Every finding on record at Lhcg Cxlv, LLC

This report is the result of an unannounced Federal Complaint survey, C#2992037, completed on May, 20, 2026 at Patient Care. It was determined the facility is not in substantial compliance with the requirements of 42 CFR Part 484, Subpart B Conditions of Participation for Home Health Agencies.

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on a review of facility policy, medical record review and staff interview, it was determined that the facility failed to ensure Patient (P)1 received a comprehensive Occupational Therapy (OT) assessment within five days after the start of care. Findings include: Facility policy titled "Patient Assessment, Initial and Reassessment," revised 12/01/25, stated, "POLICY:...The comprehensive assessment is the responsibility of one clinician. However, the assessing clinician may obtain input from the patient, caregiver, or other healthcare personnel (i.e., physician, pharmacist, agency staff) if within the comprehensive 5-day window timeframe. For assessment items, the collaborating healthcare providers must have had direct in-person contact with the patient...PROCEDURE:...3...d. Physical Therapist, Speech Therapist, Occupational Therapist, medical Social Worker, and Dietitian may make initial evaluation of the patient status to determine the need for specific therapist. This initial discipline specific evaluation(s) will occur within 5 days from the Start of Care (SOC) date or order date or sooner if medically necessary..." On 5/20/26, at 9:26 AM, an entrance conference was conducted with Staff (S)1. At 12:59 PM, Medical Record (MR) review was conducted for Patient (P)1 and P2 and the following was revealed: On 12/31/2025, P1 was accepted for service by the facility with a diagnosis of Pneumonia. On 01/01/26, an initial assessment was conducted on P1 by his/her Registered Nurse (RN) On 01/07/26, an Occupational Therapy (OT) assessment was conducted on P1, six days after P1's initial assessment. On 12/26/25, P2 was accepted for service by the facility for "aftercare following a joint replacement surgery". On 12/27/25, an initial assessment was conducted on P2 by his/her RN. On 01/02/26, an OT assessment was conducted on P2, six days after P2's initial assessment. On 05/20/26, at 1:56 PM, S1 confirmed the above finding and stated that additional disciplines, such as physical therapy and occupational therapy, have five days to evaluate a patient after the initial assessment is completed.

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 a review of facility policy, medical record review and staff interview, it was determined that the facility failed to provide services to Patient (P)1 in accordance with his/her plan of care. Findings include: Facility policy titled "Plan of Care (POC)," last revised 3/1/26, stated, "Purpose: To assure an appropriate plan of care is developed and revised in a timely manner for each patient. To ensure that physician/authorized practitioner's orders are followed....Procedure...2. This POC includes:...b. Types, frequency, and duration of services required which may include virtual services...8. Medications, treatments, and interventions are provided by qualified agency staff as ordered by the physician or authorized provider..." On 05/20/26, at 9:26 AM, an entrance conference was conducted with Staff (S)1. At 12:59 PM, Medical Record (MR) review was conducted for Patient (P)1 and the following was revealed: On 12/31/2025, P1 was accepted to service by the facility with a diagnosis of Pneumonia. P1 was to receive Occupational Therapy (OT) services "Effective 01/04/2026 1WK6 [once a week for six weeks]." On 01/07/26, the first OT assessment was conducted on P1. P1 was due for an OT visit between 01/18/26-01/24/26. P1's schedule indicated he/she was to receive OT service on 01/21/26. The facility was unable to provide documentation that P1 received OT service on 01/21/26 or on any other date between 01/18/26 through 01/24/26. On 05/20/26 at 1:29 PM, S1 confirmed P1 did not receive OT services from 1/18/26 through 1/24/26.

Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on a review of facility policy, medical record review and staff interview, it was determined that the facility failed to ensure changes in Patient (P)1's plan of care are communicated with his/her provider. Findings include: Facility policy titled "Coordination of Care, From Admit Through Discharge," revised 12/1/25, stated, "...PROCEDURE:...4. Coordination of care with physician/authorized practitioner: At admission, throughout care, and at discharge, coordination of services is promoted through routine communication with the patient's physician:...c. When a missed visit occurs altering the Plan of Care...5. Coordination of care among disciplines and between in-person and virtual clinicians: Patient care is coordinated among various disciplines and services through care planning processes to ensure continuity of care form admission to discharge. This includes:... c...i...Missed visits and changes to scheduled visits. a. Reason for missed visit b. Changes to patient schedule... On 05/20/26, at 9:26 AM, an entrance conference was conducted with Staff (S)1. At 12:59 PM, Medical Record (MR) review was conducted for Patient (P)1 and the following was revealed: On 12/31/2025, P1 was accepted to service by the facility with a diagnosis of Pneumonia. P1 was to receive Occupational Therapy (OT) services "Effective 01/04/2026 1WK6 [once a week for six weeks]." On 01/07/26, the first OT assessment was conducted on P1. P1 was due for an OT visit between 01/18/26-01/24/26. P1's schedule indicated he/she was to receive OT service on 01/21/26. The facility was unable to provide documentation that P1 received OT services on 01/21/26, or any other day between 01/18/26 through 01/24/26. The facility was unable to provide documentation that P1's provider was notified of the missed visit. On 05/20/26, documentation between S1 and P1's Occupational Therapist, via email, was reviewed and indicated P1's OT therapist requested a personal leave of absence from 01/21/26-03/08/26. On 05/20/26 1:29 PM, S1 confirmed P1 did not receive OT services the week of 01/18/26 through 01/24/26, and that there was no documentation of notification to P1's provider of the missed visit.

This was an unannounced Federal Recertification and State Re-licensure survey completed August 1, 2024. Patient Care Home Health was in substantial compliance with the requirements of 42 CFR, Title 42, Part 484, Conditions of Participation for Emergency Preparedness. A standard level citation was identified.

HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This STANDARD is not met as evidenced by: Based on observations, staff interview, and review of facility policies and documents, it was determined the facility failed to ensure an individualized emergency preparedness plan was available in one of five patient homes visited (Patient (P) 5). Findings include: On 7/31/24 at 11:08 AM, S13, a Licensed Practical Nurse (LPN) was observed providing care for P5. A review of P5’s Plan of Care revealed the following: 1) Start of Care date: 11/13/23. 2) Functional limitations: “ambulation”. 3) Safety measures: “1 person transfer” and “ambulation precautions”. At 12:20 PM, the admission packet was asked of P5 and P5's caregiver for review by this surveyor. P5 and P5’s caregiver, were unable to locate the admission packet. P5’s caregiver stated, “it must be in my house." S13 stated that P5 was living in the caregiver’s house prior to moving to his/her current residence. P5 and P5’s caregiver stated that P5 moved to the current residence “a couple months ago.” When questioned about an emergency disaster plan, P5 stated, “I would call 911. I would get out the window.” P5 and P5’s caregiver were unable to state a clear evacuation plan for P5 in the event of an emergency or disaster. On 7/31/24 at 1:45 PM, a review of P5’s medical revealed there was no emergency disaster plan in P5’s medical record. On 7/31/24 at 3:05 PM, S1, Executive Director, confirmed the facility did not have an emergency disaster plan in the medical record for P5. Facility policy titled “Patient Assessment, Initial, and Reassessment” last revised 1/1/24 states “Purpose: to describe the process of patient assessments … Procedure: 1. Upon admission and reassessments, the qualified clinician performs the following assessment activities and collects the following data: … p. Emergency disaster plan.”

