Every finding on record at Constellation Home Care, LLC

The following statement of deficiencies represents the results of a partial extended re-certification survey of Constellation Home Care, Certified Home Health Agency, located at 6851 Jericho Turnpike, Syosset, New York 11791 conducted on 06/26/2023 through 06/30/2023, to evaluate the Agency's compliance with Federal Conditions of Participation, State requirements, and included complaints investigation #60378, # 98972. A standard re-certification survey was initiated on 06/26/2023. Deficient practices were identified within Level 1 standards in Plan of Care (484.60 Condition), resulting in a partial extended survey. The Agency reported an active patient census of 314 at the entrance conference on 06/26/2023. The survey consisted of a review of seventeen (17) Clinical Records, including five (5) discharge records, fourteen (14) 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 12 months, Patient Admission Packet, the Emergency Preparedness Plan, Complaint Log for the past 12 months, and Complaint Log for the 2021 complaint. Pre-survey activities consisted of a review on 06/23/2023 of the agency's Health Commerce System account, Home Care Worker Registry, Criminal History Record Check, Quality Improvement and Evaluation System (IQIES) for the period 04/2022 to 03/2023, and the Agency's compliance with report submissions for the 2021 statistical report and the Emergency Drill conducted 06/11/2019 through 06/13/2019. The Administrator and the Director of Clinical Services were interviewed. Findings were reviewed at the exit conference on 6/30/2023. Complaints #60378 and #98972 were determined to be substantiated. The following deficiencies are identified as a result of the survey: Federal Deficiencies: G0434 – Participate in care G0536 – Review of all current medications G0574 – Plan of Care must include the following G0578 – Conformance with Physician orders G0586 - Review and revision of the Plan of Care G0590 – Promptly alert relevant Physician changes G0598 – Discharge Plans Communication G0704 – Responsibility of Skilled Professional State Regulations: J1412 – Personnel Home Care Covid-19 and Infection Control: L001 – Unacceptable Infection Control procedures

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, the Agency failed to ensure that all Consent for services include services frequency of visits. This was evident in eleven (11) of seventeen (17) clinical records reviewed. (Patients # 1, #2, #3, #6, #7, #9, #11, #12, #15, #16 and #17). Failure to ensure that consent for services include the frequency of visits, has the potential for negative patient outcome. The findings include: 9) Patient #12 has a start of care date of 5/25/2023. There is no documented evidence the patient was informed about the services, the frequency and duration of visits the patient is to receive. 10) Patient # 15 has a start of care date of 6/6/2023. The “Plan of Care” dated 6/6/2023 lacks documented evidence that the patient was informed about the services the frequency and duration of visits the patient is to receive. 11) Patient #16 has a start of care date of 6/5/2023. The “Plan of Care” dated 6//5/2023 lacks documented evidence the patient was informed about the services, the frequency and duration of visits the patient is to receive. On 6/29/2023 at 3:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings. 7) Patient #3 has a start of care date of 06/14/2023 with diagnoses of atherosclerotic heart disease of native coronary artery, abnormality of gait and mobility, hypertensive heart disease with heart failure, and type 2 Diabetes Mellitus as documented on the "Home Health Care Certification and Plan of Care" dated 06/14/2023 to 08/12/2023. The "Home Health Care Certification and Plan of Care" dated 06/14/2023 to 08/12/2023 documents orders for "Skilled Nurse (SN) to assess and evaluate, 1wk 3wk (one visit a week for three weeks); 3 PRN (three as needed visits), Physical Therapy (PT) assess and evaluate, PT 3-5m 1m (three to five visits a month for one month; 2-3m 1m (two to three visits a month for one month); Aide 1-2wk 4wk (one to two visits a week for four weeks). The consent for services dated 06/14/2023 lacked documented evidence of the SN, PT, and Aide services frequency of visits. The survey findings and interview were conducted with the Director of Clinical Services (DCS) on 06/28/2023@ 3:20PM. No explanation was provided. 8) Patient #6 has a start of care date of 05/28/2023 with diagnoses of fracture of right clavicle, fracture of left clavicle, muscle weakness, and abnormality of gait and mobility as documented on the "Home Health Care Certification and Plan of Care" dated 05/28/2023 to 07/26/2023. The "Home Health Care Certification and Plan of Care" dated 05/28/2023 to 07/26/2023 document orders for "Skilled Nurse (SN) to assess and evaluate, 1-2m 2m (one to two visits a month for two months); 2 PRN (two as needed visits), Physical Therapy (PT) assess and evaluate, PT 3-5m 1m (three to five visits a month for one month; 1-2m 1m (one to two visits a month for one month); Occupational Therapy (OT) to assess and evaluate; Aide 1-2wk 4wk (one to two visits a week for four weeks). The consent for services dated 05/28/2023 lacked documented evidence of the SN, PT, OT, and Aide services frequency of visits. The survey findings and interview were conducted with the Director of Clinical Services (DCS) on 06/28/2023@ 3:20PM. No explanation was provided. 