Every finding on record at Chemung Co Dept Health Chha

The following statement of deficiencies represents the results of a partial extended re-certification survey of Chemung County Department of Health Certified Home Health Agency conducted on 03/18/2025 through 03/21/2025 and included complaint investigation 103444. A standard re-certification survey was initiated on 03/18/2025. Deficient practices were identified within Level 1 standards in 484.55 Condition and resulting in a partial extended survey on 03/19/2025. The survey consisted of a review of 17 (seventeen) clinical records including 6 (six) discharge records, 7 (seven) personnel records for professional and paraprofessional personnel, 2 (two) contracts, and 6 (six) observational home visits. The survey included a review of pertinent policies and procedures, Quality Improvement Meeting minutes for the past 12 months, agency’s Admission Packet, the Emergency Preparedness Plan, and Complaint Log. Pre-survey activities consisted of review on 03/17/2025 date of the agency’s Health Commerce System account, Criminal History Record Check, potentially avoidable reports for the period 01/01/2024 - 12/31/2024, and the agency’s compliance with report submissions for the 2023 statistical report and the Emergency Drill conducted in 2019. The total number of active patients was 93 (ninety- three). The Director of Patient Services, Registered Nurse Supervisor, and staff were interviewed. Findings were reviewed at the exit conference on 03/21/2025. The allegation in complaint 103444 were determined substantiated. The following deficiencies are identified as a result of the survey: G-0514, G-0520, G-0528, G-0536, G-0544, G-0574, G-0576, G-0580, G-0590, G-0608, G-0716, G-0808, G-0984, G-1022, G-1024, J-1136, J-1140, J-1168, J-1260, J-1424, J-1456, J-1460, and J-1476.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on review of clinical records and staff interview for three (3) of seventeen (17) patients (Patient #’s 1, 11, and 16), the agency failed to ensure the Registered Nurse conducted an initial assessment of the patient within twenty-four (24) hours of referral, the patient's return home, or on the physician-ordered start of care date. Failure to conduct the initial assessment within the required time frame has the potential to result in unmet patient needs and negative patient outcomes. The agency failed to ensure the Registered Nurse conducted an initial assessment of the patient within twenty-four (24) hours of referral, the patient's return home, or on the physician-ordered start of care date as evidenced by: Patient #1 – This 80-year-old patient with the diagnoses of encounter for surgical aftercare following surgery of the digestive system, acute cholecystitis, and type 2 diabetes mellitus without complications was admitted to the home care agency on 03/01/2025. Review of the hospital discharge/referral dated 02/25/2025 revealed the patient was referred to the home care agency on 02/25/2025, however the start of care was 03/01/2025 (four (4) days after referral). During interview on 03/20/2025 at 03:38 PM, the Registered Nurse Supervisor stated there is no documentation to explain why the start of care was delayed. Patient #11 – This 58-year-old patient with the diagnoses of disruption of external operation (surgical) wound, laceration without foreign body, left lower leg, and low back pain was admitted to the home care agency on 03/06/2025. Review of the hospital discharge/referral dated 03/04/2025 revealed the patient was referred to the home care agency on 03/04/2025, however the start of care was 03/06/2025 (48 (forty-eight) hours after referral). During interview on 03/20/2025 at 01:19 PM, the Registered Nurse Supervisor stated there is no documentation to explain why the start of care was delayed. Patient #16 – This 68-year-old with the diagnoses of partial intestinal obstruction, malignant neoplasm of unspecified site of right female breast, and malignant neoplasm of unspecified site of left female breast was admitted to the home care agency on 09/05/2024. Review of the hospital discharge/referral dated 08/28/2024 revealed the patient was referred to the home care agency on 08/28/2025, however the start of care was 09/05/2024 (eight (8) days after referral). During interview on 03/20/2025 at 03:38 PM, the Registered Nurse Supervisor stated there is no documentation to explain why the start of care was delayed.

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on review of clinical records and interviews with staff, for two (2) of seventeen (17) patients, (Patient #s: 6 and 14), the agency failed to ensure that a comprehensive assessment consistent with the patient's needs was performed within five (5) calendar days after the start of care. Failure to ensure a comprehensive assessment is complete and accurate has the potential for unmet patient needs and possible negative outcomes. The agency failed to ensure that a comprehensive assessment consistent with the patient's needs was performed within five (5) calendar days after the start of care as evidenced by: Patient #6- This 78- year- old patient with diagnoses that include aftercare following joint replacement surgery, presence of left artificial hip joint, and unilateral primary osteoarthritis of the left hip was admitted to the home care agency on 03/05/2025. Review of the hospital discharge/ referral dated 03/03/2025 revealed the patient was referred to the home care agency for Skilled Nursing, Physical Therapy and Occupational Therapy. Review of the clinical record lacks an order for Occupational Therapy, or documentation stating the patient declined. During interview on 03/20/2025 at 12:58 PM, the Registered Nurse stated that it was determined that Occupational Therapy was not needed, but that was not documented. The Registered nurse further stated that they only documented that Skilled Nursing services were not needed. Patient #14- This 81- year- old patient with diagnoses that include occlusion and stenosis of right carotid artery, unspecified dementia of unspecified severity without behavioral, psychological, mood disturbance, or anxiety, and cirrhosis of the liver was admitted to the home care agency on 05/09/2024. Review of the Skilled Nurse Resumption of Care Visit dated 06/13/2024 revealed the Registered Nurse documented the following: “Clinical Summary: Patient will also require Physical therapy services for gait training, strengthening, and therapeutic home exercises. Occupational therapy services for Activities of Daily Living teaching and adaptive equipment needs.” Review of the clinical record lacks an order for Occupational therapy, or documentation stating the patient declined. During interview on 03/20/2025 at 02:17 PM, the Registered Nurse Supervisor stated that there was no documented evidence of an order for Occupational therapy.

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 review of patient care records and interview with agency staff for seventeen (17) of seventeen (17) patient records (Patient #’s: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, and 17), the agency failed to ensure the initial comprehensive assessment was of sufficient scope to identify patient needs. Failure to ensure the initial comprehensive assessment is complete and accurate has the potential for unmet patient needs and possible negative outcomes. The agency failed to ensure the initial comprehensive assessment was of sufficient scope to identify patient needs as evidenced by: Patient #6- This 78- year- old patient with the diagnoses of aftercare following joint replacement surgery, presence of left artificial hip joint, and unilateral primary osteoarthritis of the left hip was admitted to the home care agency on 03/05/2025. Review of the Skilled Nurse Admission Visit Note dated 03/05/2025 lacks an assessment of the patient’s palliative care needs. During interview on 03/20/2025 at 01:09 PM, the Registered Nurse stated that they did not know it was required to assess all patients for potential palliative care, and did not assess the patient for palliative care needs. Patient #7- This 73- year- old patient with the diagnoses of aftercare following joint replacement surgery, presence of left artificial knee joint, and unilateral primary osteoarthritis of the left knee was admitted to the home care agency on 02/27/2025. Review of the Skilled Nurse Admission Visit Note dated 02/27/2025 lacks an assessment of the patient’s palliative care needs. During interview on 03/20/2025 at 01:20 PM, the Registered Nurse Supervisor stated that the patient was not assessed for potential palliative care needs. Patient #13- This 67- year- old patient with the diagnoses of disruption of external operation (surgical) wound not elsewhere classified subsequent encounter, type 2 diabetes mellitus with diabetic neuropathic arthropathy, and cutaneous abscess of the left foot was admitted to the home care agency on 11/13/2023. Review of the Skilled Nurse Admission Visit Note dated 11/13/2023 lacks an assessment of the patient’s palliative care needs. During interview on 03/21/2025 at 09:11 AM, the Registered Nurse Supervisor stated that the patient was not assessed for potential palliative care needs. Patient #14- This 81- year- old patient with diagnoses that include occlusion and stenosis of right carotid artery, unspecified dementia of unspecified severity without behavioral, psychological, mood disturbance, or anxiety, and cirrhosis of the liver was admitted to the home care agency on 05/09/2024. Review of the Skilled Nurse Admission Visit Note dated 05/09/2024 lacks an assessment of the patient’s palliative care needs. During interview on 03/20/2025 at 02:14 PM, the Registered Nurse stated that they were focused on getting the patient into an Assisted Living Facility and did not assess for potential palliative care needs. Patient #2 – This 70-year-old patient with the diagnoses of intestinal obstruction, Parkinson's Disease without dyskinesia without mention of fluctuations, and essential primary hypertension, was admitted to the home care agency on 02/28/2025. Review of the Skilled Nurse Admission Visit Note dated 02/28/2025 lacks an assessment of the patient’s palliative care needs. During interview on 03/20/2025 at 03:03 PM, the Director of Patient Services stated the agency was not aware of the requirement for each patient to be assessed for palliative care needs and therefore does not have a process currently in place. Patient #5 - This 78-year-old patient with the diagnoses of urinary tract infection, type 2 diabetes mellitus, and spinal stenosis was admitted to the home care agency on 03/02/2025. Review of the Skilled Nurse Admission Visit Note dated 03/02/2025 lacks an assessment of the patient’s palliative care needs. During interview on 03/20/2025 at 2:52 PM, the Director of Patient Services stated the agency was not aware of the requirement for each patient to be assessed for palliative care needs and therefore does not have a process currently in place. Patient #3- This 49- year- old patient with the diagnoses of stroke, type 2 diabetes mellitus, and chronic pain syndrome, bipolar, and hemiplegia was admitted to the home care agency on 02/25/2025. Review of the Skilled Nurse Admission Visit Note dated 02/25/2025 lacks an assessment of the patient’s palliative care needs. During interview on 03/20/2025 at 01:40 PM, the Director of Patient Services stated being unaware that each patient needs an assessment of palliative care needs. Patient #8- This 66- year- old patient with the diagnoses of cellulitis left foot ulcer, type 2 diabetes mellitus, acute osteomyelitis, anxiety, and depression was admitted to the home care agency on 12/26/2024. Review of the Skilled Nurse Admission Visit Note dated 12/26/2024 lacks an assessment of the patient’s palliative care needs. During interview on 03/20/2025 at 01:40 PM, the Director of Patient Services stated being unaware that each patient needs an assessment of palliative care needs. Patient #9- This 64- year- old patient with the diagnoses of osteoarthritis of hip unspecified, left anterior arthroplasty, chronic pain, and essential hypertension was admitted to the home care agency on 03/07/2025. Review of the Skilled Nurse Admission Visit Note dated 03/07/2025 lacks an assessment of the patient’s palliative care needs. During interview on 03/20/2025 at 01:40 PM, the Director of Patient Services stated being unaware that each patient needs an assessment of palliative care needs. Patient #10- This 81- year- old patient with the diagnoses of covid pneumonia, peripheral neuropathy, arthritis, and frequent falls was admitted to the home care agency on 03/06/2025. Review of the Skilled Nurse Admission Visit Note dated 03/06/2025 lacks an assessment of the patient’s palliative care needs. During interview on 03/20/2025 at 01:40 PM, the Director of Patient Services stated being unaware that each patient needs an assessment of palliative care needs. Patient #12- This 85- year- old patient with the diagnoses of urinary retention, neurogenic bladder, chronic indwelling catheter, chronic obstructive pulmonary disease (COPD) was admitted to the home care agency on 01/17/2025. Review of the Skilled Nurse Admission Visit Note dated 01/17/2025 lacks an assessment of the patient’s palliative care needs. During interview on 03/20/2025 at 01:40 PM, the Director of Patient Services stated being unaware that each patient needs an assessment of palliative care needs. Patient #1 – This 80-year-old patient with the diagnoses of encounter for surgical aftercare following surgery of the digestive system, acute cholecystitis, and type 2 diabetes mellitus without complications was admitted to the home care agency on 03/01/2025. A. Review of the Skilled Nurse Admission Visit Note dated 03/01/2025 lacks an assessment of the patient’s palliative care needs. During interview on 03/20/2025 at 01:10 PM, the Director of Patient Services stated the agency was not aware that each patient needs an assessment of palliative care needs. B. Review of the hospital discharge/referral dated 02/25/2025 revealed the patient was referred to the home care agency for Skilled Nursing, Physical Therapy, Occupational Therapy, and Home Health Aide services. Review of the Skilled Nurse Admission Visit Note dated 03/01/2025 revealed “made aware the patient would benefit from Home Health Aide services, Occupational Therapist to assess the need.” Review of the Occupational Therapy Evaluation Visit Note dated 03/04/2025 lacks documented evidence the Occupational Therapist assessed the patient’s need for Home Health Aide services. During interview on 03/20/2025 at 03:29 PM, the Registered Nurse Supervisor stated there is no note to explain why the need for Home Health Aide services was not addressed. Patient #4 – This 94-year-old patient with the diagnoses of osteoarthritis, rheumatoid arthritis, and chronic pain syndrome was admitted to the home care agency on 01/23/2025. Review of the Skilled Nurse Admission Visit Note dated 01/23/2025 lacks an assessment of the patient’s palliative care needs. During interview on 03/20/2025 at 01:10 PM, the Director of Patient Services stated the agency was not aware that each patient needs an assessment of palliative care needs. Patient #11 – This 58-year-old patient with the diagnoses of disruption of external operation (surgical) wound, laceration without foreign body, left lower leg, and low back pain was admitted to the home care agency on 03/06/2025. Review of the Skilled Nurse Admission Visit Note dated 03/06/2025 lacks an assessment of the patient’s palliative care needs. During interview on 03/20/2025 at 01:10 PM, the Director of Patient Services stated the agency was not aware that each patient needs an assessment of palliative care needs. Patient #15 – This 51-year-old with the diagnoses of atherosclerotic heart disease of native coronary artery with unspecified angina pectoris, type 2 diabetes mellitus with hyperglycemia, and hypertension was admitted to the home care agency on 10/16/2024. Review of the Skilled Nurse Admission Visit Note dated 10/16/2024 lacks an assessment of the patient’s palliative care needs. During interview on 03/20/2025 at 01:10 PM, the Director of Patient Services stated the agency was not aware that each patient needs an assessment of palliative care needs. Patient #16 – This 68-year-old with the diagnoses of partial intestinal obstruction, malignant neoplasm of unspecified site of right female breast, and malignant neoplasm of unspecified site of left female breast was admitted to the home care agency on 09/05/2024. Review of the Skilled Nurse Admission Visit Note dated 09/05/2024 lacks an assessment of the patient’s palliative care needs. During interview on 03/20/2025 at 01:10 PM, the Director of Patient Services stated the agency was not aware that each patient needs an assessment of palliative care needs. Patient #17 – This 67-year-old patient with the diagnoses of pressure of ulcer sacral region, stage 3, abscess of epididymis of testis, type 2 diabetes mellitus with hyperglycemia was admitted to the home care agency on 06/12/2024. Review of the Skilled Nurse Admission Visit Note dated 06/12/2024 lacks an assessment of the patient’s palliative care needs. During interview on 03/20/2025 at 01:10 PM, the Director of Patient Services stated the agency was not aware that each patient needs an assessment of palliative care needs.

