Every finding on record at Gamzel Ny, Inc

This Statement of Deficiencies is a result of an on-site investigation of complaint 114948 conducted at Revival Home Health Care, located at 75 Vanderbilt Avenue, 3rd Floor, Staten Island, NY 10304 on 05/29/2025 to evaluate the agency's compliance with Federal regulations. The active patient census is 1606. The investigation consisted of a review of three (3) clinical records (identified as Patient #1, #2, and #3), and a review of three (3) personnel records (identified as Employee #1, #2, and #3) the agency's complaint log, and interviews with the Administrator, and the Director of Quality and Compliance. Pre-survey activities consisted of review on 05/27/2025 of the agency's Health Commerce System account and compliance history. Findings were reviewed at the exit conference. The allegation in complaint #114948 was determined substantiated. The following deficiencies are being cited as result of the survey: G0478 – Investigate complaints made by patient G0574 – Plan of care must include the following G0580 – Only as ordered by a physician G0590 – Promptly alert relevant physician of changes

Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) The HHA must— (i) Investigate complaints made by a patient, the patient's representative (if any), and the patient's caregivers and family, including, but not limited to, the following topics: (A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; (B) Mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on clinical record review, and staff interviews, the agency failed to investigate all complaints made by a patient. This was evident for one (1) of three (3) clinical records reviewed (Patient #1). Failure to ensure all complaints are investigated, has the potential risk for negative patient outcomes. The Findings Are: 1. Patient #1 has a Start of Care date of 03/20/2025 with diagnoses: Disruption of External Operation (Surgical) Wound, Malignant Neoplasm Colon, Anemia in Neoplastic Disease, Encounter for Attention to Colostomy documented in the Home Health Certification and Plan of Care for the Certification Period 03/20/2025 to 05/18/2025. The Home Health Certification and Plan of Care for the Certification Period 03/20/2025 to 05/18/2025 documents an order for "SN (Skilled Nursing) 1WK2 (one visits a week for two weeks), 2WK1 (two visit a week for one week), 1WK5 (one visits a week for five weeks).” The Clinical Coordination Note dated 04/04/25 documents: “PT (patient) reports not wanting anymore nursing visits because she feels it did not help her at all and the only things she needs right now are PT (Physical Therapy), Wound Specialist, and additional supplies.” The clinical record lacks documented evidence of a complaint investigation addressing the patient's unsatisfaction with Skilled Nurse services. On 05/27/2025 at 3:45 PM, the Administrator, and the Director of Quality and Compliance were interviewed and did not provide an explanation for the findings.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record review, and staff interviews, the agency failed to establish an individualized plan of care that includes all the required information. This was evident for one (1) of three (3) clinical records reviewed (Patient #1). Failure to ensure individualized plan of care includes all the required information, has the potential risk for negative patient outcomes. The Findings Are: 1. Patient #1 has a Start of Care date of 03/20/2025 with diagnoses Disruption of External Operation (Surgical) Wound, Malignant Neoplasm Colon, Anemia in Neoplastic Disease, Encounter for Attention to Colostomy documented in the Home Health Certification and Plan of Care for the Certification Period 03/20/2025 to 05/18/2025. The Home Health Certification and Plan of Care for the Certification Period 03/20/2025 to 05/18/2025 documents an order for "SN (Skilled Nursing) 1WK2 (one visits a week for two weeks), 2WK1 (two visit a week for one week), 1WK5 (one visits a week for five weeks).” The Complaint Investigation dated 04/03/25 documents: “The patient reported that she had not received any ostomy supplies and had assumed that the visiting nurse would bring them.” The Physician Order dated 04/03/25 documents: “Ostomy supplies, Coloplast Brand: REF #120700 HCPCS AA4362 – 20/box-order: 1 Box, REF #120115 HCPCS A4456 – 30/Box – order: 1 Box, REF #16716 HCPCS A5057 10/box -order: 2 Boxes.” The clinical record lacks documented evidence of the Registered Nurse assessing the patient’s need for ostomy supplies from 03/20/25- 04/03/2025. The Home Health Certification and Plan of Care lacks documented evidence of a physician order for ostomy supplies from 03/20/25- 04/03/202, and a physician order for ostomy care/treatment. The Clinical Coordination Note dated 04/29/25 documents: “Addendum to SOC (Start of Care) visit note from 03/20/25: Observed patient’s abdominal incision to be nearly closed w(with)/no drainage or signs/symptoms of infection. RN (Registered Nurse) cleansed w(with)/normal saline and covered with dry dressing.” The Clinical Coordination Note dated 04/29/25 documents: “Addendum to SOC (Start of Care) visit note from 03/25/25: wound care was provided to the patient’s abdominal incision cite. The site was cleansed with normal saline, patted dry, and covered with a dry sterile dressing.” The Clinical Coordination Note dated 04/29/25 documents: “Addendum to SOC (Start of Care) visit note from 04/02/25: Performed wound care to the patient’s abdominal incision site. Area was gently cleaned with normal saline and dried. A clean, dry dressing was applied, the incision appeared to be healing appropriately, with no signs of infection, drainage, or dehiscence observed.” The Home Health Certification and Plan of Care lacks documented evidence of the physician order for abdominal incision site treatment. There is no documented evidence that the agency established an individualized plan of care. On 05/27/2025 at 3:45 PM, the Administrator, and the Director of Quality and Compliance were interviewed and did not have an explanation for the findings.