This report is the result of an unannounced standard-level Federal Recertification and State Re-licensure Survey completed August 1, 2024 at Patient Care. It was determined the facility is in substantial compliance with Federal requirements of 42 CFR Part 484, Subpart B Conditions of Participation for Home Health Agencies and State requirements of N.J.A.C. Title 8 Chapter 42 Home Health Agency Licensing Standards.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, patient and staff interview, and a review of facility documents, it was determined the facility failed to ensure staff followed the policy to prevent transmission of infections and communicable diseases in two of four patients (Patient (P) 5 and P15). On 7/30/24 at 12:26 PM, Staff (S) 10, a Physical Therapist (PT), was observed providing care for P15. At 12:28 PM, S10 donned gloves and placed a barrier pad on a table in the patient's living room. S10 placed his/her equipment bag in the center of the pad. S10 then placed a second barrier on P15’s dining room table and removed vital signs equipment (thermometer, sphygmomanometer and blood pressure cuff, pulse oximeter, stethoscope, and tablet) from the equipment bag and placed them on the barrier pad on the dining room table. S10 then began taking P15’s vital signs. S10 completed vital signs and entered vital signs onto tablet without doffing gloves. At 12:58 PM, after the completion of the PT exercises, S10 began cleaning the vital signs equipment. After cleaning the vital signs equipment, S10 placed the cleaned equipment on the barrier pad that also shared space with the equipment bag. The equipment bag was occupying most of the space on the barrier pad and there was only a narrow space around the bag for the clean equipment to be placed. The cleaned stethoscope and sphygmomanometer were observed touching the outside of the equipment bag and touching the living room table thus creating an opportunity for cross-contamination from the outside of the bag and the patient’s table to the newly cleaned equipment. S10, without re-cleaning the equipment, placed the equipment back into the clean interior of the equipment bag. At 1:00 PM, S10 asked P15 for a signature on the tablet. P15 used his/her finger to sign the tablet. S10 failed to clean the tablet before placing it back in the equipment bag. On 7/31/24 at 11:08 AM, S13, a Licensed Practical Nurse (LPN), was observed providing care for P5 in the patient’s bedroom. At 11:10 AM, S13 performed hand hygiene, donned gloves, and began placing barrier pads on P5’s bed. S13’s badge fell off his/her uniform and landed on the floor of the bedroom. P5’s mother picked up the badge and handed it to S13. S13 placed it back on his/her uniform without cleaning it. At 12:02 PM, after finishing P2’s wound care, S13 was observed leaning over the bed and the dirty badge on S13’s uniform touched the clean wound care supplies that were on a clean barrier pad that had been placed on the bed thus providing a potential for cross-contamination. S13 did not replace the wound care supplies that were touched by the badge and continued with providing care to the patient. At 12:09 PM, S13 began cleaning the vital signs equipment (pulse oximeter, stethoscope, thermometer, sphygmomanometer and blood pressure cuff) and placed them on a clean barrier pad. The cleaned stethoscope and thermometer were observed hanging off the edge of the designated clean barrier pad and touching P5’s bed before being placed back in the equipment bag. S13 placed used, dirty supplies in P5’s trash can near bed and returned to cleaning the remaining pieces of vital signs equipment (pulse oximeter, blood pressure cuff and sphygmomanometer) without changing gloves and performing hand hygiene. On 8/1/24 at 1:13 PM, the above findings were shared with S1, Executive Director during exit conference. S1 confirmed that there was an opportunity for cross-contamination if the above techniques were used. Facility policy titled “Standard Precautions” last reviewed 12/01/21 states “Purpose: to prevent the spread of disease and infection between and among patients and staff … Procedure: … 4. Standard Precautions include: a. Hand Hygiene … ii. Perform hand hygiene immediately after gloves are removed, between patient contacts, and when otherwise indicated to avoid transfer of microorganisms to other patients or environments…” Facility policy titled “Standard Precautions” last revised 12/01/21 states “Purpose: to prevent the spread of disease and infection between and among patients and staff … Procedure: … 4. Standard Precautions include: d. Patient-Care Equipment: … ii. Ensure that reusable equipment is not used for the care of another patient until it has been cleaned appropriately.” Facility policy titled “Cleaning of Re-Useable Equipment” last revised on 6/01/22 states “Purpose: to assure equipment required for patient care is clean and sanitized to prevent the spread of infections … Procedure: … 6. … a. The hand-held computer device (i.e. tablet or Smartphone) should be wiped down with a low-level disinfectant at the beginning and end of each visit…”

The facility is not in compliance with Appendix Z-Emergency Preparedness for All Provider and Supplier Types, Interpretive Guidance 484.22, Conditions of Participation for Home Health Agencies for this survey.

HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This STANDARD is not met as evidenced by: Based on staff interview and review of three (3) of five (5) medical records (#1, #2, and #5), it was determined the facility failed to ensure all patients receive an individualized emergency plan as part of their comprehensive assessment. Findings include: 1. Upon review of the "Patient Disaster Plan ID Form" for Patient #1, the following was noted: a. The Evacuation Destination was blank. b. The Evacuation address was "Hospital/Shelter." 2. Upon review of the "Patient Disaster Plan ID Form" for Patient #2, the following was noted: a. The Evacuation Destination was "nearest shelter." b. The Evacuation address was blank. 3. Upon review of the "Patient Disaster Plan ID Form" for Patient #5, the following was noted: a. The Evacuation Destination was "Refer to Red Cross." b. The Evacuation address was blank. 4. The above findings were confirmed with Staff #11 on 9/3/21 at 12:30 PM.

Survey dates: 8/30/21, 9/1/21, and 9/3/21 This was a Federal Recertification survey, Federal COVID-19 Focused Infection Control survey and State Relicensure survey. Atlanticare Home Health is not in compliance with Federal requirements under 42 CFR Part 484 regulations for Home Health Agencies and State requirements under Title 8, Chapter 42, Licensing Standards for Home Health Agencies. The following Condition was determined to be out of compliance: 484.75 Skilled Professional Services Standard level deficiencies were also cited.