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 review of clinical records and interviews with agency staff, for two (2) of seventeen (17) patients (Patient #s: 3 and 6), the clinical records lack documented evidence of a complete review of all medications the patient is currently using to identify any potential adverse effects and drug reactions or concerns. Failure to conduct a complete medication review has the potential for the patient to experience medication side effects or to receive incorrect medication dosages. The clinical staff failed to complete a review of all medications the patient is currently using to identify any potential adverse effects and drug reactions or concerns as evidenced by: Patient #6- This 78- year- old patient with the diagnoses of aftercare following joint replacement surgery, presence of left artificial hip joint, and unilateral primary osteoarthritis of the left hip was admitted to the home care agency on 03/05/2025. Review of the Discharge Medication Instructions dated 03/04/2025 revealed the order for “aspirin 81 milligram chewable tablet, by mouth, two (2) times per day.” Review of the Home Health Certification and Plan of Care for 03/05/2025 to 05/03/2025 revealed the order: “aspirin low- dose 81 milligram tablet, delayed release, tale one (1) tablet, (81 milligrams), by mouth, two (2) times per day from 03/05/2025 to 04/03/2025.” Review of the clinical records lacks documented evidence the Registered Nurse clarified the formulation of the patient’s aspirin. During interview on 03/20/2025 at 01:03 PM, the Registered Nurse stated that they did not realize that the formulations were different and did not clarify this medication. HV Patient #3- This 49- year- old patient with the diagnoses of stroke, type 2 diabetes mellitus, chronic pain syndrome, bipolar, and hemiplegia was admitted to the home care agency on 02/25/2025. Review of the Physician referral dated 02/24/2025 revealed the order for "vitamin D2 250 micrograms one (1) capsule oral every month." Review of the Home Health Certification and Plan of Care for 02/25/2025 to 04/25/2025 revealed the order for "vitamin D2 1,250 micrograms (50,000 unit) capsule one (1) capsule oral every month." Review of the clinical record lacks documented evidence the Registered Nurse contacted the physician regarding the discrepancy. During interview on 03/20/2025 at 01:48 PM, the Registered Nurse Supervisor stated the doses of medication are different and the Registered Nurse did not contact the physician regarding the discrepancy.

Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than- This STANDARD is not met as evidenced by: Based on clinical record review and staff interview for three (3) of seventeen (17) patients (Patient #’s: 2, 5, and 12) requiring updates to the comprehensive assessment, the agency failed to ensure the assessments were of sufficient scope to identify current patient needs. Failure to ensure comprehensive assessments contain complete and accurate information has the potential for unmet patient needs. The agency failed to ensure the assessments were of sufficient scope to identify current patient needs as evidenced by: Patient #12- This 85- year- old patient with the diagnoses of urinary retention, neurogenic bladder, chronic indwelling catheter, and chronic obstructive pulmonary disease (COPD) was admitted to the home care agency on 01/17/2025. Review of the Skilled Nurse Routine Visit Note dated 01/28/2025 revealed: “patient did have sediments noted in foley bag. Skilled Nurse called physician’s office to report, left message. No other signs/ symptoms at this time.” Review of the clinical record lacks documented evidence the Skilled Nurse followed up with the patient’s physician regarding the sediments noted in the foley bag. During interview on 03/20/2025 at 02:20 PM, the Registered Nurse stated that a message was left for the patient's primary care provider, but they did not receive a call back. The Registered Nurse added there should have been followed up with the physician. Patient #2 – This 78-year-old patient with the diagnoses of urinary tract infection, type 2 diabetes mellitus, and spinal stenosis was admitted to the home care agency on 03/02/2025. Review of the Physical Therapy Visit Routine Note dated 3/11/2025 revealed the following intervention: “Assess and evaluate effectiveness of all pain control measures including all prescribed pain medications, rest and repositioning: Patient reports severe low back pain radiating from the back to the hip, sometimes as high as 9/10 (nine out of ten, ten being the highest), patient only taking tylenol. Patient reports the pain comes and goes for the last few weeks and is not related to his recent fall. Primary care physician's office notified (spoke with employee).” During interview on 03/20/2025 at 1:46 PM, the Physical Therapist stated that a message was left with the primary care physician's office but they never received a call back from the provider. The Physical Therapist stated the patient was refusing to take any medications for pain besides tylenol, and the pain experienced was related to a chronic condition relieved by repositioning and stretching. The clinician did not feel it was necessary to follow-up on the call previously made to the physician regarding the fall and hip/back pain. Patient #5 – This 78-year-old patient with the diagnoses of urinary tract infection, type 2 diabetes mellitus, and spinal stenosis was admitted to the home care agency on 03/02/2025. A. Review of the Skilled Nurse Routine Note dated 03/04/2025 revealed the following intervention: “Reconcile and review all medications, including visualization of all prescription bottles, over the counter medications and creams in the home. Medical Doctor to be notified of any discrepancies with verbal orders being sent as necessary: Performed – Yes.” Review of the Skilled Nurse Routine Note dated 03/04/2025 revealed “Note: Patient also reports he has stopped taking torsemide. Patient reports he was unable to take as it was making him urinate way too much and he was having issues making it to the bathroom and was unable to stand up well from his chair. Patient reported he would be in agreement to discuss use of a different diuretic with primary care physician. Skilled Nurse called and informed primary care physician of above stated information. Skilled nursing waiting on return phone call.” Review of the Skilled Nurse Routine Note dated 03/11/2025 revealed: “Clinical findings/interventions: Right lower extremity +1 (plus one) edema. No edema left lower extremity. Skilled Nurse educated patient on importance of elevating bilateral lower extremities and reducing salt in the diet. Patient receptive and verbalized understanding and patient did elevate legs during visit. Patient has not received a call back from primary care physician re: torsemide but patient has appointment with medical doctor Thursday.” Review of the Skilled Nurse Routine Visit dated 03/15/2025 revealed the following intervention: “Reconcile and Review all medications, including visualization of all prescription bottles, over the counter medications and creams in the home. Medical Doctor to be notified of any discrepancies with verbal orders being sent as necessary: Performed – Yes.” Review of the Skilled Nurse Routine Visit dated 03/15/2025 revealed: “Note: patient reports no medication changes and no changes from primary care physician phone consult. Unable to follow up with office on changes due to weekend visit.” Review of the Skilled Nurse PRN (as needed) Visit dated 03/17/2025 revealed the following intervention: “Interdisciplinary communication/progress towards discharge/clinical note: Skilled Nurse reviewed office visit note from primary care physician for the following: torsemide 20 milligrams: take one (1) tablet by mouth daily as needed for edema.” During interview on 03/20/2025 at 02:28 PM, the Registered Nurse stated they would typically follow-up with the Registered Nurse Supervisor when a physician's office doesn't return a phone call but forgot this time.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on review of clinical records and staff interviews for five (5) of seventeen (17) patients (Patient #s: 1, 5, 9, 12, and 15) the agency failed to develop individualized plans of care that are complete and accurate and address the total needs of the patients. Failure to ensure that a comprehensive individualized plan of care is developed has the potential for unmet patient needs. The agency failed to develop individualized plans of care that are complete and accurate and address the total needs of the patients as evidenced by: Patient #12- This 85- year- old patient with the diagnoses of urinary retention, neurogenic bladder, chronic indwelling catheter, and chronic obstructive pulmonary disease (COPD) was admitted to the home care agency on 01/17/2025. A.) Review of the Skilled Nurse Admission Visit Note dated 01/17/2025 revealed the Registered Nurse documented the patient has a chair lift. Review of the Home Health Certification and Plan of Care for 01/17/2025 to 03/17/2025 lacks an order for a chair lift. During interview on 03/21/202 at 09:30 AM, the Registered Nurse Supervisor stated that there is no order for a chair lift on the plan of care. B.) Review of the Skilled Nursing Routine Visit Note dated 01/20/2025 revealed the Skilled Nurse documented the following: "Patient to apply splint to left wrist daily as needed for comfort." Review of the Home Health Certification and Plan of Care for 01/17/2025 to 03/17/2025 lacks an order for the application of splint to the left wrist. During interview on 03/21/202 at 09:30 AM, the Registered Nurse Supervisor stated that there is no order for a splint to be applied to left wrist on the plan of care. Patient #9- This 64- year- old patient with the diagnoses of osteoarthritis of hip unspecified, left anterior arthroplasty, chronic pain, and essential hypertension was admitted to the home care agency on 03/07/2025. Review of the Physical Therapy Evaluation visit note dated 03/07/2025 revealed the Physical Therapist documented the following: "Pain control measures: Heat/Cold." Review of the Home Health Certification and Plan of Care for 03/07/2025 to 05/05/2025 lacks documentation of orders for the application of heat or cold. During interview on 03/20/2025 at 01:36 PM, the Physical Therapist they do not have the option to order either heat or cold. Patient #5 – This 78-year-old patient with the diagnoses of urinary tract infection, type 2 diabetes mellitus, and spinal stenosis was admitted to the home care agency on 03/02/2025. A. Review of the Home Health Certification and Plan of Care for 03/02/2025 to 04/30/2025 revealed an order for the medication "Repatha sureclick 140 milligram/milliliter subcutaneous pen injection. Inject 1 milliliter (140 milligrams) by subcutaneous route every two (2) weeks in the abdomen, thigh or outer area of upper arm (rotate sites). Patient to self-administer." Review of the plan of care lacks an order for alcohol wipes to clean the site prior to injection. During an observational home visit with Registered Nurse on 03/19/2025, the patient requested alcohol wipes from Registered Nurse's supply bag, stating he does not have any. He has been using lense cleansing wipes to clean the injection site prior to administering his repatha injection. The Registered Nurse provided the patient with alcohol wipes and instructed that he could purchase alcohol wipes from the pharmacy where he gets his prescriptions. During interview on 03/20/2025 at 02:25 PM, the Registered Nurse stated they weren’t sure if the alcohol wipes were provided by the agency. The Registered Nurse Supervisor stated that the alcohol wipes should be ordered on the plan of care. B. Review of the Skilled Nurse PRN (as needed) Visit on 03/17/2025 revealed the patient received an order for a new medication "torsemide 20 milligrams: take one (1) tablet by mouth daily as needed for edema." Review of the clinical record lacks an order to for the torsemide medication. During interview on 03/20/2025 at 02:29 PM, the Registered Nurse confirmed she forgot to put an order in for the as needed torsemide, but did complete at the next visit. C. Review of the Skilled Nurse Routine Visit dated 03/05/2025 revealed a verbal order was obtained from the primary care physician office for the following: "xanax 0.25 milligrams: take one (1) tablet two (2) times per day as needed." Review of the clinical record lacks an order for the new medication. During interview on 03/20/2025 at 02:25 PM, the Registered Nurse stated she forgot to put the medication order in. D. Review of the Home Health Certification and Plan of Care for 03/02/2025 to 04/30/2025 revealed an order "norco 5 milligram-325 milligram tablet. Take one (1) tablet by oral route every 6 (six) hours as needed for pain." Review of the clinical record lacks orders for a bowel regimen for a patient receiving narcotics. During interview on 03/20/2025 at 02:56 PM, the Registered Nurse Supervisor confirmed there was no bowel regimen in place for the patient and stated the expectation for all patients receiving narcotics is education on constipation and at least an “as needed” medication order. E. Review of the Discharge Instruction Form from skilled nursing facility dated 02/26/2025 revealed the following discharge instructions: “Current treatment and therapies: Walk with rolling walker. Lab work scheduled for one week CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel), magnesium level, and BNP (B-type Natriuretic Peptide). Continue consistent carbohydrate diabetic diet.” Review of the Skilled Nursing Admission Visit dated 03/02/2025 lacks evidence of follow-up on discharge orders for blood work. During interview on 03/20/2025 at 02:54 PM, the Registered Nurse Supervisor confirmed that there was no documentation at admission that the blood work appointment or services were confirmed or followed up on. Patient #1 – This 80-year-old patient with the diagnoses of encounter for surgical aftercare following surgery of the digestive system, acute cholecystitis, and type 2 diabetes mellitus without complications was admitted to the home care agency on 03/01/2025. Review of the Home Health Certification and Plan of Care for 03/01/2025 to 04/29/2025 revealed “Patient/caregiver will demonstrate understanding of how to live with diabetes, as evidenced by checking blood sugars and responding appropriately.” Review of the plan of care lacks orders for blood glucose testing supplies, parameters for when to call the physician, and medications to treat diabetes. During interview on 03/20/2025 at 03:30 PM, the Registered Nurse Supervisor stated the patient does not check her blood glucoses. The patient’s primary care provider manages her diabetes using A1C (glycated hemoglobin) levels. This information was missing from the plan of care. Patient #15 – This 51-year-old with the diagnoses of atherosclerotic heart disease of native coronary artery with unspecified angina pectoris, type 2 diabetes mellitus with hyperglycemia, and hypertension was admitted to the home care agency on 10/16/2024. Review of the Home Health Certification and Plan of Care for 10/16/2024 to 12/14/2024 revealed “Skilled Nursing to monitor for scabbed area to right breast from previous tear for signs and symptoms of infection. Patient may apply dressing for comfort daily.” Review of the plan of care lacks an order stating what dressing is to be used. During interview on 03/20/2025 at 03:15 PM, the Registered Nurse Supervisor said there is no order specifying what the dressing the patient is to use.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview for two (2) of seventeen (17) patient records (Patient #'s: 1 and 16), failed to include evidence that orders were obtained for changes in the plan of care. Failure to obtain an order for changes in the plan of care has the potential for agency staff to act on inaccurate and incomplete information and places patient health and welfare at risk. The clinical staff failed to include evidence that orders were obtained for changes in the plan of care as evidenced by: HV Patient #1 – This 80-year-old patient with the diagnoses of encounter for surgical aftercare following surgery of the digestive system, acute cholecystitis, and type 2 diabetes mellitus without complications was admitted to the home care agency on 03/01/2025. A. Review of the Home Health Certification and Plan of Care for 03/01/2025 to 04/29/2025 revealed the order for oxycodone 5 milligram tablet take one half tablet by oral route every six (6) hours as needed. During an observational home visit on 03/18/2025 at 11:30 AM, the patient told the Occupational Therapist that she wanted oxycodone to be taken off the medication list. The patient stated she never filled it and will never take it. Review of the clinical record lacks an order to discontinue the oxycodone. During interview on 03/20/2025 at 03:33 PM, the Registered Nurse Supervisor stated the medication was not discontinued. B. During an observational home visit on 03/18/2025 at 11:30 AM, the patient wore a splint on her right hand. Review of the clinical record lacks an order for the splint. During interview on 03/20/2025 at 03:33 PM, the Registered Nurse Supervisor stated there is no order for a splint. Patient #16 – This 68-year-old with the diagnoses of partial intestinal obstruction, malignant neoplasm of unspecified site of right female breast, and malignant neoplasm of unspecified site of left female breast was admitted to the home care agency on 09/05/2024. Review of the Home Health Certification and Plan of Care for 09/05/2024 to 11/03/2024 revealed the order for a "low residue diet." Review of the Skilled Nurse Resumption of Care Visit Note dated 09/13/2024 revealed “diet to be regular.” Review of the clinical record lacks an order for a regular diet. During interview on 03/20/2025 at 03:23 PM, the Registered Nurse Supervisor stated the patient’s diet order was not updated.

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 review of clinical records, and interviews with agency staff for four (4) of seventeen (17) patients (Patient #s: 3, 5, 8, and 10), the agency failed to ensure drugs and treatments are administered in accordance with physician orders. Failure to administer drugs and treatments without a physician's order has the potential to result in poor quality of care. The agency failed to ensure drugs and treatments are administered in accordance with physician orders as evidenced by: Patient #3- This 49- year- old patient with the diagnoses of stroke, type 2 diabetes mellitus, chronic pain syndrome, bipolar, and hemiplegia was admitted to the home care agency on 02/25/2025. Review of the Home Health Certification and Plan of Care for 02/25/2025 to 04/25/2025 revealed: "Vital sign parameters: report to medical doctor if: blood pressure less than 80/50 or higher than 170/110, heart rate less than 60 or more than 120, respirations less than 10 or greater than 24 per minute, temperature less than 96.0 or greater than 101.5, oxygen saturation less than 90 percent." Review of the Physical Therapy Evaluation Visit Notes dated 02/25/2025 and 02/27/2025 lack documented vital signs at each visit. During interview on 30/20/2025 at 01:52 PM, the Physical Therapist stated that they would only assess the vital signs if patient presented with any concerns. The Registered Nurse Supervisor confirmed the expectation is that they are done at each visit. Patient #8- This 66- year- old patient with the diagnoses of cellulitis left foot ulcer, type 2 diabetes mellitus, acute osteomyelitis, anxiety, and depression was admitted to the home care agency on 12/26/2024. Review of the Skilled Nurse Routine Visit Note dated 12/30/2024 revealed the following intervention: "Vital sign parameters: report to medical doctor if: blood pressure less than 80/50 or higher than 170/110, heart rate less than 60 or more than 120, respirations less than 10 or greater than 24 per minute, temperature less than 96.0 or greater than 101.5, oxygen saturation less than 90 percent... Note: VSS (vital signs stable)." Review of the Skilled Nurse Routine Visit Note dated 12/30/2024 lacks documented vital signs. During interview on 03/20/2025 at 02:09 PM, the Registered Nurse stated that the vital signs were obtained but not documented. Patient #10- This 81- year- old patient with the diagnoses of covid pneumonia, peripheral neuropathy, arthritis, and frequent falls, was admitted to the home care agency on 03/06/2025. Review of the Home Health Certification and Plan of Care for 03/06/2025 to 05/04/2025 revealed the order for ‘‘Vital signs parameters to report to MD. Blood pressure less than 90/50, or greater than 170/110, heart rate less than 60 greater than 120, respiration less than 10 greater than 24, temperature less than 96. 0 greater than 101.5, oxygen saturation less than 90 percent.” Review of the Physical Therapy Visit Routine Note dated 03/16/2025 lacks documented vital signs. During interview on 03/21/2025 at 08:53 AM, the Registered Nurse Supervisor stated there weas no documentation of the patient’s vital signs. Patient #5 – This 78-year-old patient with the diagnoses of urinary tract infection, type 2 diabetes mellitus, and spinal stenosis was admitted to the home care agency on 03/02/2025. Review of the Skilled Nurse Routine Visit dated 3/15/2025 revealed the following intervention: Teach patient the signs and symptoms of urinary tract infection and methods of preventions: performed - yes Note: Patient called this writer requesting a urine sample because he reports he's had dark, foul-smelling urine. Skilled Nurse called on-call services requesting a call back from the doctor-on-call for primary care physician. At 11:30 AM Skilled Nurse received a call back from on-call medical doctor and gave medical doctor patient's report and verbal order given for urine sample. Urine not obtained because urine would have been obtained and then lab used by agency would have been closed. Lab closes at 12 noon on Saturday and is closed on Sunday. Lab behind mall is closed on weekends. Urine to be obtained at next scheduled visit. During interview on 3/20/2025 at 02:00 PM, the Registered Nurse stated the patient was only having foul dark urine and not his normal urinary tract infection symptoms. The lab was closed, they did not think it would be an issue to wait until Monday to obtain urine a sample. The Registered Nurse Supervisor confirmed the Registered Nurse should have made a plan to test the patient as soon as possible.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on review of clinical records and interviews with staff for one (1) of seventeen (17) patients (Patient #17), the agency failed to ensure the physician is notified of changes in the patient's condition or needs that suggest the plan of care may need to be altered. Failure to promptly notify the physician to changes in the patient's condition or needs that may suggest that outcomes are not being achieved and/or the plan of care should be altered has the potential to result in unmet patient needs and negative patient outcomes. The agency failed to ensure the physician is notified of changes in the patient's condition or needs that suggest the plan of care may need to be altered as evidenced by: Patient #17 – This 67-year-old patient with the diagnoses of pressure of ulcer sacral region, stage 3, abscess of epididymis of testis, type 2 diabetes mellitus with hyperglycemia was admitted to the home care agency on 06/12/2024. Review of the Home Health Certification and Plan of Care for 06/12/2024 to 08/10/2024 revealed “Teach and instruct daily foot care including inspection, cleansing, keeping moisturized, and wearing shoes… patient has type 2 diabetes mellitus with hyperglycemia.” Review of the Skilled Nursing Routine Visit Note dated 06/19/2024 revealed “Patient has loose toenail on right second toe, no drainage or signs/symptoms of infection.” Review of the clinical record lacks documented evidence of an intervention for the toenail or notification to the physician. During interview on 03/20/2025 at 03:07 PM, the Registered Nurse Supervisor stated there is no documentation stating the physician was notified or a plan to treat the toenail.

