Every finding on record at Extraordinary Home Care

An onsite complaint 97347 was conducted 05/03/2023 – 05/04/2023 at St. Mary’s Home Health Agency located at 5 Dakota drive, New Hyde Park 10042. Three (3) patient records, two (2) personnel record, the Discharge criteria for Home Care Services policy, Patient Complaint Log for 1st Quarter 2023 and the Patient Incident/Accident Report dated 01/17/23 were reviewed. Interview was conducted with the Agency's Physical Therapy Assistant and Registered Nurse, and Supervisor on 05/03/2023 Complaint 97347 is unsubstantiated. The following deficiencies are cited as a result of the survey: G0580 – Only as ordered by a Physician G1010 - Contents of the clinical record

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, the Agency failed to ensure that Physical Therapy (PT) and Occupational Therapy (OT) services are provided in accordance to the Physician's Order. This is evident in one (one) of three (3) patient records reviewed. Patient #1. Failure to ensure that PT and OT services are provided in accordance to the Physician's Order, has the potential for negative patient outcome. The findings include: The patient has a start of care date of 05/05/2017 with a primary diagnosis of Cerebral Palsy and secondary diagnoses of Unspecified lack of expected normal physiological development in childhood and Urinary Incontinence as documented on the "Home Health Certification and Plan of Care" dated 12/05/2022. The "Home Health Certification and Plan of Care" for certification period 12/05/2022 to 02/02/2023 documents orders for Physical Therapy services 2 -3x within 5 days (two to three visits within five days). PT to perform “Ambulation training, bed mobility training, chest pt (physiotherapy), contracture intervention, coordination and motor planning, activities/exercise training, postural exercises/activities, Rang of Motion exercises/activities, standing training, transfer training, lower extremity exercise”. Registered Nurse (RN) services "1 within five days and 3 (three) PRN (as needed) visits for "changes in clinical status, medications or assessment in home/telehealth". Occupation Therapy (OT) services “2 -3x within 5 days (two to three visits within five days). OT to perform "Therapeutic exercise, UE (Upper Extremity) weight bearing exercises fine motor exercise, hand exercises, balance exercise". Medications include "Motrin 00 mg (milligram)/5ml (milliliter) 20 ml PRN (as needed Q 4 - 6 (every four to six) hours, pupose -pain". DME (Durable Medical Equipment) includes wheelchair and AFO (Ankle Foot Orthotics". The "Clinical Coordination" note dated 01/10/2023, the RN Supervisor documents "Phone call made to patient who reported that while performing walking and ROM exercise, he lost his gait when knees buckle and injured his left ankle". He reports he (patient) has pain and swelling to left ankle. He is currently taking Motrin 100 mg (milligram)/5ml (milliliter) which he takes 20 ml to equal 400". Patient reports that he will see MD Friday 01/13/23 and will have left tibia an ankle X-Ray. Patient advised that his OT/PT will be placed on hold until cleared for therapy". "Telephone call made to MD to report above and advised that PT/OT services will be on hold MD is in awareness". The clinical record lacks documented evidence of PT services from 01/10/2023 - 01/23/23. The Agency failed to obtain a Physician's Order to hold PT/OT services from 01/10/23 - 01/23/23. The survey findings were reviewed on 05/04/2023 with the Agency's Associated Director of Quality, Assistant Director of Operations, and Clinical Improvement Manager. No explanation was provided.

Contents of clinical record CFR(s): 484.110(a) Standard: Contents of clinical record. The record must include: This STANDARD is not met as evidenced by: Based on patient records review and staff interviews, the Agency failed to ensure that a comprehensive nursing assessment is completed and maintained for each patient. This was evident for one (1) of one (3) patient care records reviewed (Patient # 3). Failure to document a comprehensive nursing assessment has the potential for negative patient outcomes. The findings are: Patient #3 has a start of care date of 06/05/2021 with a diagnosis of Extreme Immaturity of Newborn, Gestational Age 24 completed weeks as documented on the "Home Health Certification" dated 04/03/2023. The "Home Health Certification" documented orders for skilled nursing (SN) "one (1) x fifty-six to sixty (60) days for reassessment and 2-3 times as needed (prn)". The “Skilled Nursing Recertification Visit” dated 04/03/2023 documents inconsistent findings throughout the assessment. 1) The “Cognitive Overview Assessment” dated 04/03/2023, the SN documents that cognitive function was assessed and there are no significant findings. The memory section of this assessment documents “unable to register, retain, and/or recall information both new and old”. 2) The “Functional Ability Overview Assessment” dated 04/03/2023, the SN documents that current ability to perform functional activities was assessed and there are no significant findings. The activities of daily living (ADL) section of this assessment documents “unable to perform one or more ADL’s independently”. The instrumental activities of daily living (IADL) section of this assessment documents “unable to perform one or more IADL’s independently”. The activities permitted section of this assessment documents “patient has activity restrictions in place”. 3) The “Gastrointestinal Overview Assessment” dated 04/03/2023, the SN documents the gastrointestinal system was assessed and there are no significant findings. The bowel control section of this assessment documents “reports changes in bowel control”. 4) The “Musculoskeletal Overview Assessment” dated 04/03/2023, the SN documents the musculoskeletal system was assessed and there are no significant findings. The muscle strength section of this assessment documents “muscle strength is not within normal limits”. The muscle tone section of this assessment documented “muscle tone is not within normal limits”. The range of motion section of this assessment documents “active and passive range of motion are not within normal limits for all joints”. The posture section of this assessment documents “posture is not well-proportioned”. The joints section of this assessment documents “joint problems noted”. The clinical documenation lacks consistency and does not clearly indicate the patient status. Failure to document an accurate, comprehensive patient assessment has the potential for negative outcomes. The findings were reviewed with the Clinical Improvement Manager and Associate Director of Quality on 05/04/2023 at 3:20PM. No additional explanation was given.