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 staff interviews and review of five (5) of eighteen (18) medical records (#4, #5, #7, #10, and #18), it was determined the agency failed to ensure that services ordered by the physician are provided as indicated in the plan of care. Findings include: 1. Upon review of the Home Health Certification and Plan of Care, dated 7/16/2021 to 9/13/2021, for Patient #4, the following was noted: a. Frequency/Duration of Visits, states, "SN (skilled nursing) 1wk1 (one time a week for one week), 3wk8 (three times a week for eight weeks)" i. The week of 8/15/21, the patient had two skilled nursing visits. 2. Upon review of the Home Health Certification and Plan of Care, dated 8/16/2021 to 10/14/2021, for Patient #5, the following was noted: a. Frequency/Duration of Visits, states, "SN 6wk1 (six times a week for one week)" i. The week of 8/16/21, the patient had three skilled nursing visits. 3. Upon review of the Home Health Certification and Plan of Care, dated 7/19/2021 to 9/16/2021, for Patient #7, the following was noted: a. Frequency/Duration of Visits, states, "PT (physical therapy) 1wk4 (one time a week for four weeks)" i. The week of 8/1/21, the patient did not have a PT visit. 4. Upon review of the Home Health Certification and Plan of Care, dated 8/5/2021 to 10/3/2021, for Patient #10, the following was noted: a. Frequency/Duration of Visits, states, "PT (physical therapy) 1wk1 (one time a week for one week)" i. The week of 8/8/21, the patient did not have a PT visit. 5. Upon review of the Home Health Certification and Plan of Care, dated 8/5/2021 to 10/3/2021, for Patient #18, the following was noted: a. Orders of Discipline and Treatments, states, "...Medical Social Services to evaluate/assess and develop social work plan of care that will be approved by the physician prior to implementation. ..." i. The patient was not evaluated by a social worker. 6. The above findings were confirmed with Staff #2 on 9/3/21 at 11:30 AM. N.J.A.C. 8:42- 13.2(a)6

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 staff interviews, review of two (2) of two (2) medical records (#17 and #18) of patients who fell, and review of facility policy and procedure, it was determined the agency failed to ensure patient/family education is provided according to the fall reduction program. Findings include: Reference: Facility policy titled "Patient Fall Reduction Program" states, "...Patients that are identified to have fall risk factors will receive appropriate intervention, including but not limited to the delivery of the Fall Prevention Management Education Tool. ... The patient's Plan of Care is modified to adequately address identified and individualized care requirements and patient/family education needs. ..." 1. Upon review of Medical Record #17, the following was noted: a. The patient fell on 8/29/21. b. The Fall Prevention Management Education Tool was not provided to the patient. c. The patient's Plan of Care was not modified to address identified and individualized care requirements and patient/family educational needs. 2. Upon review of Medical Record #18, the following was noted: a. The patient fell on 8/28/21. b. The Fall Prevention Management Education Tool was not provided to the patient. c. The patient's Plan of Care was not modified to address identified and individualized care requirements and patient/family educational needs. 3. The above findings were confirmed with Staff #2 and Staff #11 on 9/3/21 at 2:00 PM. N.J.A.C. 8:42-6.2(3)

Track adverse patient events CFR(s): 484.65(c)(2) Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions. This STANDARD is not met as evidenced by: Based on staff interview and documentation review, it was determined the facility failed to ensure adverse patient events are analyzed. Findings include: 1. On 8/31/21, upon review of the document titled, "ACE 2 Total Event Annual Tracking Report," the following numbers of patient falls were documented for 2020: a. January 2020 - twenty-six (26) falls; February 2020 - sixteen (16) falls; March 2020 - thirty three (33) falls; April 2020 - nineteen (19) falls; May 2020 - eighteen (18) falls; June 2020 - twelve (12) falls; July 2020 - thirteen (13) falls; August 2020 - thirteen (13) falls; September 2020 - twenty-one (21) falls; October 2020 - twenty-nine (29) falls; November 2020 - twenty-five (25) falls; December 2020 - twenty-two (22) falls. 2. On 9/3/21, upon review of the document titled, "ACE 2 Total Event Annual Tracking Report," the following numbers of patient falls were documented for 2021: a. January 2021 - twelve (12) falls; February 2021 - fifteen (15) falls; March 2021 - seventeen (17) falls; April 2021 - thirteen (13) falls; May 2021 - seven (7) falls; June 2021 - nine (9) falls. 2. Upon request, Staff #11 did not provide documentation that the QAPI (Quality Assurance Performance Improvement) program analyzed patient falls to reduce their occurrence.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: A. Based on observation of one (1) of five (5) home visits, staff interviews, and review of facility policy and procedure, it was determined the agency failed to ensure hand hygiene is performed according to agency policy. Findings include: Reference: Facility policy titled "Hand Hygiene" states, "...Staff performs hand hygiene ... after contact with inanimate objects ..." 1. During a home visit on 9/1/21 for Patient #8, the following was observed: a. At 9:45 AM, Staff #8 entered information into his/her tablet with gloved hands, cleaned the tablet and his/her gloves with an alcohol wipe, and proceeded to remove the patient's dressing. 2. The above findings were confirmed with Staff #2 and Staff #11 on 9/3/21 at 1:25 PM. N.J.A.C. 8:42-12.2(b) B. Based on observation, staff interview, and review of facility documentation, it was determined the facility failed to ensure all visitors are screened for temperature as per facility documentation. Findings include: Reference: Facility document titled, "Daily Temperature Check Instructions" states, "...Only individuals who enter the agency/facility will need to be screened. ...Thermometer use and agency/facility daily procedures: An individual and a backup should be identified to serve as temperature screener for each work day. ..." 1. Upon arrival at the home health agency, the following was noted: a. On 8/31/21 at approximately 9:35 AM, Staff #12 did not check the temperatures of the surveyors upon their entry into the facility. b. On 9/1/21 at approximately 9:18 AM, Staff #12 did not check the temperatures of the surveyors upon their entry into the facility. 2. The above findings were confirmed with Staff #11 upon exit. N.J.A.C. 8:42-12.2(b)5

Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This CONDITION is not met as evidenced by: Based on staff interviews, medical record review, and review of facility documents, it was determined the Home Health Agency failed to ensure patients receive the skilled professional services of a medical social worker. Findings include: 1. The HHA failed to ensure that skilled professional services of a medical social worker are available to all patients. (G702) 2. The HHA failed to ensure that all needed skilled professional staff is involved in the patient's plan of care. (G706) 3. The HHA failed to ensure that skilled professional services of a medical social worker are delivered according to physicians orders. (G710)

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on staff interview, it was determined the facility failed to ensure skilled professional services of a medical social worker are provided directly or through written agreement to patients who need such services. Findings include: 1. A list of current employees was provided by Staff #1. a. Under the title "Social Worker" the space was blank. b. Staff #1 stated, "We do not have a Social Worker at this time." c. Staff #11 stated, "The last day we had a social worker was 5/8/2020." 2. The above findings were confirmed with Staff #2 and Staff #11 on 9/3/21 at 1:25 PM. N.J.A.C. 8:42-9.1

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on staff interviews and review of two (2) of two (2) medical records (#11 and #12) that required social work intervention, it was determined the agency failed to ensure all needed skilled professional staff is involved in the patient's plan of care. Findings include: 1. Upon review of Medical Record #11, the following was noted: a. The Client Coordination Note Report dated 8/17/21, states, "T/C (telephone call) from [name of clinician] reports home has mouse feces and roaches, has an eviction notice and needs a proper bed. Instructed to make a referral for a social worker from [name of organization] which is partnered with APS (Adult Protective Services) ..." b. The Client Coordination Note Report dated 8/19/21, states, "... Clinician explained that [name of agency] currently does not have a social worker on staff to research services on his behalf. ..." 2. Upon review of Medical Record #12, the following was noted: a. The Client Coordination Note Report dated 9/1/21, states, "Patient/CG (care giver) provided [name of organization] contact numbers to schedule follow up to assist with long term care needs. ..." 3. The above findings were confirmed with Staff #2 and Staff #11 on 9/3/21 at 1:25 PM. N.J.A.C. 8:42-9.2(a)5

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 staff interview and review of one (1) of one (1) medical record (#18) where a social worker was ordered, it was determined the agency failed to ensure medical social services ordered by the physician are provided as indicated in the plan of care. Findings include: 1. Upon review of the Home Health Certification and Plan of Care dated 8/5/2021 to 10/3/2021, for Patient #18, the following was noted: a. Orders of Discipline and Treatments, states, "... Medical Social Services to evaluate/assess and develop social work plan of care that will be approved by the physician prior to implementation. ..." i. The patient was not evaluated by a social worker. 2. The above findings were confirmed with Staff #2 on 9/3/21 at 11:30 AM. N.J.A.C. 8:42-9.2(a)1