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 records and interviews with agency staff for one (1) of seventeen (17) patients (Patients #5), the agency failed to coordinate care delivery and ensure patient needs are addressed. Failure to coordinate care delivery has the potential for negative patient outcomes. The agency failed to coordinate care delivery and ensure patient needs are addressed as evidenced by: HV Patient #5 – This 78-year-old patient with the diagnoses of urinary tract infection, type 2 diabetes mellitus, and spinal stenosis, was admitted to the home care agency on 03/02/2025. During an observational home visit on 03/19/2025 at 11:30 AM, the patient and Skilled Nurse discussed how the patient is not following through on set up of medication delivery as patient is having difficulty accessing pharmacy to obtain medications, missed cardiology visit due to difficulty leaving the home, and non-compliance with scheduling follow-ups with primary care provider as evidenced by patient changing in-person follow-up post-hospitalization to "phone consult.” The patient stated they were hesitant and not ready to leave the home. The Skilled Nurse was observed providing education on pharmacy delivery set up, importance of compliance with appointments, and offered to call to schedule cardiology follow-up. Review of the clinical record lacks evidence of coordination between the Skilled Nurse and Medical Social Worker to assess and address the patient's needs. During interview on 3/20/2025 at 02:33 PM, the Skilled Nurse stated she tried to assist him through educating on resources such as delivery from pharmacy, but the patient had yet to complete set up. The Registered Nurse further stated that she did not think of a social work referral but does believe it would be appropriate for this patient.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on review of clinical records and interviews with staff, for five (5) of seventeen (17) patients (Patient #s: 2, 5, 4, 6, and 10), the agency failed to prepare and document complete and accurate clinical notes. Failure to document complete and accurate clinical and progress notes has the potential for unmet patient needs. The agency failed to prepare and document complete and accurate clinical notes as evidenced by: Patient #10- This 81- year- old patient with the diagnoses of covid pneumonia, peripheral neuropathy, arthritis, and frequent falls, was admitted to the home care agency on 03/06/2025. Review of the Physical Therapy Evaluation Visit Note dated 03/07/2025 revealed the following assessment: “Assistive Device: has single point cane.” Review of the Home Health Certification and Plan of Care for 03/06/2025 to 05/04/2025 lacks an order for a single point cane. During interview on 03/21/2025 at 08:55 AM, the Registered Nurse Supervisor stated the patient does not use a single point cane, the documentation was in error. Patient #2 – This 70-year-old patient with the diagnoses of intestinal obstruction, Parkinson's Disease without dyskinesia without mention of fluctuations, and essential primary hypertension was admitted to the home care agency on 02/28/2025. A. Review of the Physical Therapy Evaluation Visit Note dated 03/04/2025 revealed the following intervention: Vital sign parameters: report to medical doctor if: blood pressure less than 80/50 or higher than 170/110, heart rate less than 60 or more than 120, respirations less than 10 or greater than 24 per minute, temperature less than 96.0 or greater than 101.5, oxygen saturation less than 90 percent. Performed: Yes Note: Vital Signs Stable (VSS) Review of the Physical Therapy Evaluation Visit Note dated 03/04/2025 lacks documented vital signs. During interview on 03/20/2025 at 01:29 PM, the Physical Therapist stated they did obtain vital signs but did not record them in the visit note. B. Review of the Physical Therapy Routine Visit Note dated 03/14/2025 revealed the following intervention: Vital sign parameters: report to medical doctor if: blood pressure less than 80/50 or higher than 170/110, heart rate less than 60 or more than 120, respirations less than 10 or greater than 24 per minute, temperature less than 96.0 or greater than 101.5, oxygen saturation less than 90 percent. Performed: Yes Note: O2 saturations staying between 95-98% during PT activities today Review of the Physical Therapy Visit Note dated 03/14/2025 lacks documented vital signs. During interview on 03/20/2025 at 1:29 PM, the Physical Therapist stated they did obtain vital signs but did not record them in the visit note. Patient #5 – This 78-year-old patient with the diagnoses of urinary tract infection, type 2 diabetes mellitus, and spinal stenosis was admitted to the home care agency on 03/02/2025. A. Review of the Physical Therapy Evaluation Note dated 03/4/2025 revealed the following: "Physical Therapy evaluation completed. Present as well as (Registered Nurse/Case Manager), joint visit scheduled as both Registered Nurse and Physical Therapist had a difficult time contacting patient/his family to schedule appointment. Present as well (patient's friend), roommate, and "occ" caregiver." Review of the Physical Therapy Visit Note dated 03/14/2025 contained use of an unidentified abbreviated term "occ." During interview on 03/20/2025 at 1:53 PM, the Physical Therapist stated it was a documentation error and meant to type occasional. B. Review of the Patient Information Summary which contains the patient's demographics revealed the following: Referral: 02/27/2025. Review of the Skilled Nurse Admission Visit dated 02/28/2025 revealed the following: "(M0104) Date of Referral: 02/21/2025." During interview on 03/20/2025 at 3:01 PM, the Registered Nurse Supervisor confirmed the referral management department made a transcription error in the patient's demographics, and the correct date of referral was 02/21/2025. Patient #6- This 78- year- old patient with the diagnoses of aftercare following joint replacement surgery, presence of left artificial hip joint, and unilateral primary osteoarthritis of the left hip was admitted to the home care agency on 03/05/2025. Review of the Skilled Nurse Admission Visit dated 03/05/2025 revealed the following: (O0110) G3. CPAP (continuous positive airway pressure): 0- No. Other (Assistive Device): Has- Other (specify): leg lifter, incentive spirometer, CPAP and associated supplies. There is a discrepancy as to whether the patient uses a continuous positive airway pressure (CPAP) device or not. During interview on 03/20/2025 at 01:05 PM, the Registered Nurse stated that the answer to G3. was a typographical error, the answer should be Yes, since the patient does use a CPAP during sleep. Patient #4 – This 94-year-old patient with the diagnoses of osteoarthritis, rheumatoid arthritis, and chronic pain syndrome was admitted to the home care agency on 01/23/2025. Review of the Physical Therapy Evaluation Visit Note dated 01/24/2025 revealed the following intervention: Vital sign parameters: report to medical doctor if: blood pressure less than 80/50 or higher than 170/110, heart rate less than 60 or more than 120, respirations less than 10 or greater than 24 per minute, temperature less than 96.0 or greater than 101.5, oxygen saturation less than 90 percent. Performed: Yes Review of the Physical Therapy Evaluation Visit Note dated 01/24/2025 lacks documented vital signs. During interview on 03/20/2025 at 1:45 PM, the Physical Therapist stated they did obtain vital signs but did not record them in the visit note.

