Every finding on record at L. Woerner, Inc.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on clinical record review the agency failed to ensure home health aides provide all services included in the plan of care (POC), are permitted to be performed under state law; and consistent with the home health aide training in one of one record reviewed of patients receiving paraprofessional aide services (Patient # 4). Failure to ensure home health aides provide all services included in the plan of care (POC), are permitted to be performed under state law; and are consistent with the home health aide training may result in poor quality of care and possible negative outcomes. Findings: Patient # 4 (start of care 02/06/2025) has diagnoses of Type 2 Diabetes Mellitus without Complications and Essential (Primary) Hypertension. The record contains an aide POC for the episode period 08/05/2025 through 10/03/2025 that instructs the aide to provide: Ambulate "assist as needed" every visit walker and clean/make/change beds weekly or as needed. An assessment of 'as needed' is outside the paraprofessional's scope of practice. Also, the aide POC instructs the aide to provide: Ambulate assist as needed every visit walker. The Aide Care Plan Reports lack documented evidence this task was completed as directed stating "N (No)" and "Not required this visit" on the following dates: 08/11/2025, 08/14/2025, 08/25/2025, 08/28/2025, 09/08/2025, 09/11/2025 and 09/15/2025. The findings were confirmed on 09/15/2025 at 3:30 PM with the Executive Director and Director of Patient Services; no additional evidence was provided.

The following statement of deficiencies represents the results of a re-certification survey of HCR Home Care Agency, a Certified Home Health Agency (Oneonta), conducted September 23 through September 27, 2024. A standard re-certification survey was initiated on September 23, 2024. Deficient practices were identified within Level 1 standards in: 484.60 Condition Care Planning, Coordination and Quality of Care resulting in a partial extended survey. The survey consisted of a review of seventeen clinical records including five discharge records, seven personnel records for professional personnel and seven observational home visits. The survey included a review of pertinent policies and procedures, Quality Improvement Meeting Minutes for the past twelve months, agency's Admission Packet, the Emergency Preparedness Plan and the Complaint Log. The census at the time of the survey was one hundred and seventy-one. Pre-survey activities consisted of review on September 12, 2024, of the agency's Health Commerce System account, Home Care Worker Registry, Criminal History Record Check, Certification and Survey Provider Enhanced Reports (CASPER) for the period 06/01/2023 through 05/31/2024, the Home Health Agency (HHA) Error Summary by Agency Report for the period 01/01/2023 through 12/31/2023 and the agency's compliance with report submissions for the 2022 statistical report. The agency's Chief Nursing Officer/Administrator and Director of Patient Services were interviewed. Findings were reviewed at the exit conference on September 27, 2024. The following deficiencies are identified as a result of the survey: Federal: G0372, G0572, G0574, G0590 and G0798. State: J0404, J0452, J1108, J1156, J1168, J1268, J1412, J1420, J1424, J1426, J1440, J1444, J1460 and R0510.

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on the Home Health Agency (HHA) Error Summary by Agency Report for the period 01/01/2023 through 12/31/2023 and staff interview the agency failed to encode and electronically transmit each completed Outcome and Assessment Information Set (OASIS), regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within thirty days of completing the assessment of the beneficiary. Failure to encode and electronically transmit each complete OASIS assessment, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within thirty days of completing the assessment of the beneficiary has the potential for incorrect and incomplete reporting data. On 09/12/2024 the surveyors reviewed Certification and Survey Provider Enhanced Reports (CASPER), "Home Health Agency Error Summary Report by Agency" for report period 01/01/2023 - 12/31/2023. The report contains a warning code -3330 "Record Submitted Late": The submission date is more than thirty days after M0090 "Date Assessment Completed" on this new record. The CASPER Report states 20 (0.75%) out of 2673 assessments processed were submitted more than thirty days after M0090. The agency lacks documented evidence the agency submitted required documents timely for 20 out of 2673, or for 0.75% of submissions. The finding was confirmed on 09/27/2024 at 9 AM with the Chief Nursing Officer/Administrator and Director of Patient Services; no additional evidence was provided.