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interviews, the agency failed to ensure that all treatments are administered in accordance with physician orders. This was evident for one (1) of three (3) clinical records reviewed (Patient #1). Failure to ensure that all treatments are administered in accordance with physician orders, has the potential for negative patient outcomes. The Findings Are: 1. Patient #1 has a Start of Care date of 03/20/2025 with diagnoses: Disruption of External Operation (Surgical) Wound, Malignant Neoplasm Colon, Anemia in Neoplastic Disease, Encounter for Attention to Colostomy documented in the Home Health Certification and Plan of Care for the Certification Period 03/20/2025 to 05/18/2025. The Home Health Certification and Plan of Care for the Certification Period 03/20/2025 to 05/18/2025 documents an order for "SN (Skilled Nursing) 1WK2 (one visits a week for two weeks), 2WK1 (two visit a week for one week), 1WK5 (one visits a week for five weeks).” The Clinical Coordination Note dated 04/29/25 documents: “Addendum to SOC (Start of Care) visit note from 03/20/25: The ostomy site was noted to be red and irritated. Patient reported difficulty with the appliance, stating it would not stay in place and that she was unable to control her bowel movements. She stated that stool was coming out continuously in a liquid form, causing the appliance to leak. RN cleanse the area with Normal Saline and applied Ostomy Powder. RN contacted Case Manager (name) during the visit and discussed the ongoing Ostomy Issues. Clinical Manager recommended trial of a different ostomy appliance to improve adherence and reduce leakage.” The Clinical Coordination Note dated 04/29/25 documents: “Addendum to SOC (Start of Care) visit note from 03/25/25: Ostomy Site was assessed. Peristomal skin appeared red and mildly irritated. Patient reported frequent leakage due to loose stools and difficulty keeping the appliance in place. The area was cleaned with Normal Saline and Ostomy Powder applied. A new ostomy bag was applied, and the patient tolerated the change well. Appliance maintained good adherence with no immediate leakage noted.” The Clinical Coordination Note dated 04/29/25 documents: “Addendum to SOC (Start of Care) visit note from 04/02/25: Ostomy site evaluated surrounding skin was noted to be reddened and slightly irritated. Patient expressed concern over continuous leakage due to loose stool and poor appliance adherence. The stoma area was cleaned with normal saline ostomy powder applied, and a new ostomy appliance was fitted patient tolerated the procedure without discomfort. Seal was secured at time of visit with no leakage noted.” The Home Health Certification and Plan of Care lacks documented evidence of a physician order for ostomy care/treatment. The Clinical Coordination Note dated 04/29/25 documents: “Addendum to SOC (Start of Care) visit note from 03/20/25: Observed patient’s abdominal incision to be nearly closed w(with)/no drainage or signs/symptoms of infection. RN (Registered Nurse) cleansed w(with)/normal saline and covered with dry dressing.” The Clinical Coordination Note dated 04/29/25 documents: “Addendum to SOC (Start of Care) visit note from 03/25/25: wound care was provided to the patient’s abdominal incision cite. The site was cleansed with normal saline, patted dry, and covered with a dry sterile dressing.” The Clinical Coordination Note dated 04/29/25 documents: “Addendum to SOC (Start of Care) visit note from 04/02/25: Performed wound care to the patient’s abdominal incision site. Area was gently cleaned with normal saline and dried. A clean, dry dressing was applied, The incision appeared to be healing appropriately, with no signs of infection, drainage, or dehiscence observed.” The Home Health Certification and Plan of Care lacks documented evidence of an order for abdominal incision site treatment. There is no documented evidence of the treatments being administered in accordance with physician orders. On 05/27/2025 at 3:45 PM, the Administrator, and the Director of Quality and Compliance were interviewed and did not have an explanation for the findings.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on clinical record review, and staff interviews, the agency failed to ensure that the physician is promptly alerted to any changes in the patient's condition or needs. This was evident for one (1) of three (3) clinical records reviewed (Patient #1). Failure to ensure the physician are promptly alerted to any changes in the patient's condition or needs, has the potential for negative patient outcomes. The Findings Are: 1. Patient #1 has a Start of Care date of 03/20/2025 with diagnoses: Disruption of External Operation (Surgical) Wound, Malignant Neoplasm Colon, Anemia in Neoplastic Disease, Encounter for Attention to Colostomy documented in the Home Health Certification and Plan of Care for the Certification Period 03/20/2025 to 05/18/2025. The Home Health Certification and Plan of Care for the Certification Period 03/20/2025 to 05/18/2025 documents an order for "SN (Skilled Nursing) 1WK2 (one visits a week for two weeks), 2WK1 (two visit a week for one week), 1WK5 (one visits a week for five weeks).” The Clinical Coordination Note dated 04/29/25 documents: “Addendum to SOC (Start of Care) visit note from 03/20/25: The ostomy site was noted to be red and irritated. Patient reported difficulty with the appliance, stating it would not stay in place and that she was unable to control her bowel movements. She stated that stool was coming out continuously in a liquid form, causing the appliance to leak. RN cleanse the area with Normal Saline and applied Ostomy Powder. RN contacted Case Manager (name) during the visit and discussed the ongoing Ostomy Issues. Clinical Manager recommended trial of a different ostomy appliance to improve adherence and reduce leakage.” The Clinical Coordination Note dated 04/29/25 documents: “Addendum to SOC (Start of Care) visit note from 03/25/25: Ostomy Site was assessed. Peristomal skin appeared red and mildly irritated. Patient reported frequent leakage due to loose stools and difficulty keeping the appliance in place. The area was cleaned with Normal Saline and Ostomy Powder applied. A new ostomy bag was applied, and the patient tolerated the change well. Appliance maintained good adherence with no immediate leakage noted.” The Clinical Coordination Note dated 04/29/25 documents: “Addendum to SOC (Start of Care) visit note from 04/02/25: Ostomy site evaluated surrounding skin was noted to be reddened and slightly irritated. Patient expressed concern over continuous leakage due to loose stool and poor appliance adherence. The stoma area was cleaned with normal saline ostomy powder applied, and a new ostomy appliance was fitted patient tolerated the procedure without discomfort. Seal was secured at time of visit with no leakage noted.” There is no documented evidence of the physician being promptly notified of the changes in the ostomy assessment and the need to alter the plan of care to reflect the current status of the patient. On 05/27/2025 at 3:45 PM, the Administrator, and the Director of Quality and Compliance were interviewed and did not provide an explanation for the findings.

