Every finding on record at Calvary Hospital, Inc.

This Statement of Deficiencies represents the results of a partial extended recertification survey of Calvary Hospital CHHA, Provider #337210, located at 1740 Eastchester Road, NY, 10461 conducted on 01/05/2026 through 01/07/2026. A standard re - certification survey was initiated on 01/05/2026. Deficient practices were identified within level 1 Standards in 484.60 Care Planning Coordination, Quality of Care resulting in a partial extended survey. The survey consisted of a review of three (3) clinical records (identified as Patient #1, #2, and #3) including one (1) discharge record, one (1) observational home visit, and two (2) personnel records (identified as Employee #1, and #2). The survey included a review of pertinent policies and procedures, Quality Improvement Meeting Minutes for past 12 months, PIP (Performance Improvement Project), Admission Packet, Emergency Preparedness Plan, Complaint Log, and the agency's Infection Control and Flu policy and procedure. Pre-survey activities consisted of review on 01/02/2025 of the agency's Health Commerce System account, Internet Quality Improvement and Evaluation System reports (iQIES) for the period 09/2024 through 09/2025, The HHA Error Summary by Agency Report for the period 01/01/2025 through 12/24/2025, and compliance with statistical report submission. The active patient census is 2. Interviews were conducted throughout the survey with the Administrator/Director of Patient Services. Findings were reviewed at the exit conference on 01/07/2026. The following deficiencies were identified as a result of the survey: G0372 – Accuracy of encoded OASIS data G0514 – RN performs assessment G0574 – Plan of Care must include the following G0588 – Reviewed, revised by physician every 60 days G0620 – Other pertinent instructions G0658 – Performance improvement projects G0710 – Provide services in the plan of care J1268 – Governing authority

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on report review, and staff interviews, the agency failed to ensure that all completed OASIS (Outcome and Assessment Information Set) assessments were transmitted to the CMS (Centers for Medicare & Medicaid Services) within thirty (30) days. This was evident for three (3) of three (3) clinical records reviewed (Patients: #1, #2, and #3). Failure to ensure that all completed OASIS (Outcome and Assessment Information Set) assessments are transmitted to the CMS (Centers for Medicare & Medicaid Services) within thirty (30) days, has the potential for negative patient outcomes. The Findings Are: 1. Patient #1 has a Start of Care date of 07/18/2025 with the following diagnoses "Hemiplegia and Hemiparesis following Unspecified Cerebrovascular Disease Affecting Left Non-Dominant Side, other Abnormalities of Gait and Mobility, Bilateral Primary Osteoarthritis of Knee" documented in the Home Health Certification and Plan of Care for the Certification Period 07/18/2025 to 09/15/2025. The OASIS (Outcome and Assessment Information Set) assessments documented in the clinical record are dated: 07/18/2025, 09/15/2025, and 11/12/2025. The HHA Error Summary by Agency Report for the period 01/01/2025 through 12/24/2025 documents: “No Data Returned for Selected Criteria.” (no OASIS assessments are transmitted to the CMS). There is no documented evidence that all completed OASIS (Outcome and Assessment Information Set) assessments are transmitted to the CMS (Centers for Medicare & Medicaid Services) within thirty (30) days. On 01/07/2026 at 03:15 PM, the Administrator/Director of Patient Services, was interviewed and stated: “Unfortunately I cannot reach the individual who is in charge of transmission OASIS (Outcome and Assessment Information Set)”, no further explanation for the findings. 2. Patient #2 has a Start of Care date of 05/27/2025, with the following diagnoses "Parkinson’s Disease, Unspecified Abnormalities of Gait and Mobility" documented in the Home Health Certification and Plan of Care for the Certification Period 05/27/2025 to 07/25/2025. The OASIS (Outcome and Assessment Information Set) assessments documented in the clinical record are dated: 05/27/2025, 07/25/2025, 09/23/2025, and 11/21/2025. The HHA Error Summary by Agency Report for the period 01/01/2025 through 12/24/2025 documents: “No Data Returned for Selected Criteria.” (Meaning no OASIS assessments are transmitted to the CMS). There is no documented evidence that all completed OASIS (Outcome and Assessment Information Set) assessments are transmitted to the CMS (Centers for Medicare & Medicaid Services) within thirty (30) days. On 01/07/2026 at 03:15 PM, the Administrator/Director of Patient Services, was interviewed and stated: “Unfortunately I cannot reach the individual who is in charge of transmission OASIS (Outcome and Assessment Information Set)”, no further explanation for the findings. 