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 record review and staff interview the agency failed to ensure services are provided in accordance with the Plan of Care (POC) in three of seventeen records (Patient # 1, 4 and 17). Failure to follow the POC has the potential for patients to receive care inconsistent with the physician's orders resulting in unmet patient needs and possible negative patient outcomes. Patient # 1 (start of care 08/28/2024) has diagnoses of Pressure Ulcer of Sacral Region, Stage 2 and Alzheimer's Disease. The physician's POC for certification period 08/28/2024 through 10/26/2024 contains an order for SN (skilled nurse) visits 1WK1 (one time a week for 1 week), 2WK4 and 1WK3. The record contains documentation of SN visits on 09/06/2024 and 09/13/2024. The record lacks documented evidence two SN visits were conducted for the weeks of 09/01/2024 through 09/07/2024 and 09/08/2024 through 09/14/2024. Patient # 4 (start of care 05/31/2024) has diagnoses of Type 2 Diabetes Mellitus with Foot Ulcer and Non-Pressure Chronic Ulcer Right Foot. The physician's POC for certification period 07/30/2024-09/27/2024 contains orders for a Home Health Aide (HHA) 2WK1, 3WK8. The record lacks documented evidence of any HHA visits the week of 08/04/2024-08/10/2024. Also, the POC contains an order for "physical therapist to evaluate for physical impairments, functional limitations, home safety and rehabilitation potential". The record lacks documented evidence a physical therapy evaluation was completed. Patient # 17 (start of care 08/19/2024) has diagnoses of ST Elevation (STEMI) Myocardial Infarction and Hypertensive Heart Disease with Heart Failure. The physician's Resumption of Care (ROC) order dated 08/29/2024 contains an order for SN 1WK2, 2WK2, 1WK4. The record contains documentation of one SN visit conducted 09/16/2024 The record lacks documented evidence of a second SN visit for the week of 09/14/2024-09/20/2024. The findings were confirmed on 09/24/2024 at 3:30 PM, 09/25/2024 at 3:30 PM and 09/26/2024 at 3:30 PM with the Chief Nursing Officer/Administrator and Director of Patient Services; no additional evidence was provided.

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 a complete Plan of Care (POC) was developed to meet the individualized needs of the patient in eight out of seventeen records (Patient # 1, 2, 6, 8, 9, 11, 12 and 17). Failure to develop a comprehensive POC has the potential for unmet patient needs and places patients at risk for receiving incorrect and/or inappropriate care. Patient # 1 (start of care 08/28/2024) has diagnoses of Pressure Ulcer of Sacral Region, Stage 2 and Alzheimer's Disease. The POC for certification period 08/28/2024-10/26/2024 contains an order for: Polyethylene Glycol 3350 17 gram/dose oral powder by mouth daily as needed (prn) for constipation maximum (max) daily dose 17 grams. The order is incomplete as it is lacking instruction for reconstitution. Patient # 2 (start of care 02/07/2024) has diagnoses of Type 2 Diabetes Mellitus with Diabetic Cataract and Major Depressive Disorder. The POC for certification period 06/06/2024-08/04/2024 contains an order for: Metamucil Fiber Singles 3.4 gram oral powder packet oral 1 packet bedtime. The order is incomplete as it is lacking instruction for reconstitution and Flonase Allergy Relief 50 micrograms (mcg)/actuation nasal 2 spray daily. The order is incomplete as it does not state whether to deliver the medication in the left or right nares or into both. Also, the POC for certification period 08/05/2024-10/03/2024 contains an order for: Flonase Allergy Relief 50 micrograms (mcg)/actuation nasal 2 spray daily. The order is incomplete as it does not state whether to deliver the medication in the left or right nares or into both and AYR Saline 0.65% Nasal Spray aerosol nasal 1 spray every 6 hours as needed/as needed (prn) for dry nose maximum daily amount 4 sprays. The order is incomplete as it does not state whether to deliver the medication in the left or right nares or into both. Patient # 6 (start of care 01/04/2024) has diagnoses of Type 2 Diabetes Mellitus with Other Skin Ulcer and Non-Pressure Chronic Ulcer Right Lower Leg. The POC's for certification periods 07/02/2024-08/30/2024 and 08/31/2024-10/29/2024 contain an order for: Oxygen 2 Liter oxygen (O2) nightly. The order is incomplete as it is lacking