This statement of deficiencies is a result of an on-site investigation of complaint #112083 conducted at Revival Home Health Care located at 75 Vanderbilt Ave, 3rd Floor, Staten Island, NY 10304 on 01/09/2025. Pre-survey activities consisted of a review on 01/08/2025 of the agency's Health Commerce System account and compliance history. The active patient census is 1461. The investigation consisted of a review of three (3) clinical records (identified as Patients #1, #2, and #3), two personnel records, and interviews with the Administrator, the Vice President of Clinical Operations, and the Director of Quality Management. The allegations in complaint #112083 were determined substantiated. The following deficiencies are identified as a result of the survey: G0608 – Coordinate Care Delivery G0610 – Patients Receive Education and Training

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on record reviews, and staff interview the agency failed to ensure coordination and involvement of the patient and the patient representative/caregiver in the changes in the plan of care for home health aide services. This was evident for one (1) of three (3) clinical records reviewed (Patients #2). Failure to ensure that all clinicians involve the patient in the coordination and delivery of care has the potential for negative patient outcome. The findings are: Patient #2 has a Start of Care date of 10/31/2024 with the diagnoses Pressure Ulcer Right Buttock Stage 2, Muscle Wasting and Atrophy, Primary Generalized Osteoarthritis documented in the Home Health Certification and Plan of Care for the Certification Period 12/30/2024 to 02/27/2025. The Home Health Certification and Plan of Care for the Certification Period 10/31/2024 to 12/29/2024 documents the following orders for home health aide services: “1 Day x 4 Hours x 1 Week (one visit a week for four hours a visit for one week), 4 Days x 4 Hours x 1 Week (four visits a week for four hours a visit for one week), 3 Days x 4 Hours x 3 Weeks (three visits a week for four hours a visit for three weeks).” The following Physician Orders document multiple changes and updates to home health aide services and visit frequency: 11/12/2024 – “Administrative order for MD (Medical Doctor) notification auth (health insurance authorization) approved for (home health aide) 23 visits @ 4 hours each;” “(home health aide) Effective week of 11/10/2024 4WK1 (four visits for week), (then) 7WK1 (seven visits a week for one week), (then) 6WK1 (six visits a week for one week), (then) 1WK1 (one visit a week for one week) @ 4 hours each visit.” 12/05/2024 – “Additional (home health aide) visit are pending auth. (authorization) eff. (effective) week of 12/1/24 2 days x 4 hours x 1 week, then 5 days x 4 hours x 1 week, then 4 days x 4 hours x 1 week.” 12/15/2024 – “Order to notify MD (Medical Doctor) of update to patients POC (plan of care) missed (home health aide) visit (on) 12/7, 12/9, and 12/16 to make up 12/20-12/23 Friday, Saturday and Monday;” “(home health aide) effective 12/15/2024 5WK1 (five visits a week for one week), (then) 1WK1 (one visit a week for one week).” 12/19/2024 - “(home health aide) Effective week of 12/22/2024 4WK1 (four visits a week for one week) @ 4 hours each visit.” The MSW (Master of Social Work) Evaluation visit note dated 12/06/2024 documents: “Pt (Patient) and caregiver report they have been notified by (health insurance) that aide services has been approved. Aide service will resume on Monday 12/9. Pt (Patient) and caregiver unsure as to the frequency or duration of aide services. Caregiver reports (caregiver) was told aide services will end either 12/19 or Jan. 2025. Pt (Patient) needs ongoing aide services as caregiver burnout is possible.” The clinical record lacks documented evidence of the patient and/or the patient representative/caregiver being notified of the changes in home health aide services and the visit frequencies/schedule during the Certification Period 10/31/2024 to 12/29/2024. On 01/09/2025 at 3:35 PM, the Administrator, Vice President of Clinical Operations/ Director of Patient Services, and the Director of Quality Management were interviewed, and did not provide an explanation for the findings.

Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on review records and staff interview, the agency failed to ensure the Physical Therapist provides patients with appropriate education regarding discharge planning, rehab potential and goals for the services identified in the plan of care for the patient. This was evident for one (1) of three (3) clinical records reviewed (Patients #2). Failure to provide appropriate education has the potential to result in the patient receiving inadequate care and could result in a negative patient outcome. The findings are: Patient #2 has a Start of Care date of 10/31/2024 with the diagnoses Pressure Ulcer Right Buttock Stage 2, Muscle Wasting and Atrophy, Primary Generalized Osteoarthritis documented in the Home Health Certification and Plan of Care for the Certification Period 12/30/2024 to 02/27/2025. The Registered Nurse Start of Care Assessment visit note dated 10/31/2024 documents: the patient has “significant memory loss;” is “chairfast – ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair;” and a referral made for “PT (Physical Therapy).” The Home Health Certification and Plan of Care for the Certification Period 10/31/2024 to 12/29/2024 documents orders for Physical Therapist evaluation. The Physical Therapy Evaluation dated 11/01/2024 documents the patient’s family/caregiver was present and is involved in the patient’s care. The Physical Therapy Evaluation documents: Physical Therapy to “continue for fall prevention, therapeutic exercise, HEP (Home Exercise Program) instruction, transfer training, gait training, and patient/caregiver education.” The Physician Order dated 11/01/2024 documents an order for the continuation of Physical Therapy “1WK4 (one visit a week for four weeks).” The Physical Therapy visit notes dated 11/13/2024 and 11/20/2024 document the patient “refused to walk” and that gait goal was revised. The Physical Therapy visit note dated 11/20/2024 documents the following therapy plan for the next visit treatment (on 11/25/2024): “HEP (Home Exercise Program), ROM (Range of Motion), strengthening exercise, transfer training.” The Physical Therapy Discharge of Services visit note dated 11/25/2024 documents: Functional “deficits identified - No further rehab potential” for transfer ability and ambulation; “Patient functioning at max level of potential;” and revised goals for transfer and gait were met. The Client Coordination Note Report dated 11/25/2024 documents the following communication to the patient’s allowed practitioner: "Discipline D/C (discharge) 11/25/24;" “Patient has met the goals. Patient functioning at max level of potential.” The MSW (Master of Social Work) Evaluation visit note dated 12/06/2024 documents: “Pt (Patient) and caregiver request more PT (Physical Therapy) services” to help patient “move more and prevent sores(bedsores) from worsening.” The Physical Therapy visit notes dated 11/20/2024 and 11/25/2024 lack documented evidence of the physical therapist provding ongoing education to the patient and the patient’s representative/caregiver regarding the patient’s rehab potential, goals, and discharge planning for physical therapy services. On 01/09/2025 at 3:35 PM, the Administrator, Vice President of Clinical Operations/ Director of Patient Services, and the Director of Quality Management were interviewed, and did not provide an explanation for the findings.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on clinical records review and staff interview the agency failed to ensure that each patient receive the services that are written in an individualized plan of care. This was evident for two (2) of three (3) patient care records reviewed (Patient’s #1 and #2). Failure to ensure that each patient must receive the services that are written in an individualized plan of care, has the potential for negative patient outcomes. The findings are: 1. Patient #1 has a Start of Care date of 07/22/2024 with the following diagnoses "Pressure Ulcer of Sacral Region, Stage 2; Pressure Ulcer of Right Buttock, Stage 2" documented in the Home Health Certification and Plan of Care for Certification Period 07/22/2024 to 09/19/2024. The Physician Order dated 08/09/2024 documents: “Order Description: MD (medical doctor) notification of updated POC (plan of care) regarding home health aide service for assistance with personal care and ADL’s (activity of daily living) secondary to functional limitations, which prevent self-care. 3daysx4hoursx 2 weeks (three days times four hours for two weeks).” “Calendar Frequency: hha (home health aide) effective 08/11/2024 3WK2 (three times a week for two weeks).” The clinical record lacks documented evidence of the aide providing services for the week of 08/11/2024 to 08/17/2024, missing three visits. There is no documented evidence of the patient receiving aide services as ordered. On 09/17/2024 at 3:30pm, the Director of Patient Services and the Director of Quality Measures were interviewed and did not provide an explanation for the findings. 2. Patient #2 has a Start of Care date of 04/15/2024 with the following diagnoses "Pressure Ulcer of Sacral Region, Stage 4; Pressure Ulcer of Right Hip, Stage 3" documented in the Home Health Certification and Plan of Care for the certification period 06/14/2024 to 08/12/2024. The Physician Order dated 07/29/2024 documents: hha (home health aide) effective 07/28/2024 5WK2, 1WK1 (five times a week for two weeks, once a week for one week). The Duty Sheet documents aide services being provided on 08/05/2024 and 08/07/2024 The clinical record lacks documented evidence of the aide providing services for the week of 08/04/2024 to 08/10/2024, missing two visits. There is no documented evidence of the patient receiving aide services as ordered. On 09/18/2024 at 1:30pm, The Administrator, the Director of Patient Services and the Director of Quality Measures were interviewed and did not provide an explanation for the findings.