3. Patient #3 has a Start of Care date of 04/29/2025 and a discharge date of 06/25/2025, with the following diagnoses "Pain in Right Hip, Strain of Muscle, Fascia, and Tendon of the Posterior Muscle" documented in the Home Health Certification and Plan of Care for the Certification Period 04/29/2025 to 06/27/2025. The OASIS (Outcome and Assessment Information Set) Assessment Items For SOC/ROC (Start of Care/ Resumption of Care) documented in the clinical record is dated 04/29/25. The OASIS (Outcome and Assessment Information Set) Assessment Items For D/C (Discharge) documented in the clinical record is dated 06/25/25. The HHA Error Summary by Agency Report for the period 01/01/2025 through 12/24/2025 documents: “No Data Returned for Selected Criteria.” (no OASIS assessments are transmitted to the CMS). There is no documented evidence that all completed OASIS (Outcome and Assessment Information Set) assessments are transmitted to the CMS (Centers for Medicare & Medicaid Services) within thirty (30) days. On 01/07/2026 at 03:15 PM, the Administrator/Director of Patient Services, was interviewed and stated: “Unfortunately I cannot reach the individual who is in charge of transmission OASIS (Outcome and Assessment Information Set)”, no further explanation for the findings.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on clinical record review, and staff interview, the agency failed to ensure that initial assessments were conducted within the required time frames for all patients. This was evident for one (1) of three (3) clinical records reviewed (Patient: #1). Failure to ensure that initial assessments are conducted within the required time frames for all patients, has the potential for negative patient outcomes. The Findings Are: 1. Patient #2 has a Start of Care (SOC) date of 05/27/2025, with the following diagnoses "Parkinson’s Disease, Unspecified Abnormalities of Gait and Mobility" documented in the Home Health Certification and Plan of Care for the Certification Period 05/27/2025 to 07/25/2025. The PT (physical therapy) Initial Visit (start of care OASIS) is dated 05/27/2025. The Face Sheet printed on 01/05/2026 documents: Referral: 05/21/2025. The clinical record lacks documented evidence of the initial assessment visit being completed within 48 hours of referral. On 01/07/2026 at 11:36 AM, the Administrator/Director of Patient Services, was interviewed and stated, “We don’t have anything.”, no further 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 records review, and staff interview, the agency failed to ensure each patient's plan of care included all the required information. This was evident for two (2) of three (3) clinical records reviewed (Patients: 2, and #3). Failure to ensure that plan of care includes all the required information has the potential risk for negative patient outcomes. The Findings Are: 1. Patient #2 has a Start of Care (SOC) date of 05/27/2025, with the following diagnoses "Parkinson’s Disease, Unspecified Abnormalities of Gait and Mobility" documented in the Home Health Certification and Plan of Care for the Certification Period 05/27/2025 to 07/25/2025. The plan of care lacks documented evidence of the vital sign parameters. There is no documented evidence of the plan of care including all the required information. On 01/07/2026 at 11:36 AM, the Administrator/Director of Patient Services, was interviewed and stated, “We don’t have anything.”, no further explanation for the findings. 2. Patient #3 has a Start of Care (SOC) date of 04/29/2025 and a discharge date of 06/25/2025, with the following diagnoses "Pain in Right Hip, Strain of Muscle, Fascia, and Tendon of the Posterior Muscle" documented in the Home Health Certification and Plan of Care for the Certification Period 04/29/2025 to 06/27/2025. The plan of care lacks documented evidence of the frequency and parameters for blood glucose and vital sign’s parameters. There is no documented evidence of the plan of care including all the required information. On 01/07/2026 at 11:36 AM, the Administrator/Director of Patient Services, was interviewed and stated, “We don’t have anything.”, no further explanation for the findings.