5) Patient #9 has a start of care date of 11/22/2022 with diagnoses of Traumatic Subdural Hematoma, pressure Ulcer left Hips Stage 1, Encounter for change of non-surgical wound dressing and Pulmonary Fibrosis as documented on the "Home Health Care Certification and Plan of Care" dated 11/22/2022 to 01/20/2023. The patient has a discharge date of 01/20/2023. The "Home Health Care Certification and Plan of Care" dated 11/22/2022 to 01/20/2023 document orders for "Skileed Nurse (SN) to assess and evaluate 1 m1m, 2- 3m 1 m (one visit a month for one month, two to three visits a month for one month); 2 PRN (two as needed visits), Physical Therapy (PT) assess and evaluate, PT 1 - 2m 1m (one to two visits a month for one month; 3 - 4m 1m (three to four visits a month for one month); Occupational Therapy (OT) to assess and evaluate ; 2 - 4 m 1m (two to four visits a month for one month). The consent for services dated 11/22/2022 lacked documented evidence of the SN, PT, and OT services frequency of visits. The survey findings and interview were conducted on 06/27/2023 at 03:20 PM with the Agency's Administrator and Director of Clinical Services (DCS). The DCS reported that the "Plan of Care" (patient calender of services) is used for service frequency of visits. 6) Patient #17 has a start of care date of 05/23/2023 with diagnoses of Traumatic Subdural Hemmorhage, Abrsion Right Knee, Essential Hypertension and Alzheimer's as documented on the "Home Health Care Certification and Plan of Care" dated 05/24/2023 to 07/22/2023. The "Home Health Care Certification and Plan of Care" dated 05/24/2023 to 07/22/2023 documents orders for "Skilled Nurse (SN) 1 - 2 m 2m (one to two visits a month for two months), and 3 PRN (three visits as needed), Physical Therapy (PT) assess and evaluate, 4-6 m 1m, Occupational Therapy (OT) to assess and evaluate. The Consent for services dated 05/24/2023 lacks documented evidence that the patient was informed of the SN, PT, and OT frequency of visits. The "Plan of Care" (patient calender of services) dated 05/24/2023 documents the SN visit frequency. The Plan of Care lacks documentation of the PT and OT visit frequency. The survey findings were reviewed with the Agency's Administrator and Director of Clinical Services (DCS) at 06/29/2023 at 03:50 PM. The DCS reported that the "Plan of Care" (patient calender of services) is used for service frequency of visits. 1) Patient #1 has a start of care of 5/5/23 with diagnoses of Gout Right Wrist, Ulcer to Right Heel, and Dementia as documented on the Home Health Care Certification and Plan of Care dated 5/5/23 through 7/3/23. The Home Health Care Certification and Plan of Care dated 5/5/23 through 7/3/23 documents: Skilled Nursing (SN) 1 – 3 times a week for 8 weeks; Physical Therapy 2 – 3 times a month for 1 month, 1 – 2 times a month for 1 month. The Consent Form for services is not dated and does not document the frequency for the SN and PT services. 2) Patient #2 has a start of care date of 6/16/23 with diagnoses of Fractured Radius, Depression, and Back Pain as documented on the Home Health Care Certification and Plan of Care dated 6/16/23 through 8/14/23. The Home Health Care Certification and Plan of Care dated 6/16/23 through 8/14/23 documents: Skilled Nursing 1 – 3 times a week for 1 month; Physical Therapy 1 – 2 times a month for 1 month, 3 – 4 times a month for 1 month; Occupational Therapy (OT) evaluation; Medical Social Worker (MSW) 1 – 2 times a month for 2 months. The Consent Form for services is not dated and does not document the frequency for the SN, PT and OT services. The Consent does not document the Patient will receive MSW services. The Consent documents the Patient is to receive Speech Therapy (ST). The Plan of Care (POC) does not document Speech Therapy. 3) Patient #7 has a start of care date of 6/6/23 with diagnoses of Fractured Pelvis, Hypertension, and Hearing Loss as documented on the Home Health Care Certification and Plan of Care dated 6/6/23 through 8/4/23. The Home Health Care Certification and Plan of Care dated 6/6/23 through 8/4/23 documents: Skilled Nursing 1 – 2 times a month for 2 months; Physical Therapy 4 – 5 times a month for 1 month, 1 – 2 times a month for 1 month; Occupational Therapy evaluation. The Consent Form for services is not dated and does not document the frequency for the SN, PT and OT services. 4) Patient #11 has a start of care date of 6/6/21 with a date of discharge of 8/6/21 with diagnoses of Fractured Lower Femur, and Cardiac Disease documented on the Home Health Care Certification and Plan of Care dated 6/6/21 through 8/4/21. The Home Health Care Certification and Plan of Care dated 6/6/21 through 8/4/21 documents: Skilled Nursing 1 – 2 times a month for 1 month, 1 time a month for 1 month; Physical Therapy evaluation; Occupational Therapy evaluation. The Consent Form for services is not dated and does not document the frequency for the SN, PT and OT services. During an interview with the Director of Clinical Services (DCS) on 6/27/23 at 2:00 PM, the DCS did not provide an explanation for the above.

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 home visit observations, clinical record reviews and staff interviews, the Agency failed to ensure a review of patients' medication regimen. This was evident in four (4) of seven (7) Home Visit (HV) observations. (Patients #1HV, #2HV, #3HV and #7HV). Failure to ensure the review of the patient's medication regimen, has the potential for negative patient outcome. The findings include: 4) Patient #3 has a start of care date of 06/14/2023 with diagnoses of atherosclerotic heart disease of native coronary artery, abnormality of gait and mobility, hypertensive heart disease with heart failure, and type 2 Diabetes Mellitus as documented on the "Home Health Care Certification and Plan of Care" dated 06/14/2023 to 08/12/2023. The "Home Health Care Certification and Plan of Care" dated 06/14/2023 to 08/12/2023 document orders for "Skilled Nurse (SN) to assess and evaluate, 1wk 3wk (one visit a week for three weeks); 3 PRN (three as needed visits), Physical Therapy (PT) assess and evaluate, PT 3-5m 1m (three to five visits a month for one month; 2-3m 1m (two to three visits a month for one month); Aide 1-2wk 4wk (one to two visits a week for four weeks); Aspirin enteric coated 81 mg tablet orally daily, Atorvastatin 20mg tablet orally daily, Bumetanide 1mg tablet orally two times a day, Cinnamon 1500 mg tablet orally daily, Clopidogrel 75 mg tablet orally daily, Glimepiride 2 mg tablet orally daily, Lantus 35 units subcutaneous injection daily, Losartan 25 mg tablet orally daily, Metoprolol Succinate