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on clinical records review and staff interview the agency failed to ensure a supervisory assessment of the aide services being provided no less frequently than every 14 days. This was evident for two (2) of three (3) patient care records reviewed (Patient’s #1 and #2). Failure to ensure a supervisory assessment of the aide services being provided no less frequently than every 14 days, has the potential for negative patient outcomes. The findings are: 1. Patient #1 has a Start of Care date of 07/22/2024 with the following diagnoses "Pressure Ulcer of Sacral Region, Stage 2; Pressure Ulcer of Right Buttock, Stage 2" documented in the Home Health Certification and Plan of Care for Certification Period 07/22/2024 to 09/19/2024. The Home Health Certification and Plan of Care for the certification period 07/22/2024 to 09/19/2024 documents: “hha (home health aide) effective week of 07/28/2024 3 days x 4 hours x 2 weeks.” The Order dated 08/09/2024 documents: “Order Description: MD (medical doctor) notification of updated POC (plan of care) regarding home health aide service for assistance with personal care and ADL’s (activity of daily living) secondary to functional limitations, which prevent self-care. 3daysx4hoursx 2 weeks. Calendar Frequency: hha (home health aide) effective 08/11/2024 3WK2 (three times a week for two weeks). The Duty Sheet documents aide services being provided on: 07/29/2024, 07/31/2024, 08/02/2024, 08/05/2024, 08/07/2024, and 08/09/2024. The clinical records documents aide supervision on 08/21/2024. The clinical record lacks documented evidence of aide supervision every 14 days. On 09/17/2024 at 3:30pm, the Director of Patient Services and the Director of Quality Measures were interviewed and did not provide an explanation for the findings. 2. Patient #2 has a Start of Care date of 04/15/2024 with the following diagnoses "Pressure Ulcer of Sacral Region, Stage 4; Pressure Ulcer of Right Hip, Stage 3" documented in the Home Health Certification and Plan of Care for the Certification Period 06/14/2024 to 08/12/2024. The Physician Order documents: 07/05/2024 hha (home health aide) effective 07/07/2024 3WK5 (three times a week for five weeks) and 07/29/2024 hha (home health aide) effective 07/28/2024 5WK2, 1WK1 (five times a week for two weeks, once a week for one week). The Duty Sheet documents aide services being provided on: 07/09/2024, 07/11/2024, 07/12/2024, 07/19/2024, 07/22/2024, 07/24/2024, 07/30/2024, 07/31/2024, 08/01/2024, 08/02/2024, 08/05/2024, 08/07/2024, 08/09/204, and 08/12/2024 to 08/16/2024. The clinical record documents aide supervision conducted on 07/10/2024. The clinical record lacks documented evidence of an aide supervision every 14 days. On 09/18/2024 at 1:30pm, The Administrator, the Director of Patient Services and the Director of Quality Measures were interviewed and did not provide an explanation for the findings.

The following statement of deficiencies represents the results of a partial extended re-certification survey and included complaints investigation #70646, #61112, #59514 at Revival Home Health Care located at 5350 Kings Highway, Brooklyn, NY 11203 conducted on 09/22/2023 through 09/29/2023. The active patient census is 1573. A standard re-certification survey was initiated on 09/22/2023. Deficient practices were identified within Level 1 standards in 484.55 Comprehensive Assessment, and 484.60 Care Planning Coordination of Services and Quality of Care resulting in a partial extended survey. The survey consisted of a review of ten (10) personnel records identified as Employee #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10, eighteen (18) clinical records identified as Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, and #18, and seven (7) home visits. The survey included a review of pertinent policies and procedures, Quality Improvement Meeting Minutes for past 12 months, PIP (Performance Improvement Projects), Admission Packet, Emergency Preparedness Plan, Complaint Log, Three (3) contracts, and the agency's Infection Control and Flu policy and procedure. Pre-survey activities consisted of a review on 09/15/2023 of the agency's Health Commerce System account, Certification and Surveyor Provider Enhanced Reports (CASPER) for the period 07/2022 – 06/2023, and the agency compliance with report submissions for the 2021 statistical report and the Emergency Drill for 2019. The allegations in complaint # 70646 were determined to be unsubstantiated. The allegations in complaint # 61112 were determined to be unsubstantiated. The allegations in complaint # 59514 were determined to be substantiated. The Administrator, and staff were interviewed. Findings were reviewed at the exit conference on 09/29/2023. The following deficiencies are identified as a result of the survey: G0484 – Documented complaint and resolution G0536 – A review of all current medications G0544 – Update of the comprehensive assessment G0574 – Plan of care must include the following G0612 – Written instructions to patient include: G0710 – Provide services in plan of care G0718 – Communication with physicians

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on clinical record reviews and staff interviews, the agency failed to investigate, and document the resolution, of the complaints. This was evident for one (1) of eighteen (18) clinical records reviewed (Patient #6). Failure to ensure that all complaints will have an investigation, has the potential for negative patient outcomes. The Findings Are: 1. Patient #6 has a Start of Care date of 9/3/2021 with diagnoses” Malignant Neoplasm of Pancreatic Duct, Secondary Malignant Neoplasm of Liver and Intrahepatic Bile Duct, Secondary Malignant Neoplasm of Other Specified Sites, Bilateral Primary Osteoarthritis of Knee" documented in the Home Health Certification and Plan of Care for Certification Period 9/3/2021 to 11/1/2021. The agency’s policy “pandemic Infection Disease COVID-19 Effective :5/6/20 Updated : 11/24/20: documents: “Staff Education: With all patients, field staff will