A standard re-certification survey, focused COVID-19 Infection Control and complaint 60350 (NY00281873) survey of St Mary’s Home Care located at 5 Dakota Drive, New Hyde Park, NY 11042 was initiated on 08/08/2022 and exited 08/15/2022. Deficient practices were identified within Level 1 standards in 484.60 condition resulting in a Partial Extended survey. The agency's unduplicated patient admission is 1131 as of 08/08/2022. Seventeen (17) clinical records were reviewed and are identified as Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, and #17. Seven (7) Home Visit observations were conducted with patients #1, #2, #3, #4, #5, #6 and #7. Twelve (12) personnel records were reviewed and are identified as Employees #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, and #12. Policies and procedures for Emergency Preparedness Plan, Health Commerce System, Home Care Registry, Criminal History Record Check, Home Care Covid 19 Infection Control, and Influenza Vaccination policy were reviewed. The agency's Patient Admission Packet and Patient Complaint log for the years 08/01/2021 through 08/01/2022 were reviewed. The agency's Quality Improvement meeting minutes were reviewed for 2021 and 2022. Complaint # 60350 (NY00281873) is unsubstantiated. Pre-survey activities consisted of review on 08/05/2022 of the agency’s Health Commerce System account, Home Care Worker Registry, Criminal History Record Check. The Agency's OBQI Adverse Event Outcome Reports were reviewed for the period of 04/2021 through 04/2022. The following Federal deficiencies are cited: G0574 - Plan of Care must include the following G0578 - Conformance with Physician Orders G0590 Promptly alert relevant Physician G0598 Discharge Plan Communication The following State deficiencies are cited: J1426 - Personnel

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record reviews and staff interview, the Agency failed to develop individualized patient Plans of Care. This was evident in sixteen (16) of seventeen (17) clinical records reviewed. (Patients # 1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, and #17).. Failure to develop individualized Plans of Care, has the potential for negative patient outcome. The findings include: 9) Patient #1 has a start of care date of 3/2/2022 with diagnosis that include Spina Bifida, Presence of Cerebral Fluid Device, Unspecified Asthma as documented on the " Home Health Certification and Plan Of Care" for the Certification Period of 6/30/22 to 8/28/22. The " Home Health Certification and Plan Of Care for the Certification Period of 6/30/22 to 8/28/22 document:" Orders for Discipline and Treatments: Physical Therapy 6/30/22 - 8/28/22 2 every week for 10 weeks- 1-2 visits per week, in home or telehealth. Occupational Therapy 6/30/22 - 8/28/22, 2 every week for 10 weeks, 1-2 visits per week in home or telehealth". The " Home Health Certification and Plan Of Care" for the Certification Period of 6/30/2022 to 8/28 2022 lacks documented evidence of description of the Patient's risk factors for Emergency Department visits, hospital readmission and necessary interventions to address risk factors. The "Home Health Certification and Plan Of Care" lacks clarity for the duration of the dertification . The duration of the certification period of 10 weeks extends past the certification period of 06/30/22 to 08/28/22. There is no documented evidence the Plan is complete. 10) Patient #3 has a start of care date of 7/21/2021 , and Date of Birth ( DOB) of 5/17/2021, with diagnosis that include Congenital Pulmonary Valve Stenosis, Acute Respiratory Failure with Hypoxia, Bradycardia, Respiratory Distress of Newborn as documented on the " Home Health Certification and Plan Of Care" for the Certification Period of 7/16/2022 to 9/13/2022. The " Home Health Certification and Plan Of Care" for the Certification Period of 7/16/22 to 9/13/22 document:" Orders for Discipline and Treatments: Physical Therapy 2 every week for 10 weeks, 1-2 week in home/ telehealth, Speech Therapy/ 2 every week for 10 weeks, 1-2 times a week in home/ telehealth, Nursing 1 every other week for 10 weeks". The " Home Health Certification and Plan Of Care" for the Certification Period of 7/16/2022 to 9/13/2022 lacks documented evidence of description of the Patient's risk factors for Emergency Department visits, hospital readmission and necessary interventions to address risk factors. The " Home Health Certification and Plan Of Care" lacks clarity for the duration of the certification period. The duration of the certification period of 10 weeks extends past the certification period of 07/16/22 - 09/13/22. There is no documented evidence the Plan Of Care is complete. 11) Patient # 5 has a start of care date of 12/7/2021 and DOB 8/21/2021, and DOB 8/8/2003, with diagnosis that include Pediatric Feeding Disorder, Ventricular Septal Defect, Failure to Thrive, Supraventricular Tachycardia as documented on the " Home Health Certification and Plan Of Care" for the Certification Period of 6/5/2022 to 8/3/2022. The " Home Health Certification and Plan Of Care" for the Certification Period of 6/5/2022 to 8/3/2022 lacks documented evidence of description of the Patient's risk factors for Emergency Department visits, hospital readmission and necessary interventions to address risk factors. There is no documented evidence the Plan Of Care is complete. 12) Patient # 7 has a start of care date of 5/13/2022 with diagnosis that include Disorder of Brain, Sequelae of Inflammatory Diseases, Epilepsy as documented on the " Home Health Certification and Plan Of Care" for the Certification Period of 7/12/2022 to 9/9/2022. The " Home Health Certification and Plan Of Care" for the Certification Period of 7/12/2022 to 9/9/2022 lacks documented evidence of description of the Patient's risk factors for Emergency Department visits, hospital readmission and necessary interventions to address risk factors. There is no documented evidence the Plan Of Care is complete. 13) Patient # 10 has a start of care 6/5/2021 , and DOB of 9/2017,with diagnosis of that include Extreme Immaturity of Newborn, Chronic Obstructive Pulmonary Disease as documented on the " Home Health Certification and Plan Of Care" for the Certification Period of 6/10/2022 to 8/8/2022. The " Home Health Certification and Plan Of Care" for the Certification Period of 6/10/22 to 8/8/22 document:" Orders for Discipline and Treatments: Physical Therapy 3 every week for 10 weeks, 2-3 times per week in home/ telehealth,Speech Therapy, 2 times a week for 10 weeks, 1-2 times per week in home/ telehealth, Occupational Therapy 2 every week for 10 weeks, 1-2 times per week in home/ telehealth". The " Home Health Certification and Plan Of Care" for the Certification Period of 6/10/2022 to 8/8/2022 lacks documented evidence of description of the Patient's risk factors for Emergency Department visits, hospital readmission and necessary interventions to address risk factors. The " Home Health Certification and Plan Of Care" lacks clarity for the duration of the certification period. The duration of the certification period of 10 weeks extends past the certification period of 6/10/22 - 8/8/22. There is no documented evidence the Plan Of Care is complete. 14) Patient # 13 has a start of care date of 9/29/2021 and DOB of 9/5/2018, with diagnosis that include Dysphagia Oropharyngeal Phase Gastrointestinal Reflux Disease without Esophagitis as documented on the " Home Health Certification and Plan Of Care for the Certification Period of 5/27/2022 to 7/26/2022. The " Home Health Certification and Plan Of Care" for the Certification Period of 5/27/22 to 7/26/22 document:" Orders for Discipline and Treatments: Speech Therapy 2 every week for 10 weeks, 1-2 times per week in home or via telehealth visits". The " Home Health Certification and Plan Of Care" for the Certification Period of 5/27/2022 to 7/26/2022 lacks documented evidence of description of the Patient's risk factors for Emergency Department visits, hospital readmission and necessary interventions to address risk factors. The " Home Health Certification and Plan Of Care" lacks clarity for the duratin of the certification period. The duration of the certification period of 10 weeks extends past the certification period of 5/27/22 - 7/26/22. There is no documented evidence the Plan Of Care is complete. 15) Patient #14 has a start of care date 4/8/2022 , and DOB of 11/14/2021, with diagnosis that include Chronic Pediatric Feeding Disorder, Retinopathy of Prematurity Stage I, Apnea of Newborn as documented on the " Home Health Certification and Plan Of Care" for the Certification Period of 6/7/2022 to 8/5/2022. The " Home Health Certification and Plan Of Care" for the Certification Period of 6/7/2022 to 8/5/2022 lacks documented evidence of description of the Patient's risk factors for Emergency Department visits, hospital readmission and necessary interventions to address risk factors. There is no documented evidence the Plan Of Care is complete. 16) Patient # 17 has a start of care date of 3/7/2017 and a discharge date of 12/10/2021 with diagnosis that include Unspecified Cerebral Palsy, Unspecified Convulsions as documented on the " Home Health Certification and Plan of Care" for the Certification Period of 10/12/2021 to 12/10/2021. The " Home Health Certification and Plan Of Care" for the Certification Period of 10/12/2021 to 12/10/2021 lacks documented evidence of description of the Patient's risk factors for Emergency Department visits, hospital readmission and necessary interventions to address risk factors. There is no documented evidence the Plan of Care is complete. On 8/15 2022 at 12:45 PM, the Assistant Vice President/ Director of Patient Services was interviewed and did not have an explanation for the above findings.. 1) Patient #2 has a start of care date of 07/28/2021 with diagnoses of Encephalopathy and Seizures as documented on the "Home Health Certification and Plan of Care" dated 07/23/2022 to 09/20/2022. The "Home Health Certification and Plan of Care" for certification period from 07/23/2022 to 09/20/2022 lacks documented evidence of description of the Patient's risk factors for Emergency Department visits, hospital readmission and necessary interventions to address risk factors. 2) Patient #4 has a start of care date of 07/08/2022 with diagnoses of Cerebral Palsy and Convulsions as documented on the "Home Health Certification and Plan of Care" dated 07/31/2022 to 09/28/2022. The "Home Health Certification and Plan of Care" for certification period from 07/31/2022 to 09/28/2022 lacks documented evidence of description of the Patient's risk factors for Emergency Department visits, hospital readmission and necessary interventions to address risk factors. 3) Patient # 6 has a start of care date of 09/14/2020 with diagnoses of Spina Bifida and Cerebral Palsy as documented on the "Home Health Certification and Plan of Care" dated 07/06/2022 to 09/03/2022. The "Home Health Certification and Plan of Care" for certification period from 07/06/2022 to 09/03/2022 lacks documented evidence of description of the Patient's risk factors for Emergency Department visits, hospital readmission and necessary interventions to address risk factors. . The survey findings were reviewed with the agency's Assistant Vice President of Home Care/Director of Patient Services (AVP/DPS) and Clinical Improvement Manager (CIM) The AVP/DPS and CIM were interviewed on 08/12/2022 at 12:30 AM and acknowledge the findings. 4) Patient # 8 has a start of care date of 12/20/2021 with diagnoses of Congenital Insufficiency of Aortic Valve and Congenital Nystagmus as documented on the "Home Health Certification and Plan of Care" dated 06/18/2022 to 08/16/20. The "Home Health Certification and Plan of Care" for certification period 06/18/2022 to 08/16/2022 documents an order for "Physical Therapy 2 visits every week for 10 weeks, 1 - 2x weekly" and Occupational Therapy (OT) 2 visits every week for 10 weeks, 1 -2x weekly". The "Home Health Certification and Plan of Care" lacks clarity for the duration of the certification period. The duration period of 10 weeks extends past the cerification period of 06/18/22 - 08/16/22. The "Home Health Certification and Plan of Care" for certification period from 0618/2022 to 08/16/2022 lacks documented evidence of description of the Patient's risk factors for Emergency Department visits, hospital readmission and necessary interventions to address risk factors. An interview was conducted with the agency's Assistant Vice President of Home Care/Director of Patient Services (AVP/DPS) and Clinical Improvement Manager (CIM) on 08/12/2022 at 03:30 PM, the AVP/DPS and CIM acknowledge the findings. 5) Patient #9 has a start of care date of 12/20/2017 with diagnoses of Down's Syndrome as documented on the "Home Health Certification and Plan of Care" dated 07/27/22bto 08/24/22. The "Home Health Certification and Plan of Care" for certification period from 07/27/22bto 08/24/22 lacks documented evidence of description of the Patient's risk factors for Emergency Department visits, hospital readmission and necessary interventions to address risk factors. An interview was conducted with the agency's Assistant Vice President of Home Care/Director of Patient Services (AVP/DPS) and Clinical Improvement Manager (CIM) on 08/15/2022 at 12:30 PM, the AVP/DPS and CIM acknowledge the findings. 6) Patient # 11 has a start of care date of 07/10/2013 with diagnoses of Cerebral Palsy, Adult Personality Disorder and Convulsions as documented on the "Home Health Certification and Plan of Care" dated 07/23/2022 to 09/20/2022. The "Home Health Certification and Plan of Care" for certification period from 07/23/2022 to 09/20/2022 lacks documented evidence of description of the Patient's risk factors for Emergency Department visits, hospital readmission and necessary interventions to address risk factors. . . . An interview was conducted with the agency's Assistant Vice President of Home Care/Director of Patient Services (AVP/DPS) and Clinical Improvement Manager (CIM) on 08/15/2022 at 12:45 PM, the AVP/DPS and CIM acknowledge the findings. 7) Patient #12 has a start of care date of 07/30/2018 with diagnoses of Hemiplegia Affecting Right Dominant Side as documented on the "Home Health Certification and Plan of Care" dated 07/09/2022 to 09/06/2022. The "Home Health Certification and Plan of Care" for certification period from 07/09/2022 to 09/06/2022 lacks documented evidence of description of the Patient's risk factors for Emergency Department visits, hospital readmission and necessary interventions to address risk factors. The survey findings were reviewed with the agency's Assistant Vice President of Home Care/Director of Patient Services (AVP/DPS) and Clinical Improvement Manager (CIM) on 08/11/2022 at 02:30 PM. The AVP/DPS and CIM were interviewed on 08/12/2022 at 03:30 PM and acknowledge the findings. 8) Patient #15 has a start of care date of 09/21/2012 with diagnoses of Autistic Disorder, Constipation and Feeding Difficulties as documented on "Home Health Certification and Plan of Care" dated 08/05/2021 to 10/03/2021. The "Home Health Certification and Plan of Care" for certification period from 08/05/2021 to 10/03/2021 documents an order for "Physical Therapy 3 visits every week for 10 weeks, 2 - 3x weekly" and "Occupational Therapy 3 visits every week for 10 weeks, 2 3x weekly". The Home Health Certification and Plan of Care lacks clarity for the duration of the certification period. The duration period of 10 weeks extends past the certification period of 08/05/21 - 10/03/21. The clinical record documents PT telehealth services provided on 08/25/21, 08/30/21, 09/01/21, 09/02/21, 09/08/21, 09/09/21, 09/16/21, 09/22/21 09/27/21 and 09/29/21. The clinical record documents OT Telehealth services provided on 09/11/21, 09/12/21, 09/13/21, 09/19/21, 09/22/21, 09/29/21, 10/02/21 and 10/03/21. The clinical record lacks documented evidence of an order for Telehealth services for the PT and OT services that were provided. The survey findings were reviewed with the agency's Assistant Vice President of Home Care/Director of Patient Services (AVP/DPS) and Clinical Improvement Manager (CIM) on 08/11/2022 at 12:30 PM. The AVP/DPS and CIM were interviewed on 08/12/2022 at 02:55 PM and acknowledge the findings.. .

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 (HV) observations, clinical record reviews and staff interviews, the Agency failed to ensure that Skilled Professional Services, medications, and treatments are provided in conformance to Physician's Orders. This was evident in seven (7) of seventeen (17) clinical records reviewed. (Patients #2, #5HV, #6, #8, #9, #12, and #17). Failure to ensure that Skilled Professional Services, medications and treatments are provided, has the potential for negative patient outcome. The findings include: 6) Patient #5 has a start of care date of 12/7/2021 , and Date of Birth ( DOB) of 8/21/2021, with diagnosis that include Pediatric feeding Disorder, Supraventricular Tachycardia, Encounter for Attention to Gastrostomy as documented on the " Home Health Certification and Plan Of Care" for the Certification Period of 8/4/22 to 10/2 22. The " Home Health Certification and Plan Of Care" for the Certification Period of 8/4/22 to 10/2 22 document:" Nursing: one within 5 days for 5 days, in the home/ telehealth, As needed ( PRN) 3 reason: any change in clinical status, medications or assessment in home/ telehealth. Perform cardiovascular care assessment, home safety, Evaluation to assess home environment to ensure adequate environment, patient care, physical assessment, medication reconciliation. Equipment orders: Pulse oximeter used for spot checks, O2 saturation alarm below 70, Heart rate upper limit 180. Report to Physician if consistently out of range". Medications: Flecainide 20 mg /ml Gastrotomy Tube ( GT) 0.3 ml every 12 hours instructions flush with 5- 10 ml of water before and after , Lansoprazole 3 mg/ ml GT 2.5 ml every 12 hours , instructions flush with 5- 10 ml of water before and after, Aspirin 81 mg GT tablet chewable 1/2 tablet daily, instructions flush with 5- 10 ml of water before and after". On 8/9/22 at 2:15 PM, during an observational home visit, during the nurse assessment of the patient, the patient started getting agitated, and the patient's mother told the nurse "When the baby cries she gets more blue, the baby suppose to see the surgeon for heart surgery" The surveyor observed that the nurse did not check the patient's Oxygen saturation, and the nurse did not review the patient's medications. There is no documented evidence of medication reconciliation by the nurse. There is no documented evidence the nursing services were provided in conformance with the Physician's orders. 7) Patient # 17 has a start of care date of 3/7/2017 and a discharge date of 12/10/2021 with diagnosis that include Unspecified Cerebral Palsy, Unspecified Convulsions as documented on the " Home Health Certification and Plan Of Care" for the Certification Period of 10/12/21 to 12/10/21. The " Home Health Certification and Plan Of Care" for the Certification Period of 10/12/21 to 12/10/21 document: " Orders for Discipline and Treatments: Occupational Therapy once every week for nine weeks - in home/ telehealth, perform bed mobility, training, cognitive treatment, sequencing exercise, categorization exercise, memory exercise, Coordination and motor planning, computation exercise". There is no documented evidence of occupational therapy services for the certification period of 10/12/21 to 12/10/21. A " missed visit report period 8/3/21 to 10/22 /21 document: 10/12 21, 10/18/21 missed visit , replacement not available physician notified, patient/ family aware, agrees to stay with agency" There is no documented evidence of the reasons for missed visits from 10/19/22 to 12/10/22. There is no documented evidence the services were provided in conformance with the Physician's orders. On 8/15/22, at 10:00AM, the Assistant Vice President/ Director of Patient Services was interviewed and did not provide an explanation for the above findings.. 1) Patient #2 has a start of care date of 07/28/2021 with diagnoses of Encephalopathy and Seizures as documented on the "Home Health Certification" dated 05/24/2022 to 07/22/2022. The "Home Health Certification" for certification period from 05/24/2022 to 07/22/2022 documents an order for "Occupational Therapy (OT) 1 every week for 9 weeks, and Social Services (SS) 1 every month". The clinical record lacks documented evidence of OT visits for the weeks of 06/19/22 - 06/25/22, 06/26/22 - 07/02/22, 07/03/22 - 07/09/22, 07/10/22 - 07/16/22, and 07/17/22 - 07/23/22. The Agency failed to provide OT services in accordance the Physician Orders. The clinical record lacks documented evidence of one Social Service (SS) visits in the month of 05/01/22 - 05/31/22 and 06/01/22 - 06/30/22. The agency failed to provide Social Service visits in accordance to the Physician Orders. 2) Patient # 6 has a start of care date of 09/14/2020 with diagnoses of Spina Bifida and Cerebral Palsy as documented on the "Home Health Certification" dated 07/06/2022 to 09/03/2022. The "Home Health Certification" certification period from 07/06/2022 to 09/03/2022 documents an order for "Physical Therapy 3 visits every week for 9 weeks 2 - 3x weekly" and "Occupational Therapy 3 visits every week for 9 weeks 2 - 3x weekly". The clinical record lacks documented evidence of PT visits 2 - 3x week for the weeks of 07/10/22 - 07/16/22 and 07/17/22 - 07/23/22. The Agency failed to provide PT services in accordance the Physician Orders. The clinical record lacks documented evidence of OT visits 2 - 3x week for the week of 07/17/22 - 07/23/22. The Agency failed to provide OT services in accordance the Physician Orders. The survey findings were reviewed with the agency's Assistant Vice President of Home Care/Director of Patient Services (AVP/DPS) and Clinical Improvement Manager (CIM) on 08/11/2022 at 02:30 PM. The AVP/DPS and CIM were interviewed on 08/12/2022 at 12:30 AM and acknowledge the findings 3) Patient # 8 has a start of care date of 12/20/2021 with diagnoses of Congenital Insufficiency of Aortic Valve and Congenital Nystagmus as documented on the "Home Health Certification" dated 06/18/2022 to 08/16/2022. The "Home Health Certification" for certification period from 06/18/2022 to 08/16/2022 documents an order for "Physical Therapy (PT) 2 visits every week for 10 weeks, 1 - 2x weekly" and "Occupational Therapy (OT) 2 visits every week for 10 weeks, 1 - 2x weekly". The clinical record lacks documented evidence of PT visits 1 - 2x week for the week of 06/26/22 - 07/02/22. The agency failed to provide PT services in accordance the Physician Orders. The clinical record lacks documented evidence of OT visits 1 - 2x a week for the week of 06/25/22 - 07/02/22. The Agency failed to provide OT services in accordance the Physician Orders. On 08/12/2022 at 03:30 PM, the Assistant Vice President of Home Care/Director of Patient Services (AVP/DPS) and Clinical Improvement Manager (CIM) were interviewed, the AVP/DPS and CIM acknowledge the findings. 4) Patient #9 has a start of care date of 12/20/2017 with diagnoses of Down's Syndrome as documented on the "Home Health Certification" dated 07/27/22 to 08/24/22. The "Home Health Certification" for certification period from 07/27/22 to 08/24/22 document an order for "Physical Therapy 2 visits every week for 9 weeks, 1 - 2x weekly". The clinical record lacks documented evidence of PT visits 1 - 2x week for the week of 07/03/22 - 07/09/22. The agency failed to provide PT services in accordance the Physician Orders. On 08/15/22 at 12:30 PM, the Assistant Vice President of Home Care/Director of Patient Services (AVP/DPS) and Clinical Improvement Manager (CIM) were interviewed, and did not provide an explanantion. 5) Patient #12 has a start of care date of 07/30/2018 with diagnoses of Hemiplegia Affecting Right Dominant Side as documented on the "Home Health Certification" dated 05/10/2022 to 07/08/2022. The "Home Health Certification" for certification period from 05/10/2022 to 07/08/2022 documents an order for "Speech Therapy (ST) 3 visits every week for 9 weeks ,2 -3 x week, Occupational Therapy (OT) 3 visits every week for 9 weeks 2 - 3x weekly, and Physical Therapy (PT) 3 visits every week for 9 weeks 2 - 3x weekly". The clinical record lacks documented evidence of ST visits 2 - 3x week for the week of 05/29/22 - 06/04/22. The agency failed to provide ST services in accordance the Physician Orders. The clinical record lacks documented evidence of OT visits 2 - 3x week for the week of 05/29/22 - 06/04/22. The agency failed to provide OT services in accordance the Physician Orders. The clinical record lacks documented evidence of PT visits 2 - 3 x week for the week of 05/29/22 - 06/04/22. The agency failed to provide PT services 2 - 3x a week in accordance the Physician Orders. The survey findings were reviewed with the agency's Assistant Vice President of Home Care/Director of Patient Services (AVP/DPS) and Clinical Improvement Manager (CIM) on 08/11/2022 at 02:30 PM. The AVP/DPS and CIM were interviewed on 08/12/2022 at 03:30 PM and acknowledge the findings..

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, the Agency failed to ensure promptly alert the Physician of changes in the delivery of patient services. This was evident in six (6) of seventeen records reviewed. (Patients #2, #5, #6, #9, #15 and #17). Failure to promptly alert the physician of changes in patient care services, has the potential for negative patient outcome. The findings include: 5) Patient #5 has a start of care date of 7/21/21 and a Date of Birth of 5/17/2021, with diagnosis of Acute respiratory failure with Hypoxia, Bradycardia, Cngenital Pulmonary valve Stenosis, Failure to Thrive as documented on the " Home Health Certification and Plan Of Care " for the Certification Period of 7/16/22 to 9/13/22. The "Home Health Certification and Plan Of Care for the Certification for the Certification Period of 7/16/22 to 9/13/22 document: " Orders for discipline and Treatments: Nursing once every other week for 10 weeks, in home/ telehealth, as needed three, reason any changes in clinical status/ medications and assessment in home/ telehealth. Medications: Aspirin low dose 81 mg Gastrotomy Tube (GT) tablet delayed release 0.5 mg tablet daily, mixed in 5 ml of water, Acetaminophen 160 mg/ 5 ml G Tube 1.4 ml as needed every 4-6 hours for pain or irritability, Clonazepam 0.25 mg GT tablet disintegrating one tablet as needed, instructions take one tablet once as needed for seizures> 3 minutes for up to 1 dose. maximum daily amount 0.25 mg. Call 911 or go to the nearest emergency room if seizures do not resolve after giving medication. Purpose: Anti Seizure, Famotidine 40 mg/ 5ml G tube suspension 0.44 ml daily, Levetiracetam 100 mg/ ml G tube 3.2 ml every 12 hours". On 8/8/2022 at 2:15 PM, during an observational home visit, the surveyor observed that Aspirin and Famotidine were among the Patient's medications in the home and on the Plan Of Care. During an interview with the patient's mother, the patient's mother stated she has not been giving the Aspirin and Famotidine. The last documented nursing visits were 6/27/2022, 7/11/22. There is no documented of communication with the Physician regarding the use of Aspirin and famotidine to alert the Physician of changes in the Plan Of Care, so that the Plan Of Care can be reviewed and revised. 6) Patient # 17 has a start of care date of 3/7/2017 and a discharge date of 12/10/2021 with diagnosis that include Unspecified Cerebral Palsy, Unspecified Convulsions as documented on the " Home Health Certification and Plan Of Care" for the Certification Period of 10/12/21 to 12/10/21. The " Home Health Certification and Plan Of Care" for the Certification Period of 10/12/21 to 12/10/21 document: " Orders for Discipline and Treatments: Occupational Therapy once every week for nine weeks - in home/ telehealth, perform bed mobility, training, cognitive treatment, sequencing exercise, categorization exercise, memory exercise, Coordination and motor planning, computation exercise". A review of the record indicated there were no occupational therapy services for the certification period of 10/12/21 to 12/10/21. A " missed visit report period 8/3/21 to 10/22 /21 document: 10/12 21, 10/18/21 missed visit , replacement not available physician notified, patient/ family aware, agrees to stay with agency" There is no documented evidence of the reasons for missed visits from 10/19/22 to 12/10/22. There is no documented evidence of communication with the Physician regarding the missed visits. On 8/15/22, at 10:00AM, the Assistant Vice President/ Director of Patient Services was interviewed and did not provide explanation for the above findings.. 1) Patient #2 has a start of care date of 07/28/2021 with diagnoses of Encephalopathy and Seizures as documented on the "Home Health Certification" dated 07/23/2022 to 09/20/2022. The "Home Health Certification" for certification period from 07/23/2022 to 09/20/2022 documents an order for "Occupational Therapy services 1 every week for 10 weeks, and Social Services 1 every month for two months". The "missed visits" reports documents Occupational Therapy (OT) missed visits on 06/20/22, 06/27/22. The clinical record lacks documented evidence of OT 1 visit a week provided from 06/19/22 - 06/25/22, 06/26/22 - 07/02/22, 07/03/22 - 07/0922, 07/10/22 - 07/16/22 and 07/17/22 - 07/23/22. The Physician was notified on 08/09/2022 during survey. The "missed visits" report documents that no Social Services provided in the month of 05/01/22 - 05/31/22 and 06/01/22 - 06/30/22. The Physician was notified on 08/09/2022 during survey. The clinical record lacks documented evidence that the agency promptly notified the Physician of missed OT and SS services that suggest that outcomes are not being achieved and/or that the Plan of Care should be altered. The survey findings were reviewed with the agency's Assistant Vice President of Home Care/Director of Patient Services (AVP/DPS) and Clinical Improvement Manager (CIM) on 08/10/2022 at 02:30 PM. The AVP/DPS and CIM were interviewed on 08/11/2022 at 10:30 AM and acknowledge the findings. 2) Patient # 6 has a start of care date of 09/14/2020 with diagnoses of Spina Bifida and Cerebral Palsy as documented on the "Home Health Certification" dated 07/06/2022 to 09/03/2022. The "Home Health Certification" certification period from 07/06/2022 to 09/03/2022 documents an order for "Physical Therapy 3 visits every week for 9 weeks 2 - 3x weekly" and "Occupational Therapy 3 visits every week for 9 weeks 2 - 3x weekly". The "missed visits" reports documents Physical Therapy (PT) missed visits on 07/13/22, 07/19/22, 07/20/22 and 07/21/22. The clinical record lacks documented evidence of PT visits 2 -3 x week for the weeks of 07/10/22 - 07/16/22 and 07/17/22 - 07/23/22. The Physician was notified on 08/09/2022 during survey. The "missed visits" reports documents Occupational Therapy (OT) missed visits on 07/19/22 and 07/21/22. The clinical record lacks documented evidence of OT services 2 -3 x a week for the week of 07/17/22 - 07/23/22. The Physician was notified on 08/09/2022 during survey. The clinical record lacks documented evidence that the agency promptly notified the Physician of missed PT and OT services that suggest that outcomes are not being achieved and/or that the Plan of Care should be altered. The survey findings were reviewed with the agency's Assistant Vice President of Home Care/Director of Patient Services (AVP/DPS) and Clinical Improvement Manager (CIM) on 08/11/2022 at 02:30 PM. The AVP/DPS and CIM were interviewed on 08/12/2022 at 12:30 AM and acknowledge the findings 3) Patient #9 has a start of care date of 12/20/2017 with diagnoses of Down's Syndrome as documented on the "Home Health Certification" dated 07/27/22 to 08/24/22. The "Home Health Certification" for certification period from 07/27/22bto 08/24/22 document an order for "Physical Therapy 2 visits every week for 9 weeks, 1 - 2x weekly". The "missed visits" reports documents Physical Therapy (PT) missed visits on 07/05/22, 07/06/22 and 07/07/22. The clinical record lacks documented evidence of PT visits 1 - 2x week for the week of 07/03/22 - 07/09/22. The Physician was notified on 08/09/2022 during survey. The clinical record lacks documented evidence that the agency promptly notified the Physician of missed PT services that suggest that outcomes are not being achieved and/or that the Plan of Care should be altered. The survey findings were reviewed with the agency's Assistant Vice President of Home Care/Director of Patient Services (AVP/DPS) and Clinical Improvement Manager (CIM) on 08/15/2022 at 12:30 PM, the AVP/DPS and CIM acknowledge the findings. 4) Patient #15 has a start of care date of 09/21/2012 with diagnoses of Autistic Disorder, Constipation and Feeding Difficulties as documented on "Home Health Certification" dated 08/05/2021 to 10/03/2021. The "Home Health Certification" for certification period from 08/05/2021 to 10/03/2021 documents an order for "Physical Therapy 3 visits every week for 10 weeks, 2 - 3x weekly" and "Occupational Therapy 3 visits every week for 10 weeks, 2 - 3x weekly". The "missed visits" reports documents no Physical Therapy (PT) services was provided on 08/09/21, 08/10/21, and 08/11/21. The clinical record lacks documented evidence of PT visits 2 - 3 x week from 08/08/21 - 8/14/21. The Physician was notified on 12/14/21. The "missed visits" reports documents Occupational Therapist (OT) missed visits on 08/05/21, 08/07/21, 08/08/21, 08/09/21, 08/10/21, 08/11/21, 08/14/21, 08/15/21 and 08/17/21. The clinical record lacks documented evidence ot OT visits 2 - 3x week for the weeks of 08/05/21 - 08/08/21, 08/08/21 - 08/14/21, 08/15/21 - 08/21/21. The Physician was notified on 12/14/21. The clinical record lacks documented evidence that the agency promptly notified the Physician of missed PT and OT services that suggest that outcomes are not being achieved and/or that the Plan of Care should be altered. The survey findings were reviewed with the agency's Assistant Vice President of Home Care/Director of Patient Services (AVP/DPS) and Clinical Improvement Manager (CIM) on 08/11/2022 at 12:30 PM. The AVP was interviewed on 08/15/2022 at 02:55 PM and acknowledge the findings..

Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient's discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner's issuing orders for the HHA plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any). This ELEMENT is not met as evidenced by: Based on record reviews and staff interviews, the Agency failed to communicate to the patient , caregiver and to the Physician any revisions related to plans for the patient's discharge and who will be responsible for providing services to the Patient after discharge from the agency. This was evident in one (1) of three (3) discharge records reviewed. ( Patient # 17). Failure to consult all persons involved in the Plan Of Care and ensure a safe discharge has the potential for negative patient outcomes. any related plans for discharge have the potential for negative Patient outcomes. Patient # 17 has a start of care date of 3/7/2017 and a discharge date of 12/10/21. On 8/12/2022 at 3:45 PM , a request was made for the documentation of the discharge summary sent to the Physician. On 8/15/22, a document titled" Non Visit documentation Discharge OASIS " dated 1/4/2022 was provided. A document titled: Discharge Summary Report titled :"Discharge Summary Report" dated 1/4/2022 The document record the following: " Summary Notes" Patient > 30 days without service. Discharge from CHHA. TCT MD to inform of above". There is no documented evidence the Physician was informed of the Patient's discharge. On 8/15/2022 at 10:00AM, the Administrator was interviewed and did not have an explanation for the above findings.