ER 25 mg tablet orally daily, Ranolazine 500mg tablet orally daily, Semglee 33 units subcutaneous injection daily, Tamsulosin 0.4 mg tablet orally daily, Trulicity Pen 1.5 mg subcutaneous injection weekly, Vitamin C 250 mg tablet orally two times a day, and Vitamin D3 25 mcg tablet orally daily. The patient’s medications were reviewed during a home visit on 06/27/2023 with the Physical Therapist. The following medication was found in the home: Losartan 100 mg tablets. The bottle is dated 03/21/2023 and the patient reports he has been taking 100 mg tablets “for years”. Semglee prefilled pen 33 units injectable was not found in the home. The patient reports he does not take this medication. The clinical record does not accurately identify the medications the patient is currently taking. The Director of Clinical Services (DCS) was interviewed on 06/28/2023 at 3:20PM and survey findings reviewed. No explanation was provided. 1) Patient #1 has a start of care of 5/5/23 with diagnoses of Gout Right Wrist, Ulcer to Right Heel, and Dementia as documented on the Home Health Care Certification and Plan of Care dated 5/5/23 through 7/3/23. The Home Health Care Certification and Plan of Care dated 5/5/23 through 7/3/23 documents: Skilled Nursing (SN) 1 – 3 times a week for 8 weeks; Physical Therapy 2 – 3 times a month for 1 month, 1 – 2 times a month for 1 month; Atorvastatin 20 mg daily, Doxazosin 2 mg daily, Hydralazine 25 mg two times a day, Levothyroxine 50 mcg daily, Metoprolol Tartrate 100 mg two times a day, Santyl topical ointment to wound daily, Sertraline 100 mg daily, Spironolactone 25 mg daily, Xarelto 20 mg daily. During a home visit on 6/28/23, the Patient's medications were reviewed. The following medications were found in the home: Tylenol 500 mg two tablets every eight (8) hours as needed for pain and was started on 6/14/23. Lasix 40 mg daily. The bottle is dated 6/5/23 and the Patient stated that it was re-started on 6/14/23 and has been taking it. A Physician's verbal order dated 6/20/23 documents the Lasix 40 mg was discontinued on 6/16/23. A Physician's verbal order dated 517/23 documents: Hycodan 5 mg - 1.5 mg /5 ml- 5 ml every 6 hours as needed for cough; Albuterol 90 mcg two inhalations every 6 hours as needed for wheezing. There was no Hycodan or Albuterol found in the home during the visit. 2) Patient #2 has a start of care date of 6/16/23 with diagnoses of Fractured Radius, Depression, and Back Pain as documented on the Home Health Care Certification and Plan of Care dated 6/16/23 through 8/14/23. The Home Health Care Certification and Plan of Care dated 6/16/23 through 8/14/23 documents: Skilled Nursing 1 – 3 times a week for 1 month; Physical Therapy 1 – 2 times a month for 1 month, 3 – 4 times a month for 1 month; Occupational Therapy evaluation; Medical Social Worker 1 – 2 times a month for 2 months; medications include Tylenol 325 mg every 4 hours as needed for pain. During a home visit on 6/28/23, the Patient's medications were reviewed. The Patient had Calcium 60 mg and the Patient stated it was started on 6/22/23. The Tylenol 325 mg was in the home and the Patient stated it was being taken every 6 hours as needed for pain starting 6/21/23. The medications were not on the Plan of Care. 3) Patient #7 has a start of care date of 6/6/23 with diagnoses of Fractured Pelvis, Hypertension, and Hearing Loss as documented on the Home Health Care Certification and Plan of Care dated 6/6/23 through 8/4/23. The Home Health Care Certification and Plan of Care dated 6/6/23 through 8/4/23 documents: Skilled Nursing 1 – 2 times a month for 2 months; Physical Therapy 4 – 5 times a month for 1 month, 1 – 24 times a month for 1 month; Occupational Therapy evaluation; Amlodipine Benzapril 10/20 mg one tablet daily, Celecoxib 200 mg daily, Senna 8.6 mg at bedtime, Tylenol 325 mg two tablets every 6 hours as needed for pain, Vitamin D3 10 mcg daily. During a home visit on 6/27/23, the following was found: Aspirin 81 mg daily and Calcium 600 mg daily. The Patient states she has been taking it since she came home from Rehabilitation. The medications were not on the Plan of Care. During an interview with the Director of Clinical Services (DCS) on 6/29/23 at 12:30 PM, the DCS did not provide an explanation for the above.

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 home visit observation, clinical record reviews and staff interview, the Agency failed to establish individualized Plans of Care (POC) that includes services and frequency of visits the are specific to the patients’ health care needs. This was evident in one (1) Home Visit (HV) observation and five (5) of seventeen (17) records reviewed. (Patients#1HV, #9, #12, #15, #16) Failure to ensure individualized POC, has the potential for negative patient outcome. The findings include: 4) Patient #12 has a start of care date of 5/25/23 with diagnosis that include After care following surgery for Neoplasm, Depression, Primary Generalized Arthritis, Repeated Falls as documented on the “Home Health Certification and Plan of Care” for the Certification Period of 5/25/23 to 7/23/23. The” Home Health Certification and Plan of Care” for the Certification Period of 5/25/23 to 7/23/23 documents:” Orders/ Treatments. Discipline Orders Skilled Nursing 1m 1m 1-3 m 1 m, 3 as needed. Physical Therapy 1m 1m, 2-4 m 1m. Occupational Therapy 1-2 m 1m. Medical Social Worker 1-2m 2m to assess and evaluate and treat for community services, social and emotional factors related to patient illness. There is no documented evidence the Plans of Care include services and frequency of visits that are specific to the patients’ health care needs. 5) Patient # 15 has a start of care date of 6/6/23 with diagnosis that include Hypertensive Heart Disease with Heart Failure, Paroxysmal Atrial Fibrillation, Pulmonary Hypertension as documented on the “Home Health Certification and Plan of Care” for the Certification Period of 6/6/23 to 8/4/23. The "Home Health Certification and Plan of Care" for the Certification Period of 6/6/23 to 8/4/23 documents:” Orders/ Treatments: Discipline Orders: Physical 3-5 m 1m; 1-2 m 1m". There is no documented evidence the Plans of Care include services and frequency of visits that are specific to the patients’ health care needs. 6) Patient # 16 has a start of care date of 6/5/23 with diagnosis that include Type II Diabetes Mellitus with Hypoglycemia without Coma, Long term Use of Insulin, Long term Use Injectable Non-Insulin Antidiabetic Drugs, Type II Diabetes Mellitus with Diabetic Polyneuropathy, Pain in Right Thigh, Pain in Left Thigh, as documented on the “Home Health Certification and Plan of Care” for the Certification Period of 6/5/23 to 8/3/23. The “Home Health Certification and Plan of Care” for the Certification Period of 6/5/23 to 8/3/23 documents:” Orders/ Treatments: Skilled Nursing (SN) 1-2 week for 2 weeks, 2 as needed (PRN) for foley catheter issues or decline/ change in cardiovascular, pulmonary, or neurological status. Patient diabetic and monitors blood sugar three times a day upon awakening, before lunch, before dinner. Patient to notify physician if blood sugar 300. SN to assess and instruct sugar. Medications: Toujeo Solostar 300 unis/ml subcutaneous solution, inject 100 units/ subcutaneous 3 times a day before meals. Patient to inject according to sliding scale, Allopurinol 100 mg tablet ( tab) oral ( PO) once a day ( QD), Alprazolam 0.25 mg PO take one capsule QD, Calcitriol capsule 25 mg PO QD, Furosemide 20 mg tab PO QD, Gabapentin 300 mg capsule PO QD in the afternoon, Gabapentin 600 mg capsule PO at bedtime, Hydralazine 50 mg PO three times a day, Ozempic 1 mg dose 4 mg / 3ml subcutaneous solution, inject 1 mg/ ml subcutaneously once a week, Rivaroxaban 10 mg tab, one tab PO QD, Simvastatin 40 mg tab one tab PO at bedtime daily, Timolol Maleate Ophthalmic solution apply one in each affected eye twice a day. Physical Therapy to assess and evaluate; treat. Physical Therapy 3-5 m 1m, 1-2 m 1m". There is no documented evidence of a sliding scale in the Plan of Care. There is no documented evidence the Plans of Care include services and frequency of visits that are specific to the patients’ health care needs. On 6/29/23 t 3:30 PM, the Director of patient Services was interviewed and did not provide an explanation for the findings. 3) Patient #9 has a start of care date of 11/22/2022 with diagnoses of Traumatic Subdural Hematoma, Pressure Ulcer left Hips Stage 1, Encounter for change of non-surgical wound dressing and Pulmonary Fibrosis as documented on the "Home Health Care Certification and Plan of Care" dated 11/22/2022 to 01/20/2023. The patient has a discharge date of 01/20/2023. The "Home Health Care Certification and Plan of Care" dated 11/22/2022 to 01/20/2023 document orders for "Skilled Nurse (SN) to assess and evaluate 1 m1m, 2- 3m 1 m (one visit a month for one month, two to three visits a month for one month); 2 PRN (two as needed visits), Physical Therapy (PT) assess and evaluate, PT 1 - 2m 1m (one to two visits a month for one month; 3 - 4m 1m (three to four visits a month for one month); Occupational Therapy (OT) to assess and evaluate ; 2 - 4 m 1m (two to four visits a month for one month). The clinical record lacks documented evidence of an individualized Plan of Care for SN, PT and OT services frequency of visits that are specific to the patients’ health care needs. The survey findings and interview were conducted on 06/27/2023 at 03:20 PM with the Agency's Administrator and Director of Clinical Services (DCS). No explantion was provided. 1) Patient #1HV has a start of care of 5/5/23 with diagnoses of Gout Right Wrist, Ulcer to Right Heel, Osteoarthritis to the Right Ankle and Foot, and Dementia as documented on the "Home Health Care Certification and Plan of Care" dated 5/5/23 through 7/3/23. The "Home Health Care Certification and Plan of Care" dated 5/5/23 through 7/3/23 documents: Skilled Nursing (SN) 1 – 3 times a week for 8 weeks for assessment and evaluation; Physical Therapy 2 – 3 times a month for 1 month, 1 – 2 times a month for 1 month; Clinician to assess and instruct in pain management; Santyl ointment, one application daily to right heel wound; Patient's family members are willing to do daily dressing changes to the right heel. The SN note dated 5/5/23 documents the Patient has pain to the right wrist, the worst pain is rated a 4 on a scale of 0 to 10, and the Patient is taking OTC (Over the Counter) pain medication. The Plan of Care does not document what OTC the Patient is taking, the amount, and frequency. The SN note dated 6/2/23 documents: there is no one to do the dressing change, family members are not able to do the wound care. A verbal order dated 6/5/23 documents: Medihoney to wound three times a week, Pt/CG (patient/caregiver) to apply to heel wound; SN 1 to 3 times a week for additional wound care. During a home visit on 6/28/23 the Patient stated she was not able to do her wound care, one adult child was sick and her other adult child travels. The Plan of Care and verbal order do not document the person responsible for wound care if the nurse does not go three times a week. 2) Patient #11 has a start of care date of 6/6/21 with a date of discharge of 8/6/21 with diagnoses of Fractured Lower Femur, and Cardiac Disease documented on the "Home Health Care Certification and Plan of Care" dated 6/6/21 through 8/4/21. The "Home Health Care Certification and Plan of Care" dated 6/6/21 through 8/4/21 documents: Skilled Nursing (SN) 1 – 2 times a month for 1 month, 1 time a month for 1 month; Physical Therapy (PT) evaluation; Occupational Therapy (OT) evaluation; Medical Social Worker (MSW) 1 to 2 times a month times two months; clinician to assess and instruct in pain management; Oxycodone 5 mg every 6 hours as needed for pain. The clinical record lacks documented evidence of an individualized Plan of Care for PT and OT services frequency of visits that are specific to the patients’ health care needs. During an interview with the Director of Clinical Services (DCS) on 6/27/23 at 2:00 PM, the DCS did not provide an explanation for the above.

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 home visit observation, record reviews and staff interviews the agency failed to ensure the services are provided in accordance with the Plan of Care as established by the physician. This was evident for one (1) Home Visit (HV) observation, six (6) of seventeen (17) clinical records reviewed. (Patients #1, #2, 3HV, #7, #11 and # 16). Failure to ensure that services are provided in accordance with the Plan of Care as established by the physician, has the potential for negative patient outcomes. The findings are: 6) Patient # 16 has a start of care date of 6/5/23 with diagnosis that include Type II Diabetes Mellitus with Hypoglycemia without Coma, Long term Use of Insulin, Long term Use Injectable Non-Insulin Antidiabetic Drugs, Type II Diabetes Mellitus with Diabetic Polyneuropathy as documented on the “Home Health Certification and Plan of Care” for the Certification Period of 6/5/23 to 8/3/23. The” “Home Health Certification and Plan of Care” for the Certification Period of 6/5/23 to 8/3/23 documents:” Orders/ Treatments: Skilled Nursing ( SN) 1-2 week for 2 weeks, 2 as needed (PRN) for foley catheter issues or decline/ change in cardiovascular, pulmonary, or neurological status. Patient diabetic and monitors blood sugar three times a day upon awakening, before lunch, before dinner. Patient to notify physician if blood sugar 300. SN to assess and instruct sugar. Medications: Toujeo Solostar 300 unis/ml subcutaneous solution, inject 100 units/ subcutaneous 3 times a day before meals. Patient to inject according to sliding scale, Allopurinol 100 mg tablet ( tab) oral ( PO) once a day ( QD), Alprazolam 0.25 mg PO take one capsule QD, Calcitriol capsule 25 mg PO QD, Furosemide 20 mg tab PO QD, Gabapentin 300 mg capsule PO QD in the afternoon, Gabapentin 600 mg capsule PO at bedtime, Hydralazine 50 mg PO three times a day, Ozempic 1 mg dose 4 mg / 3ml subcutaneous solution, inject 1 mg/ ml subcutaneously once a week, Rivaroxaban 10 mg tab, one tab PO QD, Simvastatin 40 mg tab one tab PO at bedtime daily, Timolol Maleate Ophthalmic solution apply one in each affected eye twice a day. The “Skilled Nursing Visit Note” dated 6/15/23, 6/19/23, 6/21/23 lacks documented evidence of the nurse assessment of the patient blood sugar or review of a documented blood sugar log. The patient’s clinical record does not document care in accordance with the plan of care as established by the physician. On 6/28/23 at 3:30 PM, the Director of patient Services was interviewed and did not provide an explanation for the findings. 2) Patient #1 has a start of care of 5/5/23 with diagnoses of Gout Right Wrist, Ulcer to Right Heel, Osteoarthritis to the Right Ankle and Foot, and Dementia as documented on the "Home Health Care Certification and Plan of Care" dated 5/5/23 through 7/3/23. The "Home Health Care Certification and Plan of Care" dated 5/5/23 through 7/3/23 documents: Skilled Nursing (SN) 1 – 3 times a week for 8 weeks for assessment and evaluation; Physical Therapy 2 – 3 times a month for 1 month, 1 – 2 times a month for 1 month; Clinician to assess and instruct in pain management; Santyl ointment, one application daily to right heel wound; Patient's family members are willing to do daily dressing changes to the right heel. The SN notes dated 6/2/23, 6/6/23, 6/8/23, 6/11/23, and 6/19/23 lack documented evidence the Patient's pain was assessed to include the location, rating of the pain, measures taken to relieve the pain including pain medication with the amount, frequency and effectiveness of the medication. The SN notes dated 5/17/23 through 5/30/23 lack documented evidence as to whether the family is compliant with changing the dressing daily. The SN note dated 6/2/23 documents the family members are not able to change the dressing daily. The note does not document when the dressing was last changed. The patient’s clinical record does not document care in accordance with the plan of care as established by the physician. 3) Patient #2 has a start of care date of 6/16/23 with diagnoses of Fractured Radius, Depression, and Back Pain as documented on the "Home Health Care Certification and Plan of Care" dated 6/16/23 through 8/14/23. The "Home Health Care Certification and Plan of Care" dated 6/16/23 through 8/14/23 documents: Skilled Nursing (SN) 1 – 3 times a week for 1 month for assessment and evaluation; Physical Therapy (PT) 1 – 2 times a month for 1 month, 3 – 4 times a month for 1 month; Occupational Therapy (OT) evaluation; Medical Social Worker (MSW) 1 – 2 times a month for 2 months; clinician to assess and instruct in pain management; Tylenol 325 mg two tablets every four hours for pain. The SN note dated 6/22/23 documents the Patient has back pain. The pain is not rated, and the note does not document the amount of pain medication is being used with the effectiveness of the medication. The PT note dated 6/23/23 documents the Patient has right wrist pain and is using OTC (Over the Counter) medication. The note does not document a complete pain assessment to include a rating for the pain, the name of the OTC medication, the amount, frequency, and effectiveness of the medication. The OT note dated 6/26/23 lacks documented evidence of a pain assessment. The patient’s clinical record does not document care in accordance with the plan of care as established by the physician. 4) Patient #7 has a start of care date of 6/6/23 with diagnoses of Fractured Pelvis, Hypertension, and Hearing Loss as documented on the "Home Health Care Certification and Plan of Care" dated 6/6/23 through 8/4/23. The "Home Health Care Certification and Plan of Care" dated 6/6/23 through 8/4/23 documents: Skilled Nursing 1 – 2 times a month for 2 months; Physical Therapy 4 – 5 times a month for 1 month, 1 – 24 times a month for 1 month; Occupational Therapy evaluation; clinician to assess and instruct in pain management; Tylenol 325 mg two tablets every six hours for pain. The SN note dated 6/14/23 lacks documented evidence of a complete pain assessment (location of pain, rating, medications taken to relieve pain). The PT notes document: 6/11/23 -minimal to moderate pain to the hips with movement. 6/15/23 - pain to the lower back/buttocks, worst pain is a 4, OTC medications. 6/21/23 - pain to the right/side lower back/right upper buttock, worst pain is a 6, OTC medication. The PT notes lack documented evidence of the OTC medication being used, the amount, frequency and effectiveness of the pain medication. The PT notes dated 6/19/23 and 6/26/23 lack documented evidence of a complete pain assessments (location of pain, rating, medications taken to relieve pain). The OT notes document: 6/13/23 - pain to hips, the pain is a 2 and the worst is 5, OTC medication being used. 6/20/23 - groin area to low back, pain is rated a 4 and the worst pain is a 7, OTC medication being used. The OT notes do not document the name of the OTC medication being used, the amount, frequency, and effectiveness of the medication. The patient’s clinical record does not document care in accordance with the plan of care as established by the physician. 5) Patient #11 has a start of care date of 6/6/21 with a date of discharge of 8/6/21 with diagnoses of Fractured Lower Femur, and Cardiac Disease documented on the "Home Health Care Certification and Plan of Care" dated 6/6/21 through 8/4/21. The "Home Health Care Certification and Plan of Care" dated 6/6/21 through 8/4/21 documents: Skilled Nursing (SN) 1 – 2 times a month for 1 month, 1 time a month for 1 month; Physical Therapy (PT) evaluation; Occupational Therapy (OT) evaluation; Medical Social Worker (MSW) 1 to 2 times a month times two months; clinician to assess and instruct in pain management; Oxycodone 5 mg every 6 hours as needed for pain. Communication notes document the following: 7/7/21 - the SN documents "when attempting to schedule a visit on 7/6/21 for a nursing discharge on 7/7/21, Patient stated that she needs more than a days' notice when scheduling, will only accept a female nurse and is not available for a nursing visit until 7/9/21". 7/13/21 - "spoke with Patient to schedule a visit for today. Patient states she told the last male nurse that she prefers a female nurse. Informed Patient that I would let my supervisor regarding her request". There is no documented evidence of a nursing visit after the initial visit of 6/6/21. The SN note dated 6/6/21 documents the Patient has pain to the right leg and the Patient is using narcotic and OTC medication for pain relief. The SN note does not document a rating for the pain, the amount, frequency and effectiveness for the Oxycodone, and does not document the name of the OTC medication being used, the amount, frequency, and effectiveness of the medication. The PT visit notes document: 6/12/21 - pain to the right hip, daily - intermittent, pain is rated a 2. 6/25/21 - pain to the right knee, pain is a 3, the worst pain is a 5, The PT notes do not document whether the Patient is using the Oxycodone, and if so, the amount, frequency, and effectiveness of the pain medication. The OT note dated 6/18/21 documents the Patient has chronic pain rated a 2 and the worst pain is a 3. The note does not document the location of the pain, medication being used to alleviate the pain and the amount and frequency of use. The patient’s clinical record does not document care in accordance with the plan of care as established by the physician. During an interview with the Director of Clinical Services (DCS) on 6/27/23 at 1:00 PM, the DCS did not have an explanation for the above. 1) Patient #3 has a start of care date of 06/14/2023 with diagnoses of atherosclerotic heart disease of native coronary artery, abnormality of gait and mobility, hypertensive heart disease with heart failure, and type 2 Diabetes Mellitus as documented on the "Home Health Care Certification and Plan of Care" dated 06/14/2023 to 08/12/2023. The "Home Health Care Certification and Plan of Care" dated 06/14/2023 to 08/12/2023 document orders for "Skilled Nurse (SN) to assess and evaluate, 1wk 3wk (one visit a week for three weeks); 3 PRN (three as needed visits), Physical Therapy (PT) assess and evaluate, PT 3-5m 1m (three to five visits a month for one month; 2-3m 1m (two to three visits a month for one month); Aide 1-2wk 4wk (one to two visits a week for four weeks); Patient to check glucose levels via fingerstick four times a day before meals and at bedtime, call MD for glucose less than 70 or greater than 400. SN to teach/reinforce how to perform blood sugar monitoring, significance of results, interventions for high/low readings, readings to report, care of meter. During a home visit on 06/27/2023 with the Physical Therapist, the patient reported he checks his fingerstick one to two times a daily at random times. He does not keep a log of results, does not know what values need to be reported to his physician, and does not understand the significance of high/low readings. Patient states “I just got a new diabetes doctor but I haven’t seen him yet”. The “Skilled Nursing Visit Note” dated 6/16/2023 lacks documented evidence of the nurse review of a documented blood sugar log or education about significance of blood sugar readings and readings to report. The patient’s clinical record does not document care in accordance with the plan of care as established by the physician. The Director of Clinical Services (DCS) was interviewed on 06/28/2023 at 3:20PM and survey findings reviewed. No explanation was provided.

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 clinical record review and staff interview, the Agency failed to review and revise the Plans of Care. This is evident in one (1) of seventeen (17) clinical records reviewed. (Patient #9) Failure to ensure that POC are reviewed and revised, has the potential for negative patient outcome. The findings include: Patient #9 has a start of care date of 11/22/2022 with diagnoses of Traumatic Subdural Hematoma, Pressure Ulcer left Hips Stage 1, Encounter for change of non-surgical wound dressing and Pulmonary Fibrosis as documented on the "Home Health Care Certification and Plan of Care" dated 11/22/2022 to 01/20/2023. The patient has a discharge date of 01/20/2023. The "Home Health Care Certification and Plan of Care" dated 11/22/2022 to 01/20/2023 document orders for "Skilled Nurse (SN) to assess and evaluate 1 m1m, 2- 3m 1 m (one visit a month for one month, two to three visits a month for one month); 2 PRN (two as needed visits), Physical Therapy (PT) assess and evaluate, PT 1 - 2m 1m (one to two visits a month for one month; 3 - 4m 1m (three to four visits a month for one month); Occupational Therapy (OT) to assess and evaluate ; 2 - 4 m 1m (two to four visits a month for one month). The "Transfer Oasis" dated 11/30/2023, the PT documents the patient hospitalized due to "decline in health". The ROC (Resumption of Care) Oasis is dated 12/13/2022. The Skilled Nurse (SN) documents that the patient's Left Hip Pressure Ulcer is "healed", and the patient is on) oxygen at 2 liters per minute via NC (Nasal Cannula) continuous. "Accu-check (glucometer) performed during visit. Teaching provided to pt. (patient) and wife. BS (Blood Sugar) 216 after eating a bagel. Educated on DM (Diabetes Mellitus) diet". Patient would benefit from resuming HHA (Home Health Aide, OT, PT, SN and MSW visit for long term planning". MSW (Medical Social Worker) visit is dated 12/18/2022, and SN visit is dated 12/20/2022. There is no documented evidence of a revised Plan of Care orders for MSW and SN services from12/13/2022 - 12/20/22. The Transfer Oasis dated 12/21/2022, the SN documents patient hospitalized for "decline in health". The ROC Oasis dated 12/29/2022, the SN documents patient is on "Prednisone 60 mg (milligram) QD (daily) decreasing by 5 mg daily, O2 (Oxygen) saturation 96% on 2 L (Liters) Oxygen via NC (Nasal Cannula), BS (Blood Sugar) 116". SN visits are dated 01/06/23, 01/13/23, 01/19/23. OT visits are dated 12/30/22, 01/04/23, 01/10/23, 01/13/23, and 01/18/23. There is no documented evidence of a revised Plan of Care orders for SN and OT services from 12/29/22 - 01/18/2023. The clinical record lacks documented evidence that the Plans of Care were reviewed and revised for SN, OT, and MSW services, Prednisone 60 mg daily, BS testing frequency, BS parameters, Oxygen at 2 L via NC continuous, and Oxygen saturation parameters The survey findings and interview were conducted on 06/27/2023 at 03:20 PM with the Agency's Administrator and Director of Clinical Services (DCS). The DCS reported that the "Plan of Care" (patient calendar of services) is used for service frequency of visits.

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 Home Visit (HV) observations, clinical records review and staff interviews, the Agency failed to promptly alert the Physician of relevant changes in patient's medications, wound status, and delivery of supplies. This was evident in one (1) Home Visit (HV) observation and four (4) of seventeen (17) clinical records reviewed. (Patients #7HV, #10, #11 and #12). Failure to promptly alert the Physician of relevant changes in patient's condition, has the potential for negative patient outcome. The findings include: 4) Patient #12 has a start of care date of 5/25/23 with diagnosis that include After care following surgery for Neoplasm, Depression, Primary Generalized Arthritis, Repeated Falls as documented on the “Home Health Certification and Plan of Care” for the Certification Period of 5/25/23 to 7/23/23. The " Home Health Certification and Plan of Care for the certification Period of 5/25/23 to 7/23/23 documents:" Supplies: Shower bench, cane, hand-held shower". The Physical Therapist " Plan of Care other supplies narrative notes" dated 5/29/23 documents:" Patient is most concerned about getting proper shower set up. patient does not have financial means to purchase transfer tub bench. Local lending closet service information provided. Grab bar set up discussed also this visit". The " Occupational Therapy Visit Note" dated 5/31/23 documents:" Recommend: tub transfer bench, long handled sponge; therapist called around Brookhaven town for leading closet. Patient cannot afford transfer bench. Found one in blue point. Recommend to sponge bath until tub transfer bench. patient currently exhibit decreased functional activity tolerance, impaired safety awareness with decreased balance and strength". There is no documented evidence the tub transfer was provided to the patient until the date of discharge of 6/8/23. There is no documented evidence the physician was notified that the tub transfer bench was not provided to the patient. On 6/28/23 at 3:30 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings. 3) Patient #10 has a start of care date of 11/28/2022 with diagnoses of Pressure Ulcer Left Buttock, Stage 4, Encounter for change of non-surgical wound dressing, and Pressure-inducted deep tissue damage to Left heel as documented on the “Home Health Care Certification and Plan of Care" for certification period from 11/28/2022 to 01/26/2023. The “Home Health Care Certification and Plan of Care" for certification period from 11/28/2022 to 01/26/2023 documents orders for “Skilled Nurse (SN) 1 -3 wk. 7, 2 PRN (one to three visits a month for seven weeks, two as needed visits)”. Decubitus/Pressure Ulcer Stage IV - Left Buttock gluteal fold Ischium, "SN/CG - cleanse with NS (squirt saline) from unit dose into wound, gently pack with strip of Calcium Alginate using applicator stick, cover with gauze followed by boarder gauze 3 x per week until resolved or order changed by MD start date 11/28/2022". SN to "assess Pressure Ulcer status including healing and complication". Pressure Ulcer: "assess skin integrity and overall condition of skin including s/s (signs/symptoms) of skin breakdown". The SN visit reports dated 12/07/22, 12/09/22, 12/12/22, 12/14/22, 12/16/22, 12/19/22, 12/23/22, 12/26/23, 12/28/22, 12/30/22, 01/01/23, 01/04/23, 01/06/23, 01/09/23, 01/11/23, 01/13/23, 01/18/23, 01/20/23, and 01/25/23, the SN documents the patient's Left Buttock Gluteal Fold Ischium/Decubitus/Pressure Ulcer Stage IV “wound edges - macerated". The clinical record lacks documented evidence that the SN promptly notified the Physician of the patient's continuous macerated wound edges. The survey findings and interview were conducted on 06/29/2023 at 10:30 AM with the Director of Patient Services. No explanation was provided. 1) Patient #7HV has a start of care date of 6/6/23 with diagnoses of Fractured Pelvis, Hypertension, and Hearing Loss as documented on the "Home Health Care Certification and Plan of Care" dated 6/6/23 through 8/4/23. The "Home Health Care Certification and Plan of Care" dated 6/6/23 through 8/4/23 documents: Skilled Nursing 1 – 2 times a month for 2 months; Physical Therapy 4 – 5 times a month for 1 month, 1 – 24 times a month for 1 month; Occupational Therapy evaluation; Amlodipine Benzapril 10/20 mg one tablet daily, Celecoxib 200 mg daily, Senna 8.6 mg at bedtime, Tylenol 325 mg two tablets every 6 hours as needed for pain, Vitamin D3 10 mcg daily. During a home visit on 6/27/23, the following was found: Aspirin 81 mg daily. The Occupational Therapist stated that she was aware of the Aspirin and had instructed the Patient to call the physician to see if she should be taking it. There is no documented evidence of communication between the Registered Nurse or the physician regarding the Aspirin. 2) Patient #11 has a start of care date of 6/6/21 with a date of discharge of 8/6/21 with diagnoses of Fractured Lower Femur, and Cardiac Disease documented on the "Home Health Care Certification and Plan of Care" dated 6/6/21 through 8/4/21. The "Home Health Care Certification and Plan of Care" dated 6/6/21 through 8/4/21 documents: Skilled Nursing 1 – 2 times a month for 1 month then 1 time a month for 1 month; Physical Therapy evaluation; Occupational Therapy evaluation, Medical Social Worker (MSW) 1 to 2 times a month for two months. The SN made a visit on 6/6/21. The record documents in Communication Notes dated 6/16/21, 7/7/2, 7/13/21, and 7/27/21 document a male nurse called to schedule a visit and was told by the Patient she only wanted a female nurse. The MSW made a visit on 6/13/21. There is no documented evidence a second visit was made in July 2021. There is no documented evidence the physician was informed the second SN and MSW visits was not performed. During an interview with the Director of Clinical Services (DCS) on 6/29/23 at 12:30 PM, the DCS did not provide an explanation for the above.

Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient's discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner's issuing orders for the HHA plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any). This ELEMENT is not met as evidenced by: Based on record reviews and staff interviews, the Agency failed to communicate to the patient revised discharge plans and discontinuation of services. This was evident in two (2) of five (5) discharge records reviewed. ( Patients # 11 and #12). Failure to communicate to the patient discharge plans, has the potential for negative patient outcomes. The findings include: 2) Patient #12 has a start of care date of 5/25/2023 and a discharge date of 6/8/2023, with diagnosis that include After care following surgery for Neoplasm, Depression, Primary Generalized Arthritis as documented on the “Home Health Certification and Plan of Care” for the Certification Period of 6/5/23 to 7/23/23. The “Communication Notes” dated 6/8/23, 9: 30 AM documents:” Received a call from patient requesting that we discharge (D/C) as she is not happy with our agency. Called Dr's office regarding patient request for DC. Left message for with office representative regarding discharge". The "Communication Notes” dated 6/8/23, 12:10 PM documents: "faxed to hospital informing them that the patient requested discharge from our agency and Speech referral needs to be made to another agency. Initial speech evaluation sent to Physician”. The “Communication Notes” Dated 6/9/23 documents: "Received a call from NYSDOH. Was contacted by the patient who wants to be discharged from agency. I clarified that patient was discharged from agency on 6/8/23. NYSDOH requested that I call patient to inform her of this. I called the patient and left a message on her voicemail and requested she call back if she has any questions or concerns”. The "Constellation Home Care Discharge Instructions” dated 6/8/2023 documents:” Home Exercise, Outpatient Rehab. Received call from patient requesting discharge”. The “Constellation Home Care Policy No.C2:043 documents:” Discharge instructions will be completed, and client will be provided with a copy”. There is no documented evidence the patient was informed about other agency services. There is no documented evidence of discharge instructions given or sent to the patient at discharge. On 6/28/2023 at 3:20 PM, the Director of Patient Services and the Clinical Supervisor were interviewed and did not provide an explanation for the findings. 1) Patient #11 has a start of care date of 6/6/21 with a date of discharge of 7/26/21 with diagnoses of Fractured Lower Femur, and Cardiac Disease documented on the "Home Health Care Certification and Plan of Care" dated 6/6/21 through 8/4/21. The "Home Health Care Certification and Plan of Care" dated 6/6/21 through 8/4/21 documents: Skilled Nursing (SN) 1 – 2 times a month for 1 month, 1 time a month for 1 month; Physical Therapy (PT) evaluation; Occupational Therapy evaluation, Medical Social Worker (MSW) 1 to 2 times a month for two months. The initial PT visit note dated 6/12/21 documents "patient lives in a second-floor apartment with 13 steps, Patient refuses to try the stairs today stating that she is not yet ready for it". The PT notes document the following: 6/25/21 - "able to negotiate 1 step, the home is cluttered, lacks adequate space for ambulation training, due to obstructions from furniture. Patient is aware of clutter created by son; Patient reports she has not bathed or showered due to lack of space in the bathroom with the rolling walker. No shower chair or handheld shower observed. Patient states she is able to bath at sink with assistance". The note does not document the person that is assisting the Patient to bath. 7/12/21 - "Patient fearful to attempt the stair training". 7/19/21 - "Patient continues to present with decreased standing balance". 7/26/21 - "ambulation- requires supervision while ambulating 320 feet with walker, Balance - still requires intermittent CGA (Contact Guard Assist) when performing balance activities; Adjustments in treatment plan needed- additional visits 2 times a week for three weeks; communication with MD". A Discharge OASIS dated 8/6/21 documents it was completed by a PT (no name) from the company the agency contracts for Physical Therapy. The discharge summary documents a visit date of 7/26/21 and the visit time in is "12:00 AM", OASIS only - start incomplete assessment; the Patient needs partial to moderate assistance in climbing steps; patient remained in community (without formal assistive services). A MSW note dated 6/13/21 documents the following: Patient unable to do stairs and would like to do the stairs, Patient receives assistance from primary caregiver once daily; unable to prepare light meals on a regular basis due to physical, cognitive, or mental limitations; Patient ambulates with a walker and needs assistance at times with ADL's (Activities of Daily Living); Patient has three adult children (one resides in NJ, one in Bethpage and one employed that lives with the patient, the apartment is cluttered and needs to be cleaned and reports the condition of the apartment is due to her being in hospital and rehab for months; community resources reviewed including PERS (Personal Emergency Response System), Access a Ride, MOW (Meals on Wheels), home visiting MD, and homebound counseling; no further intervention needed. The MSW note does not document the response of the Patient to the services reviewed or communication between family members regarding the Patient's status and needs. No further MSW visits were made to the home. The OT note dated 6/18/21 documents Patient has no shower chair, caregiver provides assistance once daily. A Discharge Summary dated 8/6/21 documents the Patient was discharged on 7/26/21. There is no documented evidence as to the reason for the discharge. There is no documented evidence of the Patient was informed of the discharge and discharge instructions given to or sent to the patient at discharge. During an interview with the Director of Clinical Services (DCS) and Clinical Supervisor on 6/27/23 at 2:00 PM and did not provide an explanation for the findings.

Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This STANDARD is not met as evidenced by: Based on clinical record review and staff interview, the Agency failed to ensure that the Skilled Nurse (SN) perform weekly wound care measurements. This was evident in one (1) of three (3) clinical records reviewed with wound care treatments. (Patient #10). Failure to ensure that the SN perform weekly wound measurement, has the potential for negative patient outcome. The findings include: The Agency's "Wound Care Policy" dated 09/2020, procedure 2 documents " The VN (Visiting Nurse) will document wound measurements in cms (centimeters) weekly at the beginning of the week, and/or as indicated by change in status". The findings include: Patient #10 has a start of care date of 11/28/2022 with diagnoses of Pressure Ulcer Left Buttock, Stage 4, Encounter for change of non-surgical wound dressing, and Pressure-inducted deep tissue damage to Left heel as documented on the “Home Health Care Certification and Plan of Care" for certification period from 11/28/2022 to 01/26/2023. The “Home Health Care Certification and Plan of Care" for certification period from 11/28/2022 to 01/26/2023 documents orders for “Skilled Nurse (SN) 1 -3 wk. 7, 2 PRN (one to three visits a month for seven weeks, two as needed visits)”. "Decubitus/Pressure Ulcer Stage IV - Left Buttock gluteal fold Ischium, SN/CG (caregiver) - cleanse with NS (squirt saline) from unit dose into wound, gently pack with strip of Calcium Alginate using applicator stick, cover with gauze followed by boarder gauze 3 x per week until resolved or order changed by MD start date 11/28/2022". SN to "assess Pressure Ulcer status including healing and complication". Pressure Ulcer: "assess skin integrity and overall condition of skin including s/s (signs/symptoms) of skin breakdown". The “Wound Care Flow sheets”, the SN documents wound care measurement of the Left Buttock Gluteal Fold Ischium/Decubitus/Pressure Ulcer Stage IV performed on 12/9/22, 01/01/23, 01/04/23, 01/11/23 and 01/25/23. The “Wound Care Flow sheets” lacks documented evidence that the SN performed wound care measurements of the patient’s Left Buttock Gluteal Fold Ischium/Decubitus/Pressure Ulcer Stage IV on 12/16/22, 12/19/22, 12/23/22, 12/26/23, 12/28/22, 12/30/22, and 01/11/23, 01/18/23, 01/20/23, and 01/23/23. The clinical record lacks documented evidence that the SN performed weekly wound measurement of the patient’s Left Buttock Gluteal Fold Ischium/Decubitus/Pressure Ulcer Stage IV. The survey findings and interview were conducted on 06/29/2023 at 10:30 AM with the Director of Patient Services. No explanation was provided.