be educated to: Perform Hand hygiene frequently, washing hands for 20 seconds with soap and water at the beginning of each visit and at the end of each visit. Hand hygiene with hand sanitizer will be employed before donning protective equipment, including gloves and masks and at other intervals throughout the visit. Staff are to perform frequent hand hygiene throughout the day. Wear mask and gloves during visits with all patients and at all times out in the field as recommended for the public.” On 9/27/23 at 9:40 am the agency’s Complaint Log for September 2021 was reviewed and documents: Date of Complaint : 9/21/21: Rec’d (received) From: DOH – Rec’d Via : Telephone call – Services involved: HHA (Home Health Aide) - Category: Service Delivery: - Resolution Date: 9/23/21 . Nature of the Complaint: “Received a call from NYSDOH ( New York State Department of Health) from patient’s husband stating patient has not received home health aide services and the SOC (Start of Care) was 9/3/21.” The Client Coordination Note Report dated 9/13/2021 documents: Note Type: Narrative: Entered By: RN: Note: “R/C (Return call) spoke with patient’s spouse who spent quite some time on the phone in regard to HHA, Nursing and PT(Physical Therapy )visits. He also voiced concerns regarding therapist coming into his home without a mask. Advised that I will have Nurse contact him.” There is no documented evidence of a logged complaint, follow up, investigation with resolution after the patient/ caregiver complained on 9/13/21. The Client Coordination Note Report dated 9/28/2023 documents: “Note Type: Clinical: The Senior Director of Rehabilitation : “On 9/13 (9/13/21) this writer was notified by Clinical Manager regarding this patient’s statement that Name (PT) was not wearing a mask during his visit. This writer called and spoke with PT who indicated that he was wearing a mask for the entire session. Educated the therapist on proper infection control measures in this and other homes.” The clinical record lacks documented evidence of a complaint including follow-up, communication with other disciplines, and investigation regarding the caregiver’s concerns of the PT not wearing a mask during COVID -19 as documented in the agency’s Policy and Procedure. On 9/29/23 at 10:59am, the Director of Patient Services was interviewed did not provide an explanation for the findings.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, clinical record reviews and staff interview, the agency failed to ensure that all patient's medications were reviewed and accurately reflected in the patient's plan of care. This was evident for two (2) of eighteen (18) clinical records reviewed (Patient: #2, and #8). Failure to ensure that all patient's medications are reviewed and accurately reflected in the patient's plan of care, has the potential for negative patient outcomes. The Findings Are: Patient #8 has a Start of Care date of 9/2/2023 with diagnoses” Encounter for Surgical After Care Following Surgery on the Digestive System, Unspecified Cirrhosis of Liver, Non ineffective Gastroenteritis and Colitis, unspecified” documented in the Home Health Certification and Plan of Care for Certification Period 9/2/2023 to 10/13/2023. On 9/26/23 at 10:30am review of the Client Medication Report documents: Date Reviewed 9/2/23. The following medications are listed: Creon 24,000-76,000-120,000 unit Capsule, Delayed Release 1 capsule daily oral. Ketorolac 0.55 eye drops 1 drop 4 times daily Ophthalmic (eye). Discontinued Medications: Date: 9/9/23 Doxycycline Hyclate 100 mg tablet 1 tablet 2 times daily oral. On 9/26/23 at 11:35 am a home visit was conducted to observe the Skilled Nurse. The following is a review of the patient’s current medication in the home: The patient’s spouse was interviewed and stated, “these are the medications being taken, I give them.” Myrebtriq 50mg, extended release I daily oral Vitamin D3 5,000 IU 1 daily oral Pomegranate 3 tablets daily, 2 in the morning and I in the pm oral Doxycycline Hyclate100mg tablet 1 tablet daily oral Creon 36,000 unit – spouse states the medication is taken 3 times a day oral The Client Medication Report lacks documented evidence of the RN accurately reconciling all medication the patient is currently taking and reporting discrepancies to the physician. On 9/27/23 at 12:04pm clinical record review was conducted; the RN notes were not available. On 9/28/23 at 12:57pm the Physician Order documents the following: Verbal Order: Dated 9/26/23 12:00: Doxycycline 100 mg 1 tab 1 time a day oral Vit D3 5000 UN 1 tab 1 time a day oral Myrebtriq 50 my 1 tab 1 time a dayoral On 9/28/23 The Client Coordination Note Report documents: “spoke with patient’s wife, reviewed all medications to confirm our medication list. Contacted PCP (Primary Care Physician) discrepancies reviewed and discussed patient to schedule a PCP appointment for medication review. Contacted patient’s daughter in regard to scheduling PCP appointment for medication review.” On 9/29/23 at 11:02 no additional information was provided. 1.Patient #2(PAE) has a Start of Care date of 06/02/2023 with the following diagnoses "Aftercare Following Joint Replacement Surgery, Presence of Right Artificial Knee Joint, Essential (primary) Hypertension " documented on the Home Health Certification and Plan of Care dated 06/02/2023 to 07/31/2023. The PT (Physical Therapy) visit dated 06/27/2023 documents:” Therapy Subjective: Indicate Therapy Subjective, including prior level of function and summary of relevant health history as provided by the patient or caregiver: Patient reports compliance with HEP (Home Exercise Program). Reports not feeling well due to UTI (Urinary Tract Infection). New Medication "Ciproflaxin" since 3 days ago.” There is no documented evidence of the Plan of Care or Client Medication Profile including "Ciproflaxin". There is no documented evidence of all the medications being reviewed and reconciled. On 09/29/2023 at 1:00 pm, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings.

Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than- This STANDARD is not met as evidenced by: Based on clinical record review and staff interview the agency failed to ensure that all information documented in the comprehensive assessment including the OASIS (Outcome and Assessment Information Set) is accurate. This was evident for one (1) of eighteen (18) clinical records reviewed. (Patient #3). Failure to ensure all information documented in the comprehensive assessment (including the OASIS) is accurate has the potential for negative patient outcome. The Findings Are: 1.Patient #3 has a Start of Care date of 08/18/2023 with the following diagnoses "Pressure Ulcer of Right Hip, stage 3, Encounter for Surgical Aftercare following Surgery on the Genitourinary System, Unspecified Atrial Fibrillation, Essential (primary) Hypertension " documented on the Home Health Certification and Plan of Care dated 08/18/2023 to 10/16/2023. The Home Health Certification and Plan of Care dated 08/18/2023 to 10/16/2023 documents: "SN (Skilled Nurse) 1 WK 8 (one time per week for eight weeks." The Home Health Certification and Plan of Care dated 08/18/2023 to 10/16/2023 documents:" Skilled Nurse to perform/teach Right Hip Pressure Ulcer stage 3 wound care as follows: (agency standard protocol); Clean with Saline, pat dry, cover with DPD until MD order obtained. CG (wife) will perform wound care on non-SN visits. SN to monitor for s/s of infection.” The SOC OASIS dated 08/18/2023 documents: “Integumentary (M1306) Does the patient have at least one unhealed pressure ulcer/injury at stage 2 or higher or designated as unstageable? (Excludes stage 1 pressure injuries and all healed pressure ulcers/injuries) – NO.” The SOC OASIS Wound Section documents: “Wound #2 – Low Back, Right Skin Tear.” The RN (Registered Nurse) visit dated 08/24/2023 Wound Section documents:” Wound #2 – Low Back, Right Pressure Ulcer Stage III." There is no documented evidence of the RN comprehensive assessment accurately documenting the patient's integumentary status. On 09/29/2023 at 1:00 pm, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to ensure each patient's individualized plan of care included all the required information. This was evident for one (1) of eighteen (18) clinical records reviewed (Patient: #14). Failure to ensure individualized plan of care is established for all patients has the potential risk for negative patient outcomes. The Findings Are: 1. Patient #14 has a Start of Care date of 09/08/2023 with diagnoses Fracture of unspecified part of neck of right Femur, Subsequent Encounter for Closed Fracture with Routine Healing and Unspecified Fall Subsequent Encounter documented in the Home Health Certification and Plan of Care dated 09/08/2023 to 11/06/2023. The Home Health Certification and Plan of Care dated 09/08/2023 to 11/06/2023 documents the following orders for Home Health Aide visit frequency: “Effective week of 09/10/2023: 5WK2 (five visits/days a week for two weeks).” The Client Coordination Note dated 09/07/2023 documents: “HHA (Home Health Aide) Placement: Begin HHA eff. (effective) 9/11 (Monday); HHA frequency: 5x4x2 (five days/week times four hours/day times two weeks).” The communication note dated 09/11/2023 documents: Patient’s family “requested to start service on Wednesday 9/13 - Monday, Wednesday, and Friday (three days per week visit frequency). Please update the auth (vendor authorization).” There is no documented evidence of the Plan of Care being updated to include the frequency of visits for home health aide services. On 9/28/2023 at 10:200am, the Administrator was interviewed and did not provide an explanation for the finding.

Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This STANDARD is not met as evidenced by: Based on observation, clinical record review and staff interview, the agency failed to ensure that all patients receive a copy of the paraprofessional Plan of Care. This was evident for one (1) of eighteen (18) clinical records reviewed. (Patient #14). Failure to ensure that all patients receive a copy of the paraprofessional Plan of Care, has the potential for negative patient outcome. The Findings Are: 1. Patient #14 has a Start of Care date of 09/08/2023 with diagnoses Fracture of unspecified part of neck of right Femur Subsequent Encounter for Closed Fracture with Routine Healing and Unspecified Fall Subsequent Encounter documented in the Home Health Certification and Plan of Care dated 09/08/2023 to 11/06/2023. The Home Health Certification and Plan of Care dated 09/08/2023 to 11/06/2023 documents the following order for Home Health Aide visit frequency: “Effective week of 09/10/2023: 5WK2 (five visits(days) a week for two weeks).” The clinical record documents the “Aide Care Plan Report” dated 09/08/2023 by the Registered Nurse. On 09/26/2023, an observational home visit was conducted with the Physical Therapist. During the visit, the agency admission packet provided by the agency at the start of care was reviewed. The “Home Health Aide Plan of Care" form was observed in the packet to be blank (not completed) and lacked the written instructions of tasks/care to be provided by the aide. The Physical Therapist was observed instructing the patient to have the aide assist with the Home Exercise Program. The Patient and Physical Therapist were interviewed and confirmed there is “no” copy of the aide written patient care instructions in the home. The patient stated, "no" the nurse did not leave a completed plan of care. There is no documented evidence of the patient being provided with a copy of the written patient care instructions for the home health aide. On 9/27/2023 at 2:30pm, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the finding.