the route of administration for the oxygen: mask and/or nasal canula. Also, the Skilled Nurse (SN) assessments conducted on 06/27/2024 and 08/26/2024 contain durable medical equipment (DME) of a walker. The POC's for certification periods 07/02/2024-08/30/2024 and 08/31/2024-10/29/2024 do not contain an order for this DME. Patient # 8 (start of care 05/24/2023) has diagnoses of Hemiplegia following Cerebral Infarction Affecting Right Dominant Side and Pressure Ulcer of Sacral Region. The POC for certification period 07/17/2024-09/14/2024 contains orders for DME of: commode, glucometer, hospital bed, Reacher, shower/tub equipment, powered wheelchair, rolling walker and elbow protector. The SN assessment conducted on 07/16/2024 does not contain this DME. Also, the POC's for certification periods 07/17/2024-09/14/2024 and 09/15/2024-11/13/2024 contain orders for: Nitrostat 0.4 milligrams(mg) sublingual tablet 1 tablet as needed/prn every 5 minutes under tongue as needed for chest pain maximum daily dose 3 tabs. The orders are incomplete as they do not direct the patient what to do if the pain persists after the 3 doses. Patient # 9 (start of care 02/22/2024) has diagnoses of Spastic Quadriplegic Cerebral Palsy and Gastrostomy Status. The POC's for certification periods 06/21/2024-08/19/2024 and 08/20/2024-10/18/2024 contain orders for: Valtoco 10 mg/spray (0.1ml) spray nasal 1 spray as needed for seizure. The orders are incomplete as they do not state whether to deliver the medication in either the left or right nares or into both. Patient # 11 (start of care 08/16/2024) has diagnoses of Age-Related Osteoporosis with Pathological Vertebrae Fractures and Hypertensive Heart Disease with Heart Failure. The POC for certification periods 08/16/2024-10/14/2024 contains an order for: Bacitracin Plus 500 Unit-19mg/gram Topical Ointment 1 centimeter (cm) daily on the skin. The order is incomplete as it is lacking the anatomical location on the skin to apply the ointment. Patient # 12 (start of care 01/24/2024 and discharged 03/06/2024) has diagnoses of Type 2 Diabetes Mellitus with Chronic Kidney Disease and Hypertensive Chronic Kidney Disease Stage 5. The SN assessment conducted on 01/24/2024 contains DME of a hospital bed. The POC for certification period 01/24/2024-03/23/2024 is lacking an order for this DME. Patient # 17 (start of care 08/19/2024) has diagnoses of ST Elevation (STEMI) Myocardial Infarction and Hypertensive Heart Disease with Heart Failure. The POC for certification period 08/19/2024-10/17/2024 contains orders for: Levothyroxine 50 mcg capsule by mouth 1 capsule daily and Levothyroxine 50 mcg tablet by mouth 1.5 tablet daily. The orders require clarification as to the total daily dosage and form of the medication: tablet vs. capsule. The findings were confirmed on 09/24/2024 at 3:30 PM, 09/25/2024 at 3:30 PM and 09/26/2024 at 3:30 PM with the Chief Nursing Officer/Administrator and Director of Patient Services; no additional evidence was provided.

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 evidence is lacking in three of seventeen records (Patient #'s 1, 4 and 17) the physician was contacted regarding changes that alter or suggest the need to alter the Plan of Care (POC). Failure to consult with the physician when changes occur in the patient's condition has the potential for unmet patient needs and/or negative patient outcomes. Patient # 1 (start of care 08/28/2024) has diagnoses of Pressure Ulcer of Sacral Region, Stage 2 and Alzheimer's Disease. The physician's POC for certification period 08/28/2024 through 10/26/2024 contains an order for SN (skilled nurse) 1WK1 (one time a week for 1 week) 2WK4 and 1WK3. The record lacks evidence the physician was notified of a missed SN visit for the weeks of 09/01/2024 through 09/07/2024 and 09/08/2024 through 09/14/2024. Patient # 4 (start of care 05/31/2024) has diagnoses of Type 2 Diabetes Mellitus with Foot Ulcer and Non-Pressure Chronic Ulcer Right Foot. The physician's POC for certification period 07/30/2024-09/27/2024 contains orders for a Home Health Aide (HHA) 2WK1, 3WK8. The record lacks evidence the physician was notified there were no HHA visits the week of 08/04/2024-08/10/2024. Patient # 17 (start of care 08/19/2024) has diagnoses of ST Elevation (STEMI) Myocardial Infarction and Hypertensive Heart Disease with Heart Failure. The physician's Resumption of Care (ROC) order dated 08/29/2024 contains an order for SN 1WK2, 2WK2, 1WK4. The record lacks evidence the physician was notified of missed SN visits for the weeks of 09/14/2024 through 09/20/2024. The findings were confirmed on 09/24/2024 at 3:30 PM, 09/25/2024 at 3:30 PM and 09/26/2024 at 3:30 PM with the Chief Nursing Officer/Administrator and Director of Patient Services; no additional evidence was provided.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on review of three clinical records of a patients receiving paraprofessional aide services and staff interview the agency failed to ensure in one of three records reviewed (Patient # 11) the aide Plan of Care (POC) was complete to meet the individualized needs of the patient. Failure to ensure the development of a comprehensive aide POC to reflect the patient's needs has the potential to result in inappropriate care, unmet patient needs and possible negative outcomes. Patient # 11 (start of care 08/16/2024) has diagnoses of Age-Related Osteoporosis with Pathological Vertebrae Fractures and Hypertensive Heart Disease with Heart Failure. The record contains an Aide Care Plan Report dated 08/16/2024-10/14/2024 instructing the aide to provide: Bath/Shower Assist as needed every visit. The POC is incomplete as it does not contain parameters of when to provide assistance for this task; an assessment of 'as needed' is outside the paraprofessional's scope of practice. The finding was confirmed on 09/26/2024 at 3:30 PM with the Chief Nursing Officer/Administrator and Director of Patient Services; no additional evidence was provided.

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 evidence is lacking in one of six patient records (Patient # 2) the physician was contacted regarding changes that alter or suggest the need to alter the Plan of Care (POC). Failure to consult with the physician when changes occur in the patient's condition has the potential for unmet patient needs and/or negative patient outcomes. Finding: Patient # 2 (start of care 01/05/2022) has diagnoses of Pressure Ulcer of Sacral Region, Stage 3 and Urinary Tract Infection. The record contains a Client Episode Coordination Notes Report dated 05/05/2022 that states "Patient states he fell 2 days ago, no injury noted just tenderness to right knee and right wrist. Range of motion is within normal limits". The record lacks any documented evidence the physician was notified of the fall or of the patient's complaints of tenderness to right knee and right wrist. The finding was confirmed on 05/10/2022 at 3:45 PM with the Director of Patient Services; no additional evidence was provided.

The following statement of deficiencies represents the results of a standard re-certification survey of L. Woerner Inc. DBA HCR/HCR Home Care, Certified Home Health Agency conducted on 10/18/2021 through 10/21/2021. The survey consisted of a review of seventeen clinical records including five discharge records, five observational home visits, seven personnel records. The survey included review of pertinent policies and procedures, Quality Improvement Meeting minutes for the past twelve months, the agency's Admission Packet, Emergency Preparedness Plan, and the Complaint Log. The patient census at the time of the survey was two hundred and twenty four. Pres-survey activities consisted of review on 10/12/2021 of the agency's Health Commerce System account, Home Care Worker Registry, Criminal History Record Check, Certification and Survey Provider Enhanced Reports (CASPER) for the period 08/2020 through 07/2021, the agency's compliance with report submissions for the 2020 statistical report and participation in the June 11 through June 13, 2019 Emergency Preparedness drill. A focused COVID 19 survey was conducted in conjunction with the recertification survey. The Director of Patient Services and staff was interviewed. Findings were reviewed at the exit conference on 10/21/2021. The following deficiencies are identified as a result of the survey: Federal: G0512 Standard: Initial Assessment visit; G0572 Plan of Care; G0574 Plan of Care Must Include the Following; State: J0404 Policies and Procedures of Service Delivery; J0452 Policies and Procedures of Service Delivery; J0752 Clinical Records; J1108 Governing Authority; J1416 Personnel; J1420 Personnel; J1426 Personnel; J1440 Personnel; and J1512 Records and Reports.

Standard: Initial assessment visit. CFR(s): 484.55(a) Standard: Initial assessment visit. This STANDARD is not met as evidenced by: Based on clinical record review and staff interview evidence is lacking in one of seventeen records (Patient # 9) the initial assessment visit was conducted within 48 hours of receiving the referral for services, within 48 hours of the patient's return home or on the physician ordered start of care date. Failure to conduct the initial assessment within the required time frame has the potential to result in unmet patient needs and negative patient outcomes. Finding: Patient # 9 (start of care 08/08/2021, discharged 09/14/2021) has diagnoses of Chronic Obstructive Pulmonary Disease and Spinal Stenosis, Lumbar Region without Neurogenic Claudification. The record contains a community referral dated 08/04/2021, with no specific physician ordered start of care date. The Skilled Nurse (SN) conducted the initial assessment on 08/08/2021, four days after the agency received the referral. The finding was confirmed on 10/19/2021 at 2:50 PM with the Director of Patient Services, no additional evidence was provided.

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 record review and staff interview the agency failed to ensure services are provided in accordance with the physician's Plan of Care (POC) in three of seventeen patient records (Patient # 7, 9 and 14). Failure to follow the POC has the potential for patients to receive care that is inconsistent with the physician's orders resulting in unmet patient needs and possible negative patient outcomes. Findings: Patient # 7 (start of care 06/16/2021, discharged 1011/2021) has diagnoses of Rheumatoid Arthritis with Rheumatic Factor Multiply Sites without Organ/System Involvement. The POC for the certification period 08/16/2021 through 10/14/2021 contains an order for Physical Therapist (PT) visits one time a week for five weeks. The record lacks documented evidence of PT visits the weeks of 09/05/2021 and 09/12/2021. Patient # 9 (start of care 08/08/2021, discharged 09/14/2021) has diagnoses of Chronic Obstructive Pulmonary Disease (COPD) with (Acute) Exacerbation and Spinal Stenosis, Lumbar Region without Neurogenic Claudification. The POC for certification period 08/08/2021 through 10/06/2021 contains an order for Skilled Nurse (SN) visits three times a week for one week, two times a week for two weeks and one time a week for three weeks. The record lacks documented evidence of a second SN visit being conducted the week of 08/22/2021. Patient # 14 (start of care 10/04/2021) has diagnoses of Encounter for Surgical Aftercare Following Surgery on the Circulatory System and Essential (Primary) Hypertension. The POC for certification period 10/04/2021 through 12/02/2021 contains an order to call medical doctor (MD) for weight change greater than 2 pounds in twenty four hours or five pounds in one week. The record lacks documented evidence the patient's weight was assessed after start of care. The findings were confirmed on 10/19/2021 at 12:35 PM and 2:50 PM, and 10/20/2021 at 2:10 PM with the Director of Patient Services; no additional evidence was provided.

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 a complete Plan of Care (POC) was developed to meet the individualized needs of the patient in twelve of seventeen patient records reviewed (Patient # 1, 2, 3, 4, 5, 6, 10, 12, 13, 14, 15 and 17). Failure to develop a comprehensive POC has the potential for unmet patient needs and places patients at risk for receiving incorrect and/or inappropriate care. Findings: Patient # 1 (start of care 09/08/2021) has diagnoses of Major Depressive Disorder, Recurrent and Type II Diabetes Mellitus (DMII) with Diabetic Neuropathy. The POC for certification period 09/08/2021 through 11/06/2021 contains an order for Levothyroxine 25 micrograms (mcg) capsule, one capsule oral daily. The order is incomplete as it lacks instructions to take the medication thirty minutes to one hour prior to consuming food. Also, the Skilled Nurse (SN) notes in the initial assessment (dated 09/08/2021) the patient utilizes Durable Medical Equipment (DME) and Supplies, specifically a cane, lift recliner, CPAP and Glucometer. The POC is incomplete as it does not contain DME and Supplies, specifically a cane, left recliner, CPAP and Glucometer. Patient # 2 (start of care 09/26/2021) has diagnoses of Essential (Primary) Hypertension (HTN) and DMII without complications. The POC for certification period 09/15/2021 through 11/13/2021 contains an order for Flonase Allergy Relief, 50 mcg/actuation nasal spray. Spray to pops into nostril daily as needed for congestion. The order is incomplete as it does not state which nare (or both) to medicate. Patient # 3 (start of care 01/08/2021) has diagnoses of Venous Insufficiency (Chronic)(Peripheral). The POC for certification period 07/07/2021 through 0904/2021 contains an order for Miralax 17 gram oral powder, daily as needed (prn) for constipation. The order is incomplete as it does not state the reconstitution instructions. Patient # 4 (start of care 06/25/2021) has diagnoses of DMII with Foot Ulcer and Non-pressure Chronic Ulcer other part of Left Foot with Fat Layer exposed. The POC for certification period 08/24/2021 through 10/22/2021 contains an order for Aspirin Children's 81 milligram (mg) Chewable Tablet, oral, one daily. The POC is incomplete as it lacks Bleeding Precautions. Patient # 5 (start of care 06/10/2021) has diagnoses of Parkinson's Disease and Dementia without Behavioral Disturbance. The POC for certification periods 08/09/2021 through 10/07/2021 and 10/08/2021 through 12/06/2021 contain orders for Prednisone 10 mg tablet, oral, daily, 8 tablets by mouth daily times seven days. The order is incomplete as it does not contain an end date. Patient # 6 (start of care 01/20/2021, discharged 09/22/2021) has diagnoses of Acute Cystitis with Hematuria and Proteus (Mirabilis)(Morgani). The POC for certification period 07/28/2021 through 09/25/2021 contains orders for: Levothyroxine 25 mcg tablet, one tablet daily. The order is incomplete as it does not state the medication is to be taken thirty minutes to one hour prior to consuming food; and Eliquis 5 mg tablet, one tablet every twelve hours. The POC is incomplete as it does not contain Bleeding Precautions. Patient # 10 (start of care 08//01/2021, discharged 08/04/2021) has diagnoses Pressure Ulcer of Sacral Region, Stage 3 and DMII with Diabetic Peripheral Angiopathy without Gangrene. The POC for certification period 08/01/2021 through 09/29/2021 contains an order for Flonase Allergy Relief, 50 mcg/actuation spray, 2 sprays. The order is incomplete as it does not state which nare (or both) to medicate. Patient # 12 (start of care 09/08/2021) has diagnoses of Acute and Chronic Respiratory Failure with Hypoxia and Hypercapnia. The SN in the initial assessment (dated 0908/2021) documents the patient utilizes DME and Supplies, specifically a walker, grab bars, suction machine, wheelchair and a tub chair. The POC for certification period 09/08/2021 through 11/06/2021 is incomplete as it does not contain DME, specifically a walker, grab bars, suction machine and a tub chair. Patient # 13 (start of care 10/14/2021) has diagnoses of Diastolic (Congestive) Heart Failure and Right Heart Failure. The SN notes in the initial assessment (dated 10/14/2021) the patient utilizes DME and Supplies, specifically a rolling walker and Reacher. The POC for certification period 10/14/2021 through 12/12/2021 is incomplete as it does not contain DME and Supplies, specifically a rolling walker and Reacher. Patient # 14 (start of care 10/04/2021) has diagnoses of Encounter for Surgical Aftercare Following Surgery on the Circulatory System and HTN. The POC for certification period 10/04/2021 through 12/02/2021 contains an order for Synthroid 150 mcg tablet daily. The order is incomplete as it does not instruct the medication is to be taken thirty minutes to one hour prior to consuming food. Also, the SN documents in the initial assessment (dated 10/04/2021) the patient utilizes DME and Supplies, specifically Lift Recliner. The POC is incomplete as it lacks DME and Supplies, specifically Lift Recliner. Patient # 15 (start of care 09/24/2021) has diagnoses of COPD and HTN. The POC for certification period 09/24/2021 through 11/22/2021 contain as order for Muro 128 5% eye drops, one drop every 8 hours. The order is incomplete as it does not state which eye (or both) the medication is to be applied to. Patient # 17 (start of care 09/15/2021) has diagnoses Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1-4/Unspecified Chronic Kidney Disease. The POC for certification period 09/15/2021 through 11/13/2021 contains orders for: Flonase Allergy Relief 50 mcg/actuation nasal spray, twice daily. The order is incomplete as it does not state which nare (or both) the medication is to be applied to; Nitroglycerin 0.1 mg/hour Transdermal 24 hour patch, daily. The order is incomplete as it does not state the site of the patch is to be rotated; and Sodium Chloride 0.65% nasal spray , one spray every twelve hours. The order is incomplete as it does not state which nare (or both) the medication is to be applied to. The findings were confirmed on 10/18/2021 at 4:10 PM, 4:15 PM, 10/19/2021 at 12:35 PM, 2:45 PM, 2:55 PM, 4:15 PM, 10/20/2021 at 9:25 AM and 2:10 PM with the Director of Patient Services; no additional evidence was provided.