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 review of clinical records and interview with agency staff, for one (1) of one (1) patients receiving Home Health Aide services from the agency (Patient #4), the agency failed to ensure the Home Health Aide was supervised at least every fourteen (14) days. Failure to provide adequate supervision of paraprofessional staff places patients at risk for negative outcomes and unmet patient needs. The agency failed to ensure the Home Health Aide was supervised at least every fourteen (14) days as evidenced by: Patient #4 – This 94-year-old patient with the diagnoses of osteoarthritis, rheumatoid arthritis, and chronic pain syndrome was admitted to the home care agency on 01/23/2025. Review of the supplemental order dated 02/04/2025 revealed the order for “Home Health Aide services twice a week for the first week and three (3) times a week for six (6) weeks.” Review of the clinical record from 02/23/2025 to 03/15/2025 revealed the Home Health Aide provided services on 02/24/2025, 02/26/2025, 02/28/2025, 03/03/2025, 03/05/2025, 03/07/2025, 03/10/2025, 03/12/2025, and 03/14/2025. Review of the clinical record from 02/23/2025 to 03/15/2025 lacks documented evidence of supervision of the paraprofessional staff. During interview on 03/19/2025 at 11:25 AM, the Registered Nurse Supervisor stated there is no documentation of supervisory visits in the clinical record during this time period.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on review of clinical records, agency policy and procedure, and staff interview for one (1) of six (6) patients discharged from the agency (Patient #13), the agency failed to follow the agency policy and procedure for patient discharge. Failure to follow established agency discharge policies and procedures has the potential for patients to be placed at risk for unsafe or poor continuity of care. The home health agency failed to follow the agency discharge policy and procedure as evidenced by the following: Review of the agency’s policy entitled “General Practice Guidelines – Patient Discharge” dated 01/2018 revealed the following: Considerations: A patient can be discharged from home care services for the following reasons: If the patient’s (or other persons in the home) behavior is so disruptive, abusive, or uncooperative that the delivery of care to the patient or the ability of the home health agency to operate effectively and safely is seriously impaired; In this case, before discharge, the home health agency will advise the patient, the representative (if any) that a discharge is being considered, make efforts to resolve the problem(s) presented by the patient’s behavior or by other person(s) in the home (as applicable), or situation (such as a dangerous animal being loose in the home), document the problem(s) and efforts made to resolve the problem(s) and enter this documentation into its clinical record. The home health agency will provide the patient and representative (if any), with contact information for other agencies or provide who would potentially be able to provide care following the discharge. Procedure: 1. If able, the agency will notify the patient of the decision to terminate services one to two visits prior to expected discharge. Medicare patients will receive generic discharge notice with their rights to appeal with the appropriate phone number provided. 3. Explain procedure to patient. 7. Provide discharge instructions and reinforcement of all teaching and assess comprehension and patient/ caregiver ability to repeat instruction, perform return demonstrations as needed. Patient #13- This 67- year- old patient with the diagnoses of disruption of external operation (surgical) wound not elsewhere classified subsequent encounter, type 2 diabetes mellitus with diabetic neuropathic arthropathy, and cutaneous abscess of the left foot was admitted to the home care agency on 11/13/2023 and was discharged from the home care agency on 12/13/2023. Review of the Case Communication Report dated 12/14/2023 revealed the Registered Nurse Supervisor documented the following: “Subject: Discharge Note- General; Patient will be attending outpatient wound care as arranged by the patient’s primary care physician. Patient is discharged from services as of 12/13/2023 for inappropriate behavior. No contact is to be made with this patient.” Review of the clinical record lacks documented evidence of any inappropriate behavior by the patient, that the patient was informed discharge was being considered, that the agency made efforts to resolve the problem, or that contact information was provided for other potential agencies who could provide care. Review of the clinical record also lacks documented evidence the patient was provided notice of discharge prior to the discharge from the agency, that the agency explained the discharge procedure to the patient, that the patient was provided a generic Medicare discharge notice or discharge instructions from the agency. During interview on 03/21/2025 at 09:16 AM, the Registered Nurse Supervisor stated there was only one incident of inappropriate behavior by the patient, and that other interventions were not attempted because when the Registered Nurse Supervisor spoke to the Administrator about the incident, it was the Administrator’s directive to discharge the patient. The Registered Nurse Supervisor further stated that they are aware the agency did not follow the agency discharge policy. During interview on 03/21/2025 at 09:27 AM, the Registered Nurse Supervisor stated that the patient’s primary care physician was contacted to report the patient’s inappropriate behavior and the physician’s office arranged for continued wound care through outpatient services. The patient was contacted by phone and notified that they were discharged from the agency and to contact their primary care physician for information on outpatient services. The Registered Nurse Supervisor also stated the patient was not provided discharge instructions because outpatient services would be taking over the patient’s care.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on review of clinical records, agency policy and procedure, and interviews with agency staff, for one (1) of six (6) discharged patients (Patient #: 13), the agency failed to complete a discharge summary and send it to the primary care practitioner within 5 (five) business days of the date of the order for discharge. Failure to complete a discharge summary and send it to the primary care practitioner within the required timeframes has the potential for unmet patient needs and an unsafe discharge. The home health agency failed to send a discharge summary to the primary care practitioner within five (5) business days of the date of the order for discharge as evidenced by the following: Review of the agency’s policy entitled “General Practice Guidelines – Patient Discharge” dated 01/2018 revealed “The agency discharge summary form will be faxed to the physician responsible for the home health agency plan of care within five (5) days of the discharge.” Patient #13- This 67- year- old patient with the diagnoses of disruption of external operation (surgical) wound not elsewhere classified subsequent encounter, type 2 diabetes mellitus with diabetic neuropathic arthropathy, and cutaneous abscess of the left foot was admitted to the home care agency on 11/13/2023 and was discharged from the home care agency on 12/13/2023. Review of the Discharge/ Transfer Summary dated 12/21/2023 revealed the patient was discharged on 12/13/2023, but the discharge summary was not signed and sent to the physician until 12/21/2023, six (6) business days later. The agency failed to complete and send the discharge summary within five (5) business days. During interview on 03/21/2025 at 09:14 AM, the Registered Nurse Supervisor stated that the discharge summary was sent on 12/21/2023, over five (5) business days after the patient was discharged.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on review of clinical records and interviews with staff, for five (5) of seventeen (17) patients (Patient #'s: 5, 6, 7, 13, and 14) the agency failed to ensure all documentation is legible, clear, complete, consistent, and appropriately authenticated, dated, and timed, in accordance with accepted standards of practice. Failure to ensure documentation is legible, clear, complete, and appropriately authenticated has the potential for patients to receive care from unlicensed staff. The home health agency failed to authenticate physician’s signatures and titles as evidenced by the following: Patient #5 – This 78-year-old patient with the diagnoses of urinary tract infection, type 2 diabetes mellitus, and spinal stenosis was admitted to the home care agency on 03/02/2025. Review of the Home Health Certification and Plan of Care for 03/02/2025 to 04/30/2025 revealed the physician's signature lacks credentials. The agency failed to ensure documentation by staff is authenticated in accordance with accepted standards of practice. During an interview on 03/20/2025 at 03:13 PM, the Director of Patient Services confirmed credentials should be included with the signature but were not. Patient #6- This 78- year- old patient with the diagnoses of aftercare following joint replacement surgery, presence of left artificial hip joint, and unilateral primary osteoarthritis of the left hip was admitted to the home care agency on 03/05/2025. A. Review of the Home Health Certification and Plan of Care for 03/05/2025 to 05/03/2025 revealed the physician's signature lacks credentials. B. Review of the Supplemental Physician Order dated 03/05/2025 revealed the physician's signature lacks credentials. The agency failed to ensure documentation by staff is authenticated in accordance with accepted standards of practice. During an interview on 03/21/2025 at 12:05 PM, the Director of Patient Services stated that none of the Signature Log signatures include credentials, the agency is currently working on correcting that. Patient #7- This 73- year- old patient with the diagnoses of aftercare following joint replacement surgery, presence of left artificial knee joint, and unilateral primary osteoarthritis of the left knee was admitted to the home care agency on 02/27/2025. A. Review of the Review of the Home Health Certification and Plan of Care for 02/27/2025 to 04/27/2025 revealed the physician's signature lacks credentials. B. Review of the Supplemental Physician Order dated 02/27/2025 revealed the physician's signature lacks credentials. The agency failed to ensure documentation by staff is authenticated in accordance with accepted standards of practice. During an interview on 03/21/2025 at 12:05 PM, the Director of Patient Services stated that none of the Signature Log signatures include credentials, the agency is currently working on correcting that. Patient #13- This 67- year- old patient with the diagnoses of disruption of external operation (surgical) wound not elsewhere classified subsequent encounter, type 2 diabetes mellitus with diabetic neuropathic arthropathy, and cutaneous abscess of the left foot was admitted to the home care agency on 11/13/2023. A. Review of the Review of the Home Health Certification and Plan of Care for 11/13/2023 to 01/11/2024 revealed the physician's signature lacks credentials. B. Review of the Supplemental Physician Orders dated 11/18/2023, 11/24/2023, and 12/0/2023 revealed the physician's signature lacks credentials. The agency failed to ensure documentation by staff is authenticated in accordance with accepted standards of practice. During an interview on 03/21/2025 at 12:05 PM, the Director of Patient Services stated that none of the Signature Log signatures include credentials, the agency is currently working on correcting that. Patient #14- This 81- year- old patient with the diagnoses of occlusion and stenosis of right carotid artery, unspecified dementia of unspecified severity without behavioral, psychological, mood disturbance, or anxiety, and cirrhosis of the liver was admitted to the home care agency on 05/09/2024. A. Review of the Review of the Home Health Certification and Plan of Care for 05/09/2024 to 07/07/2024 revealed the physician's signature lacks credentials. B. Review of the Supplemental Physician Orders dated 06/20/2024, 06/21/2024, and 07/01/2024 revealed the physician's signature lacks credentials. The agency failed to ensure documentation by staff is authenticated in accordance with accepted standards of practice. During an interview on 03/21/2025 at 12:05 PM, the Director of Patient Services stated that none of the Signature Log signatures include credentials, the agency is currently working on correcting that.

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on review of clinical records, and interview with agency staff, for two (2) of five (5) patients (Patient #'s 2 and 4), the agency failed to ensure the clinician communicated with all physicians involved in the patient's care. Failure to communicate with all physicians involved in the plan of care has the potential for unmet patient needs and patient harm. Patient #2 – This 92-year-old patient with diagnoses that include diverticulitis of the large intestine, essential hypertension and atrial fibrillation was admitted to the home health agency on 11/21/2022. Review of the Home Health Certification and Plan of Care for certification period 11/21/2022 to 01/19/2023 revealed the following ordered Skilled Nursing Intervention: Follow-up for any changes with patient’s PCP (primary care physician) from 11/22/2022 appointment. Review of the clinical record revealed the patient was seen by Skilled Nurse (SN) after the 11/22/2022 PCP appointment on 11/25/2022. Review of the Skilled Nurse Routine Visit Note dated 11/25/2022 revealed the following: “Pt. (patient) states she had phone visit with (PCP) on 11/22/2022 and states no changes. SN unable to verify d/t (due to) holiday.” Review of the clinical record lacks documented evidence of physician follow-up after the patient’s 11/22/2022 medical appointment. The SN failed to communicate with all physicians involved in the plan of care. During interview on 12/07/2022 at 03:00 PM, the Supervising Public Health Nurse stated the SN was unavailable for interview and acknowledged the record lacks follow-up regarding the identified medical appointment. Patient #4 – This 75-year-old patient with diagnoses that include an unstageable pressure ulcer of the right hip, a cutaneous abscess to the right lower limb and cellulitis of the right lower limb was admitted to the home health agency on 11/23/2022. Review of the facility discharge instructions dated 11/13/2022 revealed the following wound care orders: Apply Alginate (absorbent wound dressing), Santyl (assists in removing dead tissue) and Mepilex (absorbent foam dressing) to both wounds (wound locations not specified) daily. Review of the Home Health Certification and Plan of Care for certification period 11/23/2022 to 01/21/2023 revealed the following wound care order to the right pre-tibial trauma wound: Skilled Nurse/ Wound Center- cleanse with NS (Normal Saline), pack with Iodoform packing strip (medicated packing strip) into wound bed, cover the HFB (Hydrofera Blue) (keeps wounds moist and addresses bacteria and yeast), cover with DSD (dry sterile dressing) 3 (three) times a week and as needed if soiled or comes loose. Review of the clinical record lacks documented evidence of communication with the physician regarding the change in the wound care procedure and dressing change frequency. The SN failed to communicate with all physicians involved in the plan of care. During interview on 12/07/2022 at 01:00 PM, the Registered Nurse (RN) stated she contacted the patient’s wound clinic provider, who is not the ordering home care physician, and obtained the updated orders but failed to document this.

The following statement of deficiencies represents the results of a partial extended re-certification survey of Chemung County Health Department conducted on 06/13/2022 through 06/17/2022 and a COVID-19 vaccination survey. The agency reports five (5) patients who are COVID-19 positive. A standard re-certification survey was initiated on 06/13/2022. Deficient practices were identified within Level 1 standards in G-536 on 06/14/2022 resulting in a partially extended survey. The survey consisted of a review of seventeen (17) clinical records including five (5) discharge records, nine (9) personnel records for professional and paraprofessional personnel, two (2) contracts, and seven (7) observational home visits. The survey included a review of pertinent policies and procedures, Quality Improvement Meeting minutes for the past twelve (12) months, agency's Admission Packet, Emergency Preparedness Plan, and Complaint Log. The patient census is 151. Pre-survey activities consisted of review on 06/09/2022 of the agency's Health Commerce System account, Potentially Avoidable Reports dated 03/01/2021 to 02/28/2022 and the agency's compliance with submissions of statistical reports and Emergency Drills. The Director of Patient Services, Nursing Supervisors, and various professional and paraprofessional staff were interviewed. Findings were reviewed at the exit conference on 06/17/2022. The following deficiencies are identified as a result of the survey: G- 0374, G- 0514, G- 0526, G- 0536, G- 0544, G- 0574, G- 0578, G- 0580, G- 0586, G- 0590, G- 0610, G- 0716, G- 0984, G- 1022, J- 1512 and L- 0002.

Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient's status at the time of assessment. This STANDARD is not met as evidenced by: Based on review of the agency's Outcome Assessment Information Set (OASIS) submissions, clinical records and interviews with agency staff for one (1) of seventeen (17) patients (Patient #3), the agency failed to ensure OASIS data accurately reflects the patient's status at the time of the assessment. Failure to ensure accurate documentation of OASIS data has the potential for negative outcomes. Patient #3 – This 85-year-old patient with diagnoses that include unstageable pressure ulcer of sacrum, unstageable pressure ulcer of left lower extremity and fracture around internal prosthetic knee joint was admitted to the home care agency on 12/23/2021. Review of the Skilled Nurse Admission Visit Note dated 12/23/2021 revealed the Registered Nurse (RN) documented the following: - Does this patient have at least one unhealed pressure ulcer/ injury at stage 2 or higher or designated as unstageable? Yes; - Current number of Stage 2 pressure ulcers: 0 (zero); - Stage of most problematic unhealed pressure ulcer/ injury that is stageable: NA (not applicable), patient has no stageable pressure ulcers/ injuries; and - Current number of unstageable pressure ulcers: 6 (six). Review of the Skilled Nursing Discharge Visit dated 02/18/2022 revealed the RN documented the following: - Current number and stage of most problematic unhealed pressure ulcer/ injury that is stageable: 2 (two wounds)- stage 2. Review of the clinical record lacks documented evidence of the patient having a stage 2 pressure ulcer. The agency failed to ensure the RN discharge documentation accurately reflects the patient's status at the time of assessment. During staff interview on 06/16/2022 at 09:40 AM, the RN stated the patient did not have a stage 2 pressure ulcer and she documented incorrectly on the discharge visit.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on review of clinical records, agency policy and procedure, and staff interview for three (3) of seventeen (17) patients (Patient #’s: 1, 7, and 15), the agency failed to ensure the Registered Nurse (RN) conducted an initial assessment of the patient within forty-eight (48) hours of referral, the patient's return home, or on the physician-ordered start of care date. Failure to conduct the initial assessment within the required time frame has the potential to result in unmet patient needs and negative patient outcomes. Review of the agency policy entitled “General Practice Guidelines: Patient Admission” dated 12/2014 revealed “The admission assessment will occur within 48 (forty-eight) hours (2 calendar days) of referral or within 48 hours of the patient’s return home or knowledge of return home, or on the physician ordered start of care date.” Patient #1 – This 53-year-old patient with diagnoses that include type I diabetes mellitus with ketoacidosis without coma, type I diabetes mellitus with diabetic autonomic neuropathy, and gastroparesis was admitted to the home care agency on 12/09/2021. Review of the hospital discharge summary revealed the patient was discharged home on 11/26/2021. Review of the Skilled Nurse Admission Visit Note dated 12/09/2021 revealed the initial visit was conducted on 12/09/2021, thirteen (13) days after the patient was discharged home. Review of the clinical record lacks documentation explaining the delay in services. The agency failed to ensure the RN conducted an initial assessment of the patient within forty-eight (48) hours of referral, the patient's return home, or on the physician-ordered start of care date. During interview on 06/16/2022 at 09:45 AM, the Director of Patient Services (DPS) stated the agency initially refused the referral because they could not see the patient within 48 (forty-eight) hours. The patient tried other agencies in the area, but none were able to take the referral. The physician said it was ok for the agency to take the patient with a later start date, however, there is no documentation of this conversation in the clinical record. Patient #7 – This 94-year-old patient with diagnoses that include hypertension, atrial fibrillation, and type II diabetes mellitus was admitted to the home care agency on 06/06/2022. Review of the hospital discharge summary revealed the patient was discharged home on 06/01/2022. Review of the Admission Note Report completed by the agency staff on 06/07/2022 revealed the staff documented “Patient discharged home with family on 06/01/2022 whom will provide 24/7 (twenty-four hours a day seven days a week) care until patient can move in with daughter.” Review of the Skilled Nurse Admission Visit Note dated 06/06/2022 revealed the initial visit was conducted on 06/06/2022, five (5) days after the patient was discharged home. Review of the clinical record lacks documentation explaining the delay in services. The agency failed to ensure the RN conducted an initial assessment of the patient within forty-eight (48) hours of referral, the patient's return home, or on the physician-ordered start of care date. During interview on 06/15/2022 at 02:22 PM, the DPS stated there is no documentation to state why there is a delay in the start of care. Patient #15 – This 76-year-old patient with diagnoses that include hypertensive heart and chronic kidney disease with heart failure, congestive heart failure, and type II diabetes mellitus with diabetic chronic kidney disease was admitted to the home care agency on 06/03/2022. Review of the hospital discharge summary revealed the patient was discharged home on 05/31/2022. Review of the Skilled Nurse Admission Visit Note dated 06/03/2022 revealed the initial visit was conducted on 06/03/2022, three (3) days after the patient was discharged home. Review of the clinical record lacks documentation explaining the delay in services. The agency failed to ensure the RN conducted an initial assessment of the patient within forty-eight (48) hours of referral, the patient's return home, or on the physician-ordered start of care date. During interview on 06/16/2022 at 10:30 AM, the DPS stated the delay may have been due to the patient’s dialysis schedule but there is no documentation in the clinical record.

Content of the comprehensive assessment CFR(s): 484.55(c) 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: This STANDARD is not met as evidenced by: Based on review of clinical records and interview with agency staff for five (5) of seventeen (17) patients (Patient #’s: 2, 8, 9, 14 and 16), the agency failed to ensure the comprehensive assessment is consistent and accurately reflects the patient's status and needs. Failure to ensure comprehensive assessments accurately reflect the patient status and needs has the potential for unmet patient needs and the potential for negative patient outcomes. Findings are: Patient #8 – This 64-year-old patient with diagnoses that include sepsis due to methicillin susceptible staphylococcus aureus, hypertensive chronic kidney disease, and chronic kidney disease was admitted to the home care agency on 05/27/2022. Review of the clinical record lacks documented evidence the Registered Nurse (RN) assessed the patient’s immunization status. The agency failed to ensure the comprehensive assessment is consistent and accurately reflects the patient's status and needs. During interview on 06/16/2022 at 08:20 AM, the RN stated she did not document the patient’s immunization status. Patient #2 – This 74-year-old patient with diagnoses that include fracture of T 9 (thoracic)- T 10 vertebra, fracture of sacrum and type II diabetes mellitus was admitted to the home care agency on 12/01/2021. Review of the Skilled Nurse Admission Visit Note dated 12/01/2021 revealed the Registered Nurse (RN) performed a comprehensive assessment of the patient on 12/01/2021. The assessment lacks documented evidence of an assessment of the patient’s immunization status. The agency failed to ensure the comprehensive assessment is consistent and accurately reflects the patient's status and needs. During interview on 06/16/2022 at 10:25 AM, the Director of Patient Services stated the RN did not assess the patient’s immunization status. Patient #9 – This 60-year-old patient with diagnoses that include fracture of right lower leg, epilepsy and bipolar disorder was admitted to the home care agency on 06/03/2022. Review of the Skilled Nurse Admission Visit Note dated 06/03/2022 revealed the RN performed a comprehensive assessment of the patient on 06/03/2022. The assessment lacks documented evidence of an assessment of the patient’s immunization status. The agency failed to ensure the comprehensive assessment is consistent and accurately reflects the patient's status and needs. During interview on 06/16/2022 at 10:08 AM, the Nursing Supervisor stated the RN did not assess the patient’s immunization status. Patient #14 – This 83-year-old patient with diagnoses that include memory deficit following intracerebral hemorrhage, aphasia and urinary tract infection was admitted to the home care agency on 05/28/2022. Review of the Skilled Nurse Admission Visit Note dated 05/28/2022 revealed the RN performed a comprehensive assessment of the patient on 05/28/2022. The assessment lacks documented evidence of an assessment of the patient’s immunization status. The agency failed to ensure the comprehensive assessment is consistent and accurately reflects the patient's status and needs. During interview on 06/16/2022 at 10:50 AM, the Nursing Supervisor stated the RN did not assess the patient’s immunization status. Patient #16 – This 67-year-old patient with diagnoses that include aftercare status post laryngectomy, malignant neoplasm of glottis and dysphagia was admitted to the home care agency on 04/08/2022. Review of the Home Health Certification and Plan of Care for certification period 04/08/2022 to 06/06/2022 revealed the following Skilled Nursing (SN) goal, “Patient will demonstrate improved nutritional status, progressive weight gain or sustainment of current weight, and (be) free from signs and symptoms of malnutrition.” Review of the Skilled Nurse Admission Visit Note dated 04/08/2022 revealed the RN documented the following regarding the patient: - Is NPO (nothing by mouth); - Receives supplemental tube feedings via a G tube (gastrostomy feeding tube); and - Has lost or gained 10 (ten) pounds in the last six months involuntarily. The assessment lacks a weight being obtained or recorded. The agency failed to ensure the comprehensive assessment is consistent and accurately reflects the patient's status and needs. During interview on 06/16/2022 at 10:43 AM, the RN stated she did not obtain a weight during the assessment.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on clinical record reviews and interviews with agency staff, for five (5) of seventeen (17) clinical records (Patient #'s: 7,10,12,14 and 16) lack documented evidence of a complete review of all medications the patient currently uses to identify any potential adverse effects, drug reactions, or concerns. Failure to conduct a complete medication review and to ensure the medication regime is appropriate has the potential for the patient harm. Patient #7 – This 94-year-old patient with diagnoses that include hypertension, atrial fibrillation, and type II diabetes mellitus was admitted to the home care agency on 06/06/2022. Review of the Home Health Certification and Plan of Care for certification period 06/06/2022 to 08/04/2022 revealed the order for Tylenol PM (nighttime) extra strength 25 mg (milligrams)-500 mg tablet take 2 (two) tablets by oral route bedtime. Review of the hospital discharge summary dated 06/01/2022 lacks an order for Tylenol. The Registered Nurse (RN) failed to identify and reconcile the medication discrepancy identified in the referral for services and the POC. During interview on 06/15/2022 at 02:28 PM, the RN stated she remembers the patient taking Tylenol but did not document discussing it with the physician. Patient #10 – This 63-year-old patient with diagnoses that include hypertensive heart disease, heart failure and morbid obesity was admitted to the home care agency on 06/02/2022. Review of the hospital discharge summary dated 05/31/2022 revealed the patient was to take the following medications: - Acetaminophen (Tylenol) 325 mg (milligram) tab (tablet) by mouth every 6 (six) hours as needed if pain; and - Docusate Sodium 100 mg cap (capsule) by mouth two times per day as needed if constipated. Review of the Home Health Certification and Plan of Care for certification period 06/02/2022 to 07/31/2022 revealed the following orders: - Tylenol 325 mg tablet, take 2 (two) tablets (650 mg) by oral route every 6 (six) hours as needed for pain; and - Colace 100 mg capsule, take 1 (one) capsule (100 mg) by oral route every day as needed for constipation. Review of the clinical record lacks documented evidence of clarification of the Tylenol and Colace order discrepancies. The Registered Nurse (RN) failed to identify and reconcile the medication discrepancies identified in the referral for services and the POC. During interview on 06/14/2022 at 10:30 AM, the Director of Patient Services stated there was no documentation that clarified the identified medication discrepancies. Patient #12 – This 68-year-old patient with diagnoses that include pneumonia, malignant neoplasm of lung and malignant neoplasm of lymph node was admitted to the home care agency on 05/17/2022. Review of the hospital discharge summary dated 05/24/2022 revealed the patient had an observational hospital stay from 05/22/2022 to 05/24/2022 for complications due to the neoplasm. The patient was instructed to take Prochlorperazine Maleate (Compazine) 10 mg (milligram) tab (tablet) by mouth as needed every 6 (six) hours as needed for nausea. Review of the Home Health Plan of Care Update dated 05/25/2022 revealed the following medication orders: - Compazine 10 mg tablet, take 1 tablet by oral route every 6 (six) hours as needed for nausea; and - Prochlorperazine Maleate (Compazine) 10 mg tablet, take 5 mg by oral route 4 (four) times per day as needed for nausea. Review of the clinical record lacks documented evidence of clarification of the Prochlorperazine Maleate (Compazine) discrepancy. The Registered Nurse (RN) failed to identify and reconcile the medication discrepancy identified in the referral for services and the updated POC. During interview on 06/16/2022 at 11:20 AM, the Director of Patient Services (DPS) stated the RN was unavailable for interview. The DPS stated the Compazine orders on the updated POC were a discrepancy and should have been clarified. Patient #14 – This 83-year-old patient with diagnoses that include memory deficit following intracerebral hemorrhage, aphasia and urinary tract infection was admitted to the home care agency on 05/28/2022. Review of the hospital discharge summary dated 05/27/2022 revealed the patient was instructed to take Loratadine 10 mg tablet by mouth daily. Review of the Home Health Certification and Plan of Care for certification period 05/28/2022 to 07/26/2022 lacks an order for Loratadine. Review of the clinical record lacks documented evidence of clarification of the Loratadine discrepancy. The Registered Nurse (RN) failed to identify and reconcile the medication discrepancy identified in the referral for services and the POC. During interview on 06/16/2022 at 10:55 AM, the Director of Patient Services (DPS) stated the RN was unavailable for interview. The DPS stated there was no documentation that clarified the Loratadine discrepancy. Patient #16 – This 67-year-old patient with diagnoses that include aftercare status post laryngectomy, malignant neoplasm of glottis and dysphagia was admitted to the home care agency on 04/08/2022. Review of the hospital discharge orders dated 04/07/2022 revealed the patient was instructed to take Lactulose 20 gram/30 ml (milliliter) solution, 30 (thirty) ml by nasogastric tube route 3 (three) times a day as needed for constipation. Review of the Home Health Certification and Plan of Care for certification period 04/08/2022 to 06/06/2022 revealed an order for Lactulose 20 gram/30 ml oral solution, take 30 ml by g- tube (gastrostomy tube) route every day as needed for constipation. Review of the clinical record lacks documented evidence of clarification of the Lactulose discrepancy. The Registered Nurse (RN) failed to identify and reconcile the medication discrepancy identified in the referral for services and the POC. During interview on 06/16/2022 at 10:40 AM, the RN stated she clarified the dose but failed to document this.

Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than- This STANDARD is not met as evidenced by: Based on clinical record review and staff interview for one (1) of (17) patients (Patient # 16), the agency failed to ensure the comprehensive assessment is updated and revised to reflect changes in the patient's health status. Failure to ensure comprehensive assessments are updated and revised, has the potential for negative patient outcomes. Patient #16 – This 67-year-old patient with diagnoses that include aftercare status post laryngectomy, malignant neoplasm of glottis and dysphagia was admitted to the home care agency on 04/08/2022. Review of the Home Health Certification and Plan of Care for certification period 04/08/2022 to 06/06/2022 revealed the following Skilled Nursing (SN) goal: “Patient will demonstrate improved nutritional status, progressive weight gain or sustainment of current weight, and (be) free from signs and symptoms of malnutrition.” Review of the clinical record revealed the patient received consecutive SN visits on 04/22/2022, 04/27/2022, 04/29/2022 and 05/04/2022. Review of the Skilled Nurse Routine Visits for 04/22/2022, 04/27/2022, 04/29/2022 and 05/04/2022 lack weights being obtained or recorded. Review of the Home Health Certification and Plan of Care for certification period 06/07/2022 to 08/05/2022 revealed the following Skilled Nursing (SN) goal: “Patient will demonstrate improved nutritional status, progressive weight gain or sustainment of current weight, and (be) free from signs and symptoms of malnutrition.” Review of the Skilled Nurse Routine Visit dated 06/08/2022 lacks a weight being obtained or recorded. The SN failed to ensure updated assessments were complete to meet patient goals. During interview on 06/16/2022 at 11:11 AM, the RN stated the patient was able to stand on a scale but weights were not obtained as they failed to be added as an intervention on the plan of care and should have been.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on review of clinical records and staff interviews for two (2) of seventeen (17) patients (Patient #’s: 3 and 17), the agency failed to develop individualized plans of care (POC) that are complete and accurate and address the total needs of the patients. Failure to ensure that a comprehensive individualized plan of care is developed has the potential for unmet patient needs. Patient #3 – This 85-year-old patient with diagnoses that include unstageable pressure ulcer of sacrum, unstageable pressure ulcer of left lower extremity and fracture around internal prosthetic knee joint was admitted to the home care agency on 12/23/2021. Review of the Home Health Certification and Plan of Care for certification period 12/23/2021 to 02/20/2022 revealed the following medication orders: - Tylenol Extra Strength 500 mg (milligram) tablet take 1-2 (one to two) tabs by oral route every 4-6 (four to six) hours as needed for pain; and - Norco (a combination of Hydrocodone and Tylenol) 5 mg- 325 mg tablet take 1 (one) tablet by oral route every 6 (six) hours as needed for pain. The orders for Tylenol and Norco fail to specify the maximum daily dose of Tylenol the patient may receive within 24 (twenty-four) hours. The agency failed to develop an individualized POC that is complete, accurate and addresses the total needs of the patient. During interview on 06/16/2022 at 10:57 AM, the Director of Patient Services (DPS) stated the maximum daily dose of Tylenol was not specified on the agency referral order so was not included on the Plan of Care. Patient #17 – This 38-year-old patient with diagnoses that include type I diabetes mellitus, hyperlipidemia and nicotine dependence was admitted to the home care agency on 06/01/2022. Review of the Home Health Certification and Plan of Care for certification period 06/01/2022 to 07/30/2022 revealed the following Skilled Nursing (SN) orders: 06/01/2022- 06/08/2022- SN 1 (one) Day 1 (one). Admission and comprehensive nursing assessment and evaluation for services to be completed on 06/01/2022. The POC lacks a SN frequency after 06/08/2022. The agency failed to develop an individualized POC that is complete, accurate and addresses the total needs of the patient. During interview on 06/16/2022 at 08:40 AM, the Nursing Supervisor stated the patient received SN services beyond 06/08/2022 but an error was made and the additional SN frequencies were not included on the POC.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on review of clinical records and interview with agency staff, for one (1) of seventeen (17) patients (Patient #2), the agency failed to provide services in accordance with physician orders. Failure to ensure patient care is provided in accordance with physician orders has the potential for patients to receive poor care and for health care needs to go unmet. Patient #2 – This 74-year-old patient with diagnoses that include fracture of T 9 (thoracic)- T 10 vertebra, fracture of sacrum and type II diabetes mellitus was admitted to the home care agency on 12/01/2021. Review of the Home Health Certification and Plan of Care for certification period 12/01/2021 to 01/29/2022 revealed the following Skilled Nursing (SN) orders: - Provide diabetic education and diabetic compliance monitoring; - Assess blood glucose record for results and compliance with blood glucose testing 1-2 x (one to two times) daily; and - Consult prescribing provider parameters for blood glucose (BG) less than 60 or greater than 300. Review of the Skilled Nurse Admission Visit Note dated 12/01/2021 revealed the patient was unable to locate the glucometer at the time of SN assessment due to limited mobility and did not want SN to search the home. No BG was recorded or obtained during the assessment. Review of the next Skilled Nurse Routine Visit Note dated 12/07/2021 revealed the patient was unable to locate the glucometer at the time of SN visit due to limited mobility. The patient did not want SN to search the home and stated the glucometer would be obtained from the upstairs the following day. No BG was recorded or obtained during the assessment. The agency failed to provide services in accordance with physician orders. During interview on 06/16/2022 at 09:25 AM, the RN stated being unable to test the patient’s BG during the identified visits as clinicians do not carry glucometers with them. The RN stated she did not notify the physician of the patient’s non-compliance with the glucometer use.

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 review of clinical records and interviews with agency staff, for two (2) of seventeen (17) patients (Patient #’s: 2 and 9), the agency failed to ensure drugs and treatments are administered in accordance with physician orders. Failure to administer drugs and treatments without a physician's order has the potential to result in poor quality of care. Patient #2 – This 74-year-old patient with diagnoses that include fracture of T 9 (thoracic)- T 10 vertebra, fracture of sacrum and type II diabetes mellitus was admitted to the home care agency on 12/01/2021. Review of the Physical Therapy Assistant (PTA) Visit Note dated 12/06/2021 revealed the following: - Pain Intensity: 9; and - Pain Control Measures: Heat/ Cold, medication and relaxation. Review of the PTA Visit Note dated 12/08/2021 revealed the following: - Pain Intensity: 5; and - Pain Control Measures: Heat/ Cold, medication and relaxation. Review of the Physical Therapy Visit Routine Note dated 12/10/2021 revealed the following intervention was performed: “Patient/ caregiver may apply heat or ice to low back and groin area for pain, 20 (twenty) minutes on, 20 (twenty) minutes off while awake. Monitor for skin integrity.” Review of the clinical record lacks an order for applying heat for pain control. The agency failed to ensure drugs and treatments are administered in accordance with physician orders. During interview on 06/16/2022 at 09:05 AM, the PTA stated the patient did not use heat for pain control and she documented incorrectly on the identified visits. During interview on 06/16/2022 at 10:20 AM, the Physical Therapist stated heat was not used on this patient and she documented incorrectly. Patient #9 – This 60-year-old patient with diagnoses that include fracture of right lower leg, epilepsy and bipolar disorder was admitted to the home care agency on 06/03/2022. Review of the Skilled Nurse Routine Visit Note dated 06/08/2022 revealed the following intervention was performed: “Assess and evaluate effectiveness of all pain control measures including Tylenol. Note: Patient reports pain 5/10 (five out of ten) to her right leg. Patient states she took Tylenol this morning with reported good effect. Review of the clinical record from 06/03/2022 through 06/13/2022 (date of survey) lacks an order for Tylenol. The agency failed to ensure drugs and treatments are administered in accordance with physician orders. During interview on 06/16/2022 at 10:10 AM, the Registered Nurse stated the agency obtained an order for Tylenol on 06/14/2022 (six days after the documented Tylenol use).

Review and revision of the plan of care CFR(s): 484.60(c) Standard: Review and revision of the plan of care. This STANDARD is not met as evidenced by: Based on review of clinical records and interviews with agency staff for one (1) of seventeen (17) patients (Patient #12), the agency failed to ensure the Plan of Care (POC) is reviewed and revised to reflect the patient's current status. Failure to ensure the POC is updated and revised has the potential to result in negative patient outcomes. Patient #12 – This 68-year-old patient with diagnoses that include pneumonia, malignant neoplasm of lung and malignant neoplasm of lymph node was admitted to the home care agency on 05/17/2022. A.) Review of the Home Health Certification and Plan of Care for certification period 05/17/2022 to 07/15/2022 revealed an order for PT (Physical Therapy) 1 (one) week 1 (one). Review of the Physical Therapy Evaluation dated 05/17/2022 revealed the PT completed an evaluation visit on 05/17/2022 and documented the patient had no further PT needs. Review of the hospital discharge summary dated 05/24/2022 revealed the patient had an observational hospital stay from 05/22/2022 to 05/24/2022 for complications due to the neoplasm. Review of the Skilled Nurse Routine POC (Plan of Care) Update Note dated 05/25/2022 revealed the Registered Nurse (RN) assessed the patient as being physically weaker and documented that Physical Therapy would resume as previously ordered. Review of the clinical record lacks documented evidence of an order to refer Physical Therapy after the 05/25/2022 assessment. The updated POC lacks an order for a Physical Therapy referral. During interview on 06/16/2022 at 11:25 AM, the Director of Patient Services (DPS) stated the RN was unavailable for interview. The DPS stated an order was obtained for Physical Therapy on 06/16/2022 but should have been ordered at the time of the 05/25/2022 RN assessment visit. B.) Review of the hospital discharge summary dated 05/24/2022 revealed the patient had an observational hospital stay from 05/22/2022 to 05/24/2022 for complications due to the neoplasm. The patient was instructed to take Prochlorperazine Maleate (Compazine) 10 mg (milligram) tab (tablet) by mouth as needed every 6 (six) hours as needed for nausea. Review of the Home Health Plan of Care Update dated 05/25/2022 revealed the following medication orders: - Compazine 10 mg tablet, take 1 tablet by oral route every 6 (six) hours as needed for nausea; and - Prochlorperazine Maleate (Compazine) 10 mg tablet, take 5 mg by oral route 4 (four) times per day as needed for nausea. The updated plan of care is unclear if the patient is to take the duplicate medication and which dose the patient is to be taking. Review of the clinical record lacks documented evidence of clarification of the Prochlorperazine Maleate (Compazine) orders on the updated plan of care. The agency failed to ensure the Plan of Care (POC) is reviewed and revised to reflect the patient's current status. During interview on 06/16/2022 at 11:20 AM, the Director of Patient Services (DPS) stated the RN was unavailable for interview. The DPS stated the Compazine orders on the updated POC were a discrepancy and should have been clarified.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on review of clinical records and interviews with agency staff, for two (2) of seventeen (17) patients (Patient #’s: 1 and 2), the agency failed to ensure the physician is notified of changes in the patient's condition or needs that suggest that the Plan of Care (POC) may need to be altered. Failure to promptly notify the physician to changes in the patient's condition or needs that may suggest that outcomes are not being achieved and/or the POC should be altered has the potential to result in unmet patient needs and negative patient outcomes. Patient #1 – This 53-year-old patient with diagnoses that include type I diabetes mellitus with ketoacidosis without coma, type I diabetes mellitus with diabetic autonomic neuropathy, and gastroparesis was admitted to the home care agency on 12/09/2021. Review of the Skilled Nurse Routine Visit Note dated 12/29/2021 revealed the Skilled Nurse documented “Patient states they are feeling sick and that their stomach hurts. Patient states he has vomited a few times.” Review of the clinical record lacks documented evidence the Skilled Nurse notified the physician of the patient’s illness. The agency failed to ensure the physician is notified of changes in the patient's condition or needs that suggest that the POC may need to be altered. During interview on 06/16/2022 at 09:18 AM, the Registered Nurse (RN) stated she did not document calling the physician to report the patient’s illness. Patient #2 – This 74-year-old patient with diagnoses that include fracture of T 9 (thoracic)- T 10 vertebra, fracture of sacrum and type II diabetes mellitus was admitted to the home care agency on 12/01/2021. Review of the Home Health Certification and Plan of Care for certification period 12/01/2021 to 01/29/2022 revealed the following Skilled Nursing (SN) orders: - Provide diabetic education and diabetic compliance monitoring; - Assess blood glucose record for results and compliance with blood glucose testing 1-2x (one to two times) daily; and - Consult prescribing provider parameters for blood glucose (BG) less than 60 or greater than 300. Review of the Skilled Nurse Admission Visit Note dated 12/01/2021 revealed the patient was unable to locate glucometer at time of the SN assessment due to limited mobility and did not want SN to search the home. No BG was recorded or obtained during the assessment. Review of the clinical record revealed the next SN visit occurred on 12/07/2021. Review of the Skilled Nurse Routine Visit dated 12/07/2021 revealed the patient was unable to locate glucometer at time of the SN visit due to limited mobility. The patient did not want SN to search the home. The patient stated the glucometer would be obtained from the upstairs the following day. No BG was recorded or obtained during the assessment. Review of the clinical record lacks documented evidence the physician was notified of the patients inability to obtain or report BG readings for the identified visits. The agency failed to ensure the physician is notified of changes in the patient's condition or needs that suggest that the POC may need to be altered. During interview on 06/16/2022 at 09:27 AM, the RN stated she did not notify the physician of the patient’s non-compliance with BG testing.

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 review of clinical records and staff interview for one (1) of seventeen (17) patients (Patient #3), the agency failed to ensure the patient/caregiver receives appropriate education regarding the care and services identified in the plan of care (POC). Failure to provide appropriate education has the potential to result in the patient receiving inadequate care and could result in patient harm. Patient #3 – This 85-year-old patient with diagnoses that include unstageable pressure ulcer of sacrum, unstageable pressure ulcer of left lower extremity and fracture around internal prosthetic knee joint was admitted to the home care agency on 12/23/2021. A.) Review of the Home Health Certification and Plan of Care for certification period 12/23/2021 to 02/20/2022 revealed a Skilled Nursing (SN) order for monitoring the patient/ caregiver compliance with intermittent urinary catheterization BID (twice daily) utilizing a 14 french coude (specially designed to maneuver around obstructions) catheter. Review of the Skilled Nurse Admission Visit Note dated 12/23/2021 revealed the Registered Nurse (RN) documented the caregiver reports compliance with performing intermittent urinary catheterizations BID to the patient. The assessment lacks documented evidence the caregiver demonstrated the ability to perform the intermittent urinary catheterization to the patient. Review of the clinical record lacks documented evidence the caregiver demonstrated the ability to perform the intermittent urinary catheterization to the patient. The agency failed to ensure the caregiver was able to successfully re-demonstrate the ability to perform intermittent urinary catheterization. During interview on 06/16/2022 at 11:02 AM, the Director of Patient Services (DPS) stated the RN was unavailable for interview. The DPS stated it is the agency expectation that the caregiver demonstrate proficiency with the task and this was not documented. B.) Review of the Home Health Certification and Plan of Care for certification period 12/23/2021 to 02/20/2022 revealed the following wound care order to the patient’s unstageable coccyx pressure ulcer: SN/ CG (caregiver) to cleanse site with NS (normal saline), apply skin prep to peri- skin, Medihoney (used to remove dead tissue) to wound bed and cover with foam dressing 3 (three) times weekly and as needed if soiled or non- adherent. Review of the agency supplemental order dated 01/05/2022 revealed the wound care to the unstageable coccyx pressure ulcer was changed to: SN/ CG to cleanse site with NS, apply skin prep to peri-skin, Alginate Ag (highly absorbent antibacterial wound product) to wound bed, cover with foam dressing 1 (one) time daily and as needed if soiled or non-adherent. Review of the Skilled Nurse Routine Visit Note dated 01/05/2022 revealed the RN performed the new wound care to the patient's coccyx pressure ulcer. The Visit Note lacks documented evidence the caregiver was instructed and demonstrated the ability to perform the new daily wound care and the next nursing visit was scheduled for 01/07/2022. The agency failed to ensure the patient/caregiver was able to successfully re-demonstrate the ability to perform wound care. During interview on 06/16/2022 at 09:36 AM, the RN stated she instructed the caregiver on the new wound care but did not document this.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on review of clinical records and interviews with staff, for one (1) of seventeen (17) patients (Patient #1), the agency failed to prepare and document complete and accurate clinical notes. Failure to document complete and accurate clinical and progress notes has the potential for unmet patient needs. Patient #1 – This 53-year-old patient with diagnoses that include type I diabetes mellitus with ketoacidosis without coma, type I diabetes mellitus with diabetic autonomic neuropathy, and gastroparesis was admitted to the home care agency on 12/09/2021. Review of the undated Discharge/Transfer Summary lacks a date of the patient’s discharge. The agency failed to prepare and document complete and accurate clinical notes. During interview on 06/16/2022 at 09:21 AM, the Registered Nurse (RN) stated she did not document the date on the discharge summary, but the patient was discharged after being hospitalized. The discharge date was 12/31/2021 (date of last visit).

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on review of clinical records, policy and procedure, and interview with agency staff, for one (1) of seventeen (17) patients (Patient #3), the agency failed to follow agency policy and procedure, current clinical practice guidelines, and accepted professional standards when providing services. Failure to ensure compliance with accepted professional standards has the potential to result in unmet patient needs and inadequate care. Review of agency policy entitled “Wound Assessment” revised 08/2019 revealed the clinician is to “3 a) Reassess wounds at every visit or every dressing change. Measurements should be done weekly.” Patient #3 – This 85-year-old patient with diagnoses that include unstageable pressure ulcer of sacrum, unstageable pressure ulcer of left lower extremity and fracture around internal prosthetic knee joint was admitted to the home care agency on 12/23/2021. Review of the Home Health Certification and Plan of Care for certification period 12/23/2021 to 02/20/2022 revealed the following wound care orders: - Wound: Anterior- left dorsal side of foot unstageable pressure ulcer- SN (Skilled Nurse)/CG (caregiver) to cleanse site with NS (Normal Saline), apply skin prep to peri- skin, Medihoney (aids in removing dead tissue) to wound bed and cover with DSD (dry sterile dressing) 3 (three) times weekly and as needed if soiled or non- adherent. - Wound: Anterior- dorsal side left great toe unstageable pressure ulcer- SN/CG to cleanse site with NS, apply skin prep to peri- skin, Aquacel Ag (highly absorbent antimicrobial wound product) to wound bed and cover with DSD 3 (three) times weekly and as needed if soiled or non- adherent. - Wound: Posterior- coccyx unstageable pressure ulcer- SN/CG to cleanse site with NS, apply skin prep to peri- skin, Medihoney to wound bed and cover with foam dressing 3 (three) times weekly and as needed if soiled or non- adherent. - Wound: Left foot- 1st metatarsal head unstageable pressure ulcer- SN/CG to cleanse site with NS, apply skin prep to peri- skin, Medihoney to wound bed and cover with DSD 3 (three) times weekly and as needed if soiled or non- adherent. - Wound: Left foot- proximal outer foot unstageable pressure ulcer- SN/CG to cleanse site with NS, apply skin prep to peri- skin, Medihoney to wound bed and cover with DSD 3 (three) times weekly and as needed if soiled or non- adherent. - Wound: Left foot- heel unstageable pressure ulcer- SN/CG to cleanse site with NS, apply skin prep to peri- skin, Medihoney to wound bed and cover with foam dressing 3 (three) times weekly and as needed if soiled or non- adherent. Review of the clinical record revealed for the week of 01/16/2022 the patient was seen by SN on the following dates: 01/17/2022, 01/19/2022 and 01/21/2022. Review of the Skilled Nurse Routine Visit Notes for 01/17/2022 and 01/19/2022 lack documented evidence of wound measurements being obtained for the identified wounds. Review of the Skilled Nurse Routine Visit Note dated 01/21/2022 revealed identification and wound measurements for two new trauma wounds to the left plantar foot- 5th metatarsal head and the anterior left dorsal side of foot. The assessment lacks wound measurements for the continued wounds to the following: left plantar foot heel unstageable pressure ulcer, left plantar foot proximal outer unstageable pressure ulcer, anterior dorsal side left great toe unstageable pressure ulcer, the anterior left dorsal side of foot unstageable pressure ulcer and the posterior coccyx unstageable pressure ulcer. The agency failed to ensure wound measurements were obtained at a minimum of once per week, per agency policy. During interview on 06/16/2022 at 09:52 AM, the Director of Patient Services (DPS) stated all the patient’s wounds should have been measured during the identified week and this was an oversight.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on review of clinical records, agency policy and procedure, and interviews with agency staff, for three (3) of five (5) discharged patients (Patient #’s: 3, 4, 5), the agency failed to complete a discharge summary and send it to the primary care practitioner within 5 (five) business days of the date of the order for discharge. Failure to complete a discharge summary and send it to the primary care practitioner within the required timeframes has the potential for unmet patient needs and an unsafe discharge. Review of the agency’s policy entitled “General Practice Guidelines – Patient Discharge” dated 01/2018 revealed “The agency discharge summary form will be faxed to the physician responsible for the home health agency plan of care within five (5) days of the discharge.” Patient #4 – This 94-year-old patient with diagnoses that include spondylosis without myelopathy or radiculopathy, cervical region, unspecified dementia without behavioral disturbance, and hypertension was admitted to the home care agency on 10/25/2021. Review of the discharge summary revealed the patient was discharged on 11/24/2021, but the discharge summary was not signed and sent to the physician until 12/08/2021, 14 (fourteen days) later. The agency failed to complete the discharge summary within five (5) days. During interview on 06/15/2022 at 02:37 PM, the Director of Patient Services (DPS) stated the discharge summary was sent outside of the five (5) day window. Patient #5 – This 101-year-old patient with diagnoses that include displaced intertrochanteric fracture of right femur, dementia, and muscle weakness was admitted to the home care agency on 07/28/2021. Review of the discharge summary revealed the patient was discharged on 08/10/2021, but the discharge summary was not signed and sent to the physician until 08/18/2021, eight (8) days later. The agency failed to complete the discharge summary within five (5) days. During interview on 06/15/2022 at 10:28 AM, the DPS stated the discharge summary was sent outside of the five (5) day window. Review of the agency’s policy entitled “General Practice Guidelines – Patient Discharge” dated 01/2018 revealed “The agency discharge summary form will be faxed to the physician responsible for the home health agency plan of care within five (5) days of the discharge.” Patient #3 – This 85-year-old patient with diagnoses that include unstageable pressure ulcer of sacrum, unstageable pressure ulcer of left lower extremity and fracture around internal prosthetic knee joint was admitted to the home care agency on 12/23/2021. Review of the Skilled Nursing Discharge Visit dated 02/18/2022 revealed the patient met all goals and was discharged from the agency on 02/18/2022. Review of the Discharge/ Transfer Summary dated 03/04/2022 revealed the patient was discharged on 02/18/2022, but the discharge summary was not signed and sent to the physician until 03/04/2022, fourteen (14) days later. The agency failed to complete the discharge summary within five (5) days. During interview on 06/16/2022 at 09:45 AM, the Director of Patient Services (DPS) acknowledged the discharge summary was sent outside of the five (5) day window. The DPS stated there appears to be a system issue that is delaying the process and it will be looked into.