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on clinical record review, and staff interviews, the agency failed to provide services that are ordered by the physician as indicated in the plan of care. This was evident for two (2) of eighteen (18) clinical records reviewed (Patients: #5, and #6). Failure to provide services that are ordered by the physician as indicated in the plan of care, has the potential for negative patient outcomes. The Findings Are: Patient #6 has a Start of Care date of 9/3/2021 with diagnoses” Malignant Neoplasm of Pancreatic Duct, Secondary Malignant Neoplasm of Liver and Intrahepatic Bile Duct, Secondary Malignant Neoplasm of Other Specified Sites, Bilateral Primary Osteoarthritis of Knee" documented in the Home Health Certification and Plan of Care for Certification Period 9/3/2021 to 11/1/2021. The Home Health Certification and Plan of Care for Certification Period 9/3/21 to 11/11/21 documents : SN: 1 WK 6 (one visits a week for six weeks) PT: Effective Week of 09/05/2021 1WK1 The agency’s Physician Order documents the following: “Date 9/17/2021: No PT visits the week of 9/12, then PT: Effective the week of 9/19/2021: 2WK1, 1WK1. Date 9/17/2021: PT: Effective the week of 09/26/2021 – 2WK 1 Date 9/29/2021: SN: Effective 10/03/2021 – 1WK 2 HHA : Effective 09/26/2021 – 2WK1, 5WK1, 3WK1.” The Client Coordination Note Report documents the following: “09/23/2021: PT: Date of visit 9/22/21 scheduling conflict MD notified Y. 09/23/2021: PT: Date of visit 9/23//21: Note Type- Clinical: Writer spoke with the patient’s husband on 9/23/21 attempting to schedule a Physical Therapy visit but he refused. Writer also asked if the patient would like to continue with home physical therapy services, he didn’t answer the question and hung up the phone. 09/28/2021: Note Type: Clinical: Call received from caregiver denies receiving a call from PT on 9/23/21.” The clinical record lacks documented evidence of notification to the patient/ caregiver on 9/22/21 regarding the “scheduling conflict.” The clinical record lacks documented evidence of patient/ caregiver and MD notification for all PT missed visits the week of 9/26/21 (PT: effective week of 9/26/21 2WK1). 10/04/2021: “Note Type: HHA- Delay in Service: Note: Hha will begin on 10/6 due to the staffing issues. The agency’s Aide Care Plan Report documents : Effective Date of Current Aide Care Plan: 09/03/2021: End of Episode: 10/20/2021: The clinical record lacks documented evidence of hha visits for the weeks of 10/3/21 through patient discharge 10/20/21. On 9/29/23 at 1:10 pm the Director of Patient Services was interviewed and stated there are no duty sheets and there are no notes. 10/04/2021:SN: “date of visit 10/04/21, unsuccessful contact, was MD notified? Message left.” 10/13/2021: SN: “Patient husband called to verify continuation of nursing service stated he did not refuse nursing services.” 10/14/2021: SN: “spoke with scheduler regarding D/C (discharge) visit plotted for today. Advised we have a date extension for 1 visit till 10/22/21. Nurse scheduled will attempt D/C visit today.” The clinical record lacks documented evidence of SN missed visits for the week 10/4/21 and 10/10/21 with the appropriate notification to the patient /caregiver and the physician. The clinical record lacks documented evidence of Skilled nurse, Physical Therapy, and Home health aide service being provided as documented in the plan of care. On 9/29/23 at 1:15pm the Director of Patient Services was interviewed; no additional information was provided. 1.Patient #5 has a Start of Care date of 04/13/2023 with the following diagnoses "Hypertensive Heart Disease with Heart Failure, Acute on Chronic(Congestive) Heart Failure, Insomnia " documented on the Home Health Certification and Plan of Care dated 04/13/2023 to 06/11/2023. The Home Health Certification and Plan of Care dated 04/13/2023 to 06/11/2023 documents:" HHA (home health aide) effective week of 04/16/2023 3WK3(three times a week for three weeks) 2-4 hours/visit." The clinical record lacks documented evidence of an aide providing care for the week of: 04/30/2023 to 05/06/2023 - three missed visits. There is no documented evidence of the patient receiving aide services as ordered on the plan of care. On 09/29/2023 at 1:00 pm, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to ensure ongoing communication with the physician is maintained. This was evident for one (1) of eighteen (18) clinical records reviewed (Patient: #2). Failure to ensure ongoing communication with the physician is maintained, has the potential for negative patient outcomes. The Findings Are: 1.Patient #2 (PAE) has a Start of Care date of 06/02/2023 with the following diagnoses "Aftercare Following Joint Replacement Surgery, Presence of Right Artificial Knee Joint, Essential (primary) Hypertension " documented on the Home Health Certification and Plan of Care dated 06/02/2023 to 07/31/2023. The PT (Physical Therapy) visit dated 06/27/2023 documents:” Therapy Subjective: Indicate Therapy Subjective, including prior level of function and summary of relevant health history as provided by the patient or caregiver: Patient reports compliance with HEP (Home Exercise Program). Reports not feeling well due to UTI (Urinary Tract Infection). New Medication "Ciproflaxin" since 3 days ago.” There is no documented evidence of the Physical Therapist communicating with the Physician regarding the changes in the patient’s condition and medications. (UTI and "Ciproflaxin") On 09/29/2023 at 1:00 pm, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings.