence of the patient’s behavior and refusal with assessment or wound care from 11/08/2023 to 02/03/2024. On 02/28/2024 at 02:30pm, the Administrator, the Directors of Patient Services, and the Director of Quality Management/Compliance were interviewed and did not provide an explanation for the findings.

This Statement of Deficiencies is a result of an on-site investigation of Complaints 98617, 59000, 58999, and 58998, conducted at Americare Certified Special Services, Inc. CHHA, located at 5923 Strickland Avenue, Brooklyn, NY 11234 from 06/13/2023 to 06/15/2023 to evaluate the agency's compliance with Federal regulations. The active patient census was 4227. The investigation consisted of a review of ten (10) clinical records (identified as Patient #1, #2, #3, #4, #5, #6, #7, #8. #9, and #10), three (3) personnel records (Employee #1, #2, and #3), the agency's complaint logs/reports, pertinent policies and procedures, and interviews with the Administrator and the Director of Patient Services. Pre-survey activities consisted of review on 06/12/2023 of the agency's Health Commerce System account and compliance history. Findings were reviewed at the exit conference. The allegations in Complaint 58999 were determined unsubstantiated. The allegations in Complaints 98617, 59000, and 58998 were determined substantiated. The following deficiencies are being cited as result of the survey: G0608 – Coordinate Care Delivery

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 review of clinical record, agency policy and procedure, and interview with agency staff, the agency failed to coordinate care delivery and to involve the patient in coordination of care activities. This was evident for four (4) of ten (10) clinical records reviewed. (Patients #2, #6, #7, and #9). Failure to ensure coordinated care delivery and to involve the patient in the coordination of care has the potential for negative patient outcome. The findings are: 2. Patient #6 has a Start of Care date of 01/28/2021 and a discharge date of 03/09/2021 with the following diagnoses "Displaced Intertrochanteric Fracture of Left Femur, Acute Posthemorrhagic Anemia" documented in the Home Health Certification and Plan of Care dated 01/28/2021 to 03/28/2021. The Admission Client Service Agreement signed and dated by the registered nurse and caregiver on 01/28/2021 documents: OT (Occupational Therapy): 2 visits/week x 3 weeks (two visits per week for three weeks); HHA (home health aide): 5 visits/week x 4 weeks (five visits per week for four weeks). The Home Health Certification and Plan of Care dated 01/28/2021 to 03/28/2021 documents: OT effective 01/31/2021 1WK1, 2WK4, 1EVERY2WK2 (once a week for one week, twice a week for four weeks, one every two weeks for two weeks). The Visit Note Report dated 02/03/2021 documents: will provide therapy to increase independence and safety with ADLs (activities of daily living) and functional transfers. The Client Coordination Note Report documents: missed OT visits on 02/10/2021, 02/11/2021, 02/18/2021, 02/25/2021, 03/03/2021, and 03/04/2021. There is no documented evidence of the coordination and team discussion regarding missing OT, seen once by OT for the evaluation assessment. The Client Coordination Note Report dated 02/08/2021 documents: “Spoke with Dtr (daughter) (name) and inform her there no avail (available) aides due to area, Dtr said OK she private paying for now.” The Complaint form dated 02/23/2021 documents: “Complaint/Incident: Dtr (daughter) calling that case was never staffed with hha. I explained (agency) having difficulty staffing hha in this area.” “Recommendation: Please find aide for this case, if we are not able to staff case please refer case to another vendor who could provide aide.” There is no documented evidence aide services being provided from 01/28/2021 to 03/09/2021. There is no documented evidence of the notification to patient or family the inability to provide aide services from 01/28/2021 to 03/09/2021, after being informed in the consent. The clinical record lacks documented evidence of the communication and coordination between the patient and family/caregivers about the delay in providing aide services. On 06/14/2023 at 2:30pm, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 3. Patient #7 has a Start of Care date of 03/09/2023 with the following diagnoses "Stage 4 Pressure Ulcer of Sacral Region, Type 2 Diabetes Mellitus with Hyperosmolarity with Coma" documented in the Home Health Certification and Plan of Care dated 03/09/2023 to 05/07/2023 and 05/08/2023 to 07/06/2023. There is no documented evidence of the resumption of aide services from hospital return 05/02/2023 to 05/12/2023. The Supplemental Order dated 05/02/2023 documents: Pt (patient) admit to NYP (hospital) on 4/15 and dc (discharge) on 5/2. ROC (resumption of care) on 5/3; Calendar Frequency: PT (physical therapy) effective 04/30/2023 1WK1; OT (occupational therapy) effective 04/30/2023 1WK1; ST (speech therapy) effective 04/30/2023 1WK1. The Home Health Certification and Plan of Care dated 05/08/2023 to 07/06/2023 documents: hha 2WK1, 5WK7, 4WK1 (twice a week for one week, five times a week for seven weeks, four times a week for one week). The Visit Note Reports from 05/03/2023 documents: PT visit on 05/11/2023, ST 05/19/2023, and OT visit on 05/20/2023. The clinical record lacks documented evidence of communication and coordination between the patient and family/caregivers about the delay in providing services. On 06/14/2023 at 2:30pm, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. 4. Patient #9 has a Start of Care date of 05/19/2023 with the following diagnoses "COVID 19, Unspecified Injury of Head, Unspecified Fall" documented in the Home Health Certification and Plan of Care dated 05/19/2023 to 07/17/2023. The Home Health Certification and Plan of Care dated 05/19/2023 to 07/17/2023 documents: OT effective 05/21/2023 1WK1, hha effective 05/21/2023 4WK1, 5WK6, 3WK1. The Supplemental Order documents: 05/30/2023: OT effective 05/28/2023 1WK1 005/31/2023: OT effective 05/28/2023 1WK1, 2WK4, 1WK2. The Client Coordination Note Report documents: 05/22/2023 I would like to sincerely apologize for the delay in your (hha -home health aide) services. We are desperately trying to staff your services. We will call you back within 48 hrs (hours) with an update. 05/30/2023 Date of missed visit: 5/25; Treatment not provided for the following reason: schedule change, please reschedule. 05/30/2023 was unable to schedule this meeting due to planned vacation. 06/08/2023 date of missed visit: 6/8; Treatment not provided for the following reason: schedule change, please reschedule. The Complaint form dated 05/30/2023 documents: Pt (patient) called and very frustrated that he has not had PCA (personal care aide) for a week, and no update/call from coordination. The Member Calendar documents start of aide services being provided on 06/07/2023. The clinical record lacks documented evidence of communication including updates and coordination with the patient about the delay in providing services. On 06/14/2023 at 2:30pm, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings. The agency's "Coordination of Patient Care" Policy documents: "Coordination of Agency's internal resources includes: Notifying the patient in a timely manner about schedule changes." The agency's "Coordination of Services" Policy documents: "Coordination of services activities is documented in the patient's home care record. Each record shall contain up-to-date information regarding: Communication between involved parties." 1. Patient #2 has a Start of Care (SOC) date of 04/24/2021, Discharge Date of 06/21/2021, with diagnoses Hemiplegia Following Cerebral Infarction Affecting Right Dominant Side, Other Speech Language Deficits Following Cerebral Infarction, Facial Weakness Following Cerebral Infarction, and Muscle Weakness (Generalized) documented on the Home Health Certification and Plan of Care for the Certification Period 04/24/2021 to 06/22/2021. The SOC Assessment notes dated 04/24/2021 documents: the patient “will benefit from” Speech Therapy (ST) services and patient “requests Hindi speaking (Home Health Aide) from 10 AM to 1 PM, Mon. to Friday, 5 Days x 3 Hours.” The Home Health Certification and Plan of Care (POC) for the Certification Period 04/24/2021 to 06/22/2021 document the following orders: “ST Evaluation;” “(Home Health Aide) effective 04/25/2021: 3WK1 (three visits per week for one week), 5WK2 (five visits per week for two weeks).” The supplemental order dated 5/4/2021 documents: “Speech Therapy evaluation 1W1 effective 5/4/21” The Complaint form dated 05/04/2021 documents: “Complaint filed against (Home Health Aide), Therapy” for “Service Delay.” The aide “Duty Sheet” dated 05/05/2021 document aide services started on 05/05/2021, ten days after the effective date, 04/25/2021, on the plan of care. The “Speech Language Pathology Evaluation” dated 05/04/2021 documents speech therapy evaluation conducted on 05//04/2021, ten days after the start of care date. The clinical record lacks documented evidence of the agency informing the patient of the delay in providing home health aide and speech therapy services. There is no documented evidence of the agency coordinating care delivery and involving the patient in changes in services to be furnished, as specified in the agency's coordination policies. On 06/14/2023 at 02:20 pm, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings.