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on clinical records review, and staff interview, the agency failed to ensure the individualized plan of care is reviewed and revised by the physician at least every sixty (60) days. This was evident for two (2) of three (3) clinical records reviewed (Patients: #1, and #2). Failure to ensure that the plan of care is reviewed and revised has the potential risk for negative patient outcomes. The Findings Are: *. Patient #2 has a Start of Care (SOC) date of 05/27/2025, with the following diagnoses "Parkinson’s Disease, Unspecified Abnormalities of Gait and Mobility" documented in the Home Health Certification and Plan of Care for the Certification Period 05/27/2025 to 07/25/2025. The PT (physical therapy) Reassessment Visit (OASIS Assessment for Recertification) were dated 07/25/2025, 09/23/2025, and 11/21/2025. The patient care record lacks documented evidence that the individualized plan of care was reviewed every 60 days on 07/26/2025, 09/24/2025, and 11/23/2025. On 01/07/2026 at 11:36 AM, the Administrator/Director of Patient Services, was interviewed and stated, “We don’t have anything.”, no further explanation for the findings. *. Patient #3 has a Start of Care (SOC) date of 04/29/2025 and a discharge date of 06/25/2025, with the following diagnoses "Pain in Right Hip, Strain of Muscle, Fascia, and Tendon of the Posterior Muscle" documented in the Home Health Certification and Plan of Care for the Certification Period 04/29/2025 to 06/27/2025. The PT (physical therapy) Visit documents from 05/08/2025 to 06/16/2025: establish/upgrade home exercise program. The patient care record lacks documented evidence of the Home Exercise Program (HEP). On 01/07/2026 at 11:36 AM, the Administrator/Director of Patient Services, was interviewed and stated, “We don’t have anything.”, no further explanation for the findings. 1. Patient #1 has a Start of Care date of 07/18/2025 with the following diagnoses "Hemiplegia and Hemiparesis following Unspecified Cerebrovascular Disease Affecting Left Non-Dominant Side, other Abnormalities of Gait and Mobility, Bilateral Primary Osteoarthritis of Knee" documented on the Home Health Certification and Plan of Care for the Certification Period 07/18/2025 to 09/15/2025. The Clinical Record documents PT (Physical Therapy) services being provided from 07/18/2025 to 01/02/2026. The Clinical Record including PT (Physical Therapy) Reassessment Visit (OASIS Assessment for Recertification) dated 09/15/2025, 11/12/2025. The clinical record lacks documented evidence of a reviewed and revised Plan of Care from 09/15/2025 to present. There is no documented evidence of the Plan of Care being reviewed and revised at lease every 60 days. On 01/07/2026 at 12:05 PM, the Administrator/Director of Patient Services, was interviewed and stated, “We don’t have anything.”, no further explanation for the findings. 1. Patient #1 has a Start of Care date of 07/18/2025 with the following diagnoses "Hemiplegia and Hemiparesis following Unspecified Cerebrovascular Disease Affecting Left Non-Dominant Side, other Abnormalities of Gait and Mobility, Bilateral Primary Osteoarthritis of Knee" documented on the Home Health Certification and Plan of Care for the Certification Period 07/18/2025 to 09/15/2025. The Clinical Record documents PT (Physical Therapy) services being provided from 07/18/2025 to 01/02/2026. The Clinical Record including PT (Physical Therapy) Reassessment Visit (OASIS Assessment for Recertification) dated 09/15/2025, 11/12/2025. The Clinical Record lacks documented evidence of the Plan of Care is being reviewed and revised from 09/15/2025 to present. There is no documented evidence of the Plan of Care is being reviewed and revised at least every 60 days. On 01/07/2026 at 12:05 PM, the Administrator/Director of Patient Services, was interviewed and stated, “We don’t have anything.”, no further explanation for the findings. 2. Patient #2 has a Start of Care (SOC) date of 05/27/2025, with the following diagnoses "Parkinson’s Disease, Unspecified Abnormalities of Gait and Mobility" documented in the Home Health Certification and Plan of Care for the Certification Period 05/27/2025 to 07/25/2025. The PT (physical therapy) Reassessment Visit (OASIS Assessment for Recertification) were dated 07/25/2025, 09/23/2025, and 11/21/2025. The Clinical Record lacks documented evidence of the Plan of Care is being reviewed and revised from 07/26/2025 to present. There is no documented evidence of the Plan of Care is being reviewed and revised at least every 60 days. On 01/07/2026 at 11:36 AM, the Administrator/Director of Patient Services, was interviewed and stated, “We don’t have anything.”, no further explanation for the findings.