This Statement of Deficiencies is a result of an on-site investigation of Complaints #94005 and #94267 conducted at Americare Certified Special Services, Inc. CHHA, located at 5923 Strickland Avenue, Brooklyn, NY 11234 from 11/8/022 to 11/10/2022 to evaluate the agency's compliance with Federal regulations. The active patient census was 3380. The investigation consisted of a review of six (6) patient care records (Patient #1, #2, #3, #4, #5, and #6), including one (1) observational home visit, six (6) personnel records (Employee #1, #2, #3, #4, #5, and #6), the agency's complaint/incident logs and reports, pertinent policies and procedures, and interviews with the Administrator, the Director of Patient Services, and the Director of Staff Education. Pre-survey activities consisted of review on 11/7/2022 of the agency's Health Commerce System account and compliance history. Findings were reviewed at the exit conference. The allegations in Complaints #94005 and #94267 were determined substantiated. The following deficiencies are being cited as result of the survey: G0580 - Only as ordered by a physician G0598 - Discharge plans communication G1014 - Interventions and patient response

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to ensure that skilled nursing staff only administer drugs as ordered by the physician for each patient. This was evident for two (2) of four (4) clinical records reviewed of diabetic patients using insulin (Patient #1 and #5). Failure to ensure that drugs are administered only as ordered by the physician has the potential for negative patient outcomes. The findings are: 1. Patient #1 has a Start of Care date of 1/27/2020 with diagnoses "Type 2 Diabetes Mellitus without Complications” and “Long Term (Current) Use of Insulin” documented in the Home Health Certification and Plan of Care dated 9/13/2022 to 11/11/2022. The Home Health Certification and Plan of Care dated 9/13/2022 to 11/11/2022 documents: “SN (Skilled Nurse) for fingerstick and insulin administration 2 times a day;” "Skilled Nurse to administer SQ (Subcutaneous) insulin 2x Daily: Lantus 30 U Every PM and Humalog as per Sliding Scale 2 x Daily;” “ Medications: Humalog U-100 Insulin 100 Unit/ML Subcutaneous Solution, per instructions 2 times daily - Instructions (Sliding Scale): 200 - 250 = (administer) 2 Units, 251 – 300 = 4 Units, 301 – 350 = 6 Units, 351 – 400 = 8 Units; Lantus U-100 Insulin 100 Unit/ML Subcutaneous Solution 30 Unit Every PM.” The supplemental order dated 9/13/2022 documents: “Correction to 485 Plan of Care Order 9/13/22-11/11/22 Medications: Medication listed in error: Humalog sliding scale; Correct Medication Name: Novolog sliding scale (same sliding scale).” The SN (Employee #2, Preceptor) “Visit Note Report” dated 10/31/2022 documents: “Random Blood Sugar reading 297.” The Plan of Care medication instructions for the insulin sliding scale documents the SN should administer 4 Units for blood sugar range of 251 to 300. The SN (Employee #1, Orientee/Trainee) Email dated 10/31/2022 4:332PM to the RN Regional Director documents: “Subject: Med error;” “I did a med error and wanted to know if there is any documentation for me to fill out in this situation.” The RN Regional Director Email dated 11/1/2022 9:37 AM documents: “Please send me a detailed email what happened – we will enter everything into our system.” The SN (Employee #1) Emails dated 11/1/2022 document: “Client was due Lantus and Novolog Sliding Scale. I gave Novolog sliding Scale dose for Lantus dose instead of Lantus. I called the doctor immediately and he requested the client be sent to the hospital for observation. I monitored the client and administered dextrose gel until EMS (Emergency Medical Services) arrived. I informed facility (Adult Care Facility) staff. The client returned to the facility last night from observation.” The SN documents: “Date of Incident: 10/31/2022; Due Lantus 30 units plus Sliding Scale Novolog; Given 30 Units Novolog, no Lantus given.” On 11/9/2022 at 3:40PM, an observational home visit was documented at the Adult Care Facility (ACF) where Patient #1 resides. The SN (Employee #1) was interviewed and stated the following: she took up the Novolog vial for the Lantus vial; she administered 30 units of insulin; she realized the mistake right away and informed her SN preceptor (Employer #2) who was present in the room with her; the preceptor told her to notify the physician; SN Employee#1 said the physician told her to give the patient dextrose gel and send the patient to the hospital for observation; she reported the incident to the ACF Director; she monitored the patient; she gave the patient dextrose gel, she reassessed the patient’s blood sugar after 15 minutes and the reading was 268; she observed no sign/symptom of adverse reaction/hypoglycemia. On 11/9/2022 at 4:35PM Patient #1 was interviewed and stated on 10/31/2022 the nurse (Employee #1) gave him insulin and told him she gave 30 units of Novolog, and he had to go to the ER. The patient stated the nurse explained what happened and the doctor wanted him to go the hospital for observation. The Patient stated he “felt fine” and “didn’t want to go” to the ER. The ACF Incident Report/Case Note dated 11/2/2022 documents: “Resident (Patient) was transferred to (hospital) on 10/31/22 due to administration of incorrect dosage of insulin by CHHA nurse. Medical office of MD (name) was notified and instructed to send Resident to the hospital; 911 was called and Resident was taken to (Hospital) for evaluation. Americare supervisor was also notified. While awaiting the arrival of paramedics, Resident was monitored, and no adverse reaction was observed. He was taken to (Hospital) and returned later the same day with d/c (discharge) instruction paperwork for s/s of hypo/hyperglycemia, no new medications, treatments were recommended. Resident will continue his current insulin regimen. Resident was seen by medical office by MD (name) today and is in stable condition at this time.” The SN (Employee #2, Preceptor) “Visit Note Report” dated 10/31/2022 lacks documented evidence of SN Employee #1 administering the insulin. The visit note lacks documented evidence of the Preceptor, Employee #2, observing SN Employee #1 (Orientee/Trainee) administer the insulin medication. The SN (Employee #2) “Visit Note Report(s)” dated 11/1/2022 and 11/2/2022 documents the patient’s random blood sugar reading was 259 and 252, respectively. The Visit Notes document the SN administered Novolog 2 Units on both days. The Plan of Care medication instructions for the insulin sliding scale documents the SN should administer 4 Units for blood sugar range of 251 to 300. . The SN (Employee #3) “Visit Note Report(s)” dated 11/4/2022 and 11/5/2022 documents the patient’s random blood sugar reading was 256 and 253, respectively. The Visit Notes document the SN administered Novolog 2 Units on both days. The Plan of Care medication instructions for the insulin sliding scale documents the SN should administer 4 Units for blood sugar range of 251 to 300. The clinical record lacks documented evidence of the SNs administering in drugs as ordered by the physician. On 11/10/2021 at 12:00 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings. 2. Patient #5 has a Start of Care date of 4/28/2022 with diagnoses "Type 2 Diabetes Mellitus without Complications” and “Long Term (Current) Use of Insulin” documented in the Home Health Certification and Plan of Care dated 10/25/2022 to 12/23/2022. The Home Health Certification and Plan of Care dated 10/25/2022 to 12/23/2022 documents: “Skilled Nursing for fingerstick and insulin administration 2 times a day;” Report “RBS (Rand Blood Sugar) 400;” "Skilled Nurse to administer SQ (Subcutaneous) insulin 2x Daily (two times a day): Levemir 50 Units(U) SQ in the AM and Levemir 10 Units in the PM and Novolog Sliding Scale BID (two times a day);” “ Medications: Novolog U-100 Insulin Aspart 100 Unit/ML Subcutaneous Solution, per instructions 2 times daily - Instructions: Sliding Scale: 200 - 250 = (administer) 2U, 251 – 300 = 4U, 301 – 350 = 6U, 351 – 400 = 8U.” The SN “Visit Note Report” dated 11/8/2022 documents: the patient’s Blood Sugar reading was “420,” and the SN administered “Novolog 10 Units.” The clinical record lacks documented evidence of physician order to administer Novolog 10 units. The Plan of Care documents instruction for the SN to report blood sugar reading greater than 400. The clinical record lacks documented evidence of the SN reporting the BS above 400 to the physician for instructions to administer 10 Units of insulin. The clinical record lacks documented evidence of the SNs administering in drugs as ordered by the physician. On 11/10/2021 at 12:00 PM, the Director of Patient Services was interviewed, and the DPS stated the SN was following a sliding scale at the Adult Care Facility.

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 clinical record review, and staff interviews, the agency failed to communicate with patient prior discharge from the agency. This was evident for one (1) of three (3) discharge clinical records reviewed (Patient #2). Failure to communicate with patient prior discharge from the agency has the potential for negative patient outcomes. The findings are: Patient # 2 has a Start of Care date of 06/16/2022 with the following diagnosis "Pressure Ulcer of Right Heel, stage 3, Charcot’s Joint, Right Ankle and Foot, Non-Pressure Chronic Ulcer of Right Heel and Midfoot Limited to Breakdown of Skin” " documented on the Home Health Certification and Plan of Care for the Certification Period 08/15/2022 to 10/13/2022. The Home Health Certification and Plan of Care for the Certification Period 08/15/2022 to 10/13/2022 documents: “SN (Skilled Nursing) 3 wk 8(three times a week for eight weeks), 2 wk 1(two times a week for one week); HHA (Home Health Aide) 5 wk 8(five times a week for eight weeks); 4 wk 1(four times a week for one week)”. The Policies and Procedures reviewed 09/07/2022 documents: “ 1. Any discontinuation of care, treatment and/or services should be done in an appropriate manner and in such a way to prevent harm to the patient. Prior to discharge plans, patient or family member is provided by agency information related to the reason for discharge. 2. A patient is discharge from agency after notification of the authorized practitioner and consultation with the patient and any other professional staff involved in coordinating the plan of care no less than 48 hours prior to patient discharge. Before the patient is discharged, agency shall inform the patient of the kinds of continuing care, treatment, or services he or she will need. Patient is provided information how these treatments and services could be accessed.” The Visit (RN Discharge from Agency) Note Report dated 10/13/2022 documents: “DC (discharge) from Agency today. Patient refused to sign Notice of Medicare Non-Coverage (NOMNC) informing that SN/HHA services ending (10/13/2022).” There is no documented evidence of the patient being notified by the agency prior to the discharge regarding last day of nurse and hha visit. On 11/10/2021 at 3:40 PM, the Administrator and the Director of Patient Services was interviewed and did not provide an explanation for the findings.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on record review and staff interviews, the agency failed to ensure and maintain current, complete and accurate information of all skilled nursing (SN) interventions, including medication administration, treatments, and patient response to those interventions in all clinical records. This was evident for one (1) of six (6) clinical records reviewed (Patient: #1). Failure to ensure and maintain an accurate, current, complete and clearly documented record has the potential risk for negative patient outcomes. The findings are: The agency’s “Patient Records” Policy documents: The following will be a part of the Patient’s Records: Clinical Information “Medication administered” and “Patient’s response to care and treatment.” The agency’s “Medication Orders and Administration” Policy documents: “Documentation of medication administration will include: “Date, time, name of medication, dose, route of administration;” “Patient response to the medication including adverse reactions;” “Instruction provided to the patient/family/caregiver and their response to /understanding of those instructions. Instructions should (include) the occurrence of any reaction or unanticipated outcomes.” 1. Patient #1 has a Start of Care date of 1/27/2020 with diagnoses "Type 2 Diabetes Mellitus without Complications” and “Long Term (Current) Use of Insulin” documented in the Home Health Certification and Plan of Care dated 9/13/2022 to 11/11/2022. The Home Health Certification and Plan of Care dated 9/13/2022 to 11/11/2022 documents: “SN (Skilled Nurse) for fingerstick and insulin administration 2 times a day;” "Skilled Nurse to administer SQ (Subcutaneous) insulin 2x Daily: Lantus 30 U Every PM and Humalog as per sliding scale 2 x Daily;” “ Medications: Humalog U-100 Insulin 100 Unit/ML Subcutaneous Solution, per instructions 2 times daily - Instructions: 200 - 250 = 2 Units, 251 – 300 = 4 Units, 301 – 350 = 6 Units, 351 – 400 Units = 8 Units; Lantus U-100 Insulin 100 Unit/ML Subcutaneous Solution 30 Unit Every PM.” The supplemental order dated 9/12/2022 documents: “Correction to 485 Plan of Care Order 9/13/22-11/11/22 Medications: Medication listed in error: Humalog sliding scale; Correct Medication Name: Novolog sliding scale (same sliding scale).” The SN (Employee #2, Preceptor) “Visit Note Report” signed and dated 10/31/2022 (by Employee #2) documents: “Random Blood Sugar reading 297.” The Visit Note documents: “Late Modification Date: 11/8/2022 10:56 AM; Last Modified By: (RN Quality Reviewer’s name); Late Entry –Added by (RN Quality Reviewer’s name) on 11/8/2022 10:56AM: the following insulin was supposed to be administered; Added by (RN Quality Reviewer) 11/8/2022 10:00AM As per discussion with (SN Employee #2) the following insulin was administered: Lantus 30 U LLQ (left lower quadrant), Novolog 4U RLQ(right lower quadrant);” The Plan of Care medication instructions for the insulin sliding scale documents the SN should administer 4 Units for blood sugar range of 251 to 300. The SN (Employee #1, Orientee) Email dated 10/31/2022 4:332PM to the RN Regional Director documents: “Subject: Med error;” “I did a med error and wanted to know if there is any documentation for me to fill out in this situation.” The RN Regional Director Email dated 11/1/2022 9:37 AM documents: “Please send me a detailed email what happened – we will enter everything into our system.” The SN (Employee #1) Emails dated 11/1/2022 document: “Client as due Lantus and Novolog Sliding Scale. I gave Novolog Sliding Scale for Lantus dose instead of Lantus. I called the doctor immediately and he requested the client be sent to the hospital for observation. I monitored the client and administered dextrose gel until EMS (Emergency Medical Services) arrived. Informed facility (Adult Care Facility) staff. The client returned to the facility last night from observation.” The SN documents: “Date of Incident: 10/31/2022; Due Lantus 20 units plus Sliding Scale Novolog; Given 30 Units Novolog, no Lantus given.” On 11/9/2022 at 3:40PM, an observational home visit was documented at the Adult Care Facility (ACF) where Patient #1 resides. The SN (Employee #1) was present and stated: she took up the Novolog vial for the Lantus vial; she administered 30 units of insulin; she realized the mistake right away and informed her SN preceptor (Employer #2) who was present in the room; the preceptor told her to notify the physician; SN Employee#1 said the physician told her to give the patient dextrose gel and send the patient to the hospital for observation, she reported the incident to the ACF Director; she monitored the patient; she gave the patient dextrose gel, she reassessed the patient’s blood sugar after 15 minutes and the reading was 268; she observed no sign/symptom of adverse reaction/hypoglycemia. The SN stated she “did not have a user login” to the agency’s electronic medical record system at the time of the incidence. On 11/9/2022 at 4:35PM Patient #1 was interviewed and stated on 10/31/2022 the nurse (Employee #1) gave him 30 units of Novolog insulin, and he had to go to the ER. The patient stated the nurse explained what happened and the doctor wanted him to go the hospital for observation. The Patient stated he “felt fine” and “didn’t want to go” to the ER. The SN (Employee #2 – Preceptor) “Visit Note Report” dated 10/31/2022 lacks documented evidence that Employee #1 was the SN who administered the insulin medication. The SN Visit Note report lacks documented evidence the RN Quality Review adequately reviewed the SN visit note for accuracy and completeness. The clinical record lacks documented evidence of complete and accurate information of the SN visit and care provided on 10/31/2022. The record lacks documentation of the following information: the SN administering Novolog 30 Units and no Lantus; the SN reporting the incident to the physician; the physician’s instructions to the SN; the SN’s instructions to the patient; the SN monitoring of the patient after the medication error - including reassessing the patient’s blood sugar and giving dextrose gel; and the patient’s response to SN interventions. On 11/10/2021 at 3:40 PM, the Administrator and the Director of Patient Services was interviewed and did not provide an explanation for the findings.

An on-site investigation for complaint #71760 was conducted at Americare Certified Special Services, Inc. CHHA, located at 5923 Strickland Avenue, Brooklyn, New York, 11234 on 10/12/2022 with 3337 active census. Three (3) Clinical Care records were reviewed and are identified as (Patient #1, #2 and #3), and two (2) Personnel Records were reviewed and are identified as (Employee #1, #2). The agency’s Complaint and Incident Log from May 2022 through October 2022, active patient census, COVID-19 and Infection Control, the agency's Policies and Procedure were reviewed. The Vice President was interviewed. The findings were reviewed at the exit conference on 10/12/2022. The allegations in complaint #71760 were determined substantiated. The following deficiencies are being cited as a result of the complaint investigation: G 0572 - Plan Of Care G 0608 - Coordinate Care Delivery

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 record reviews and staff interviews, the agency failed to ensure that all patients received the care that is written in the individualized Plan Of Care. This was evident for one(1) of three (3) clinical records reviewed (Patient #1). 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: 1. Patient #1 has a Start of Care date of 07/06/2022 with the following diagnoses "Spinal Stenosis, Lumbar Region without Neurogenic Claud, Unilateral Primary Osteoarthritis, Right Hip, Chronic Kidney Disease, Hyperlipidemia" documented on the Home Health Certification and Plan of Care dated 07/06/2022 to 09/03/2022. The Home Health Certification and Plan of Care dated 07/06/2022 to 09/03/2022 documents: "HHA (home health aide) effective 07/10/2022 5 wk 3 (five times a week for three weeks)." The clinical record lacks documented evidence of the agency providing home health aide services and no documented evidence of the physician being notified of the missed aide services. The Home Health Certification and Plan of Care dated 07/06/2022 to 09/03/2022 documents: "OT (Occupational Therapy) OT Eval" The Occupational Therapy Initial Examination dated 07/21/2022. The Client Coordination Note Report dated 07/14/2022 documents: "Service Call: Call to patient Update Re: OT services. Voicemail full unable to leave message.” The Client Coordination Note Report dated 07/15/2022 documents:” Service Call: Hello my name is (K), I am calling from Americare Home care Agency. I would like to sincerely apologize for the delay in your (HHA/REHAB) services. We are desperately trying to staff your services. We will call you back Mon. (Monday) with an update. MSG left to voicemail.” The Client Coordination Note Report dated 07/18/2022 documents: "Service Call: Hello my name is (K), I am calling from Americare Home care Agency. I would like to sincerely apologize for the delay in your (OT). OT(G) will call to schedule eval. With you. Positive response noted from daughter.” There is no documented evidence of the patient receiving OT services as ordered on the plan of care. The clinical record lacks documented evidence of the communication with the patient/family related to the delay of OT services before 07/14/2022. On 10/12/2022 at 5:10 pm, the Vice President was interviewed and did not provide an explanation for the findings.

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, and staff interview the Agency failed to ensure coordinated care delivery to meet the patient's needs and to involve the patient. This was evident for one(1) of three (3) clinical records reviewed (Patient #1). Failure to ensure that the patient is involved in the coordinating and the delivery of care has the potential for negative patient outcome. The findings are: Patient #1 has a Start of Care date of 07/06/2022 with the following diagnoses "Spinal Stenosis, Lumbar Region without Neurogenic Claud, Unilateral Primary Osteoarthritis, Right Hip, Chronic Kidney Disease, Hyperlipidemia" documented on the Home Health Certification and Plan of Care dated 07/06/2022 to 09/03/2022. The email dated 07/18/2022 (from the agency/Medical Record Department to SN) documents: "Order placed"(wheelchairs order) The email dated 07/27/2022 (from the agency to SN) documents:" Garden Court is advising that the patient reach out to the vendor they returned it to because they are billing them for the transport chair which is why they cannot order another. Medicare will not allow them to order it, it will be denied as "same item or similar item on file". The email dated 08/09/2022 (from agency to Rehab Team): "Garden Court did not supply this wheelchair to the patient. Please advise patient to reach out the company they got the wheelchair from and ask about getting one that is a larger size." The email from PT (Physical Therapy) dated 08/16/2022 documents: "Hello, the old wc(wheelchair) she is using now was just given by a friend. How can we request for wc for the patient? (RN name) said that at the time of his evaluation, he has put in an order for new wc for this patient. The daughter and patient repeatedly asking for wc update that RN made through Americare." The email dated 08/22/2022 (from the agency to SN) documents: "The transport chair was not provided by us, so I do not have any information on that. I did speak with the daughter last week regarding this and she stated it was already returned. I advise her to reach out to the company she returned the transport chair to and to find out why it is still being listed as the patient having it if they really do not. I have not heard back from the daughter regarding this." There is no documented evidence of the SN coordinating with the patient/daughter and PT regarding the problem with the wheelchair. On 10/12/2022 at 5:10 pm, the Vice President was interviewed and did not provide an explanation for the findings.