Other pertinent instructions CFR(s): 484.60(e)(4) Any other pertinent instruction related to the patient's care and treatments that the HHA will provide, specific to the patient's care needs. This ELEMENT is not met as evidenced by: Based on clinical records review, and staff interview, the agency failed to provide pertinent instruction(s) related to the patient's care. This was evident for two (2) of three (3) clinical records reviewed (Patients: #2, and #3). Failure to provide pertinent instruction (s) related to the patient's care has the potential risk for negative patient outcomes. The Findings Are: 1. Patient #2 has a Start of Care (SOC) date of 05/27/2025, with the following diagnoses "Parkinson’s Disease, Unspecified Abnormalities of Gait and Mobility" documented in the Home Health Certification and Plan of Care for the Certification Period 05/27/2025 to 07/25/2025. The PT (physical therapy) Visit dated 05/27/2025 documents: "HEP (home exercise program) introduced focusing on gentle ROM (range of motion) postural alignment, and bed mobility." The clinical record lacks documented evidence of the Home Exercise Program (HEP). On 01/07/2026 at 11:36 AM, the Administrator/Director of Patient Services, was interviewed and stated, “We don’t have anything.”, no further explanation for the findings. 2. Patient #3 has a Start of Care (SOC) date of 04/29/2025 and a discharge date of 06/25/2025, with the following diagnoses "Pain in Right Hip, Strain of Muscle, Fascia, and Tendon of the Posterior Muscle" documented in the Home Health Certification and Plan of Care for the Certification Period 04/29/2025 to 06/27/2025. The PT (physical therapy) Visit dated 05/01/2025 documents: "establish/upgrade home exercise program." The clinical record lacks documented evidence of the Home Exercise Program (HEP). On 01/07/2026 at 11:36 AM, the Administrator/Director of Patient Services, was interviewed and stated, “We don’t have anything.”, no further explanation for the findings.

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on staff interviews, the agency failed to provide documented evidence that Performance Improvement Projects (PIP) were conducted. Failure to conduct Performance Improvement Projects that reflect the scope, complexity, past performance of the agency's services, quality improvements with documented measurable progress achieved has the potential for negative patient outcome. The Findings Are: On 01/05/2026 at 11:20 AM, the Performance Improvement Projects were requested, no information was provided. There is no documented evidence of the agency conducting Performance Improvement Projects. On 01/07/2026 at 03:00 PM, the Administrator/Director of Patient Services was interviewed and did not have an explanation for the findings.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on clinical records review, and staff interview, the agency failed to provide services that are ordered by the physician as indicated in the plan of care. This was evident for one (1) of three (3) clinical records reviewed (Patient: #2). Failure to provide services that are ordered by the physician as indicated in the plan of care, has the potential for negative patient outcomes. The Findings Are: 1. Patient #2 has a Start of Care (SOC) date of 05/27/2025, with the following diagnoses "Parkinson’s Disease, Unspecified Abnormalities of Gait and Mobility" documented in the Home Health Certification and Plan of Care for the Certification Period 05/27/2025 to 07/25/2025. The Orders (Interim) dated 09/24/2025 documents: PT (physical therapy) 2 Week 8 (twice a week for eight weeks). The clinical record lacks documented evidence of physical therapy services between 09/24/2025 to 09/27/2025, missed two visits, 10/05/2025 to 10/11/2025, missed one visit, 10/19/2025 to 10/25/2025, missed one visit, and 11/09/2025 to 11/15/2025, missed one visit. The clinical record documents Physical Therapy visits dated 09/23/2025, 11/18/2025, and 11/21/2025. There is no documented evidence of an order for physical therapy services on 09/23/2025, 11/18/2025, and 11/21/2025. (extra visits) The Orders (Interim) dated 11/24/2025 documents: PT (physical therapy) 2 Week 8 (twice a week for eight weeks). The clinical care record lacks documented evidence of physical therapy services between 12/07/2025 to 12/13/2025, missed two visits, 12/14/2025 to 12/20/2025, missed two visits, 12/21/2025 to 12/27/2025 missed two visits, and 12/28/2025 to 01/03/2025, missed two visits. There is no documented evidence of the patient receiving Physical Therapy services as documented in the Interim Orders. On 01/07/2026 at 11:36 AM, the Administrator/Director of Patient Services, was interviewed and stated, “We don’t have anything.”, no further explanation for the findings.