Every finding on record at Litson Certified Care, Inc., D/B/A Willcare

HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of 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:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This STANDARD is not met as evidenced by: Based on review of the Communication Directory and interview, the Governing Authority failed to have a complete and updated Communications Directory on the HPN Health Provider Network and have accurate active and discharged patient rosters. This was evident for the agency's Communication Directory and active patient rosters.(Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11 and #13) Failure to have a complete and updated HPN communications directory and ensure the maintenance of an accurate patient rosters which identifies current active and discharged patients has the potential to result in negative patient outcomes. The findings are: 1. The HPN Communication Directory was viewed and printed on 2/22/22. The Directory lacks documented evidence of an entry for the Administrator and identifies two persons as the Director of Patient Services (DPS). The Communications Directory was reviewed on 2/23/22 at 10:30 AM with the person identified as the DPS. The DPS stated the two persons identified in the Directory as being the DPS both left the agency about one year ago. The DPS stated that she started with the agency one week ago and submitted a request to have her name entered. No explanation was provided as to the reason there is no entry for the Administrator. 2. On 2/23/22 at 10:00 AM, a request was made for the agency's active and discharged patient rosters. An active patient roster was provided by the agency's Director of Patient Services (DPS) at 10:30 AM. A list of Patients identified in the complaint were compiled (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11 and #13). These Patients were not listed on the active Patient roster. A review of the discharged list documented Patient #10, #11 and #12 were discharged. During an interview with the DPS on 2/23/22 at 11:30 AM, the DPS stated that "those Patients are Certified Home Health Agency (CHHA) patients and they were were transferred over to another computer program".

An on-site investigation for complaint #61518 was conducted at Willcare Certified Home Health Care Agency on 2/23/22 and 2/24/22 at 608 Grant Ave Lake Katrine, NY 12449. The complaint investigation included: Thirteen (13) clinical records were reviewed and are identified as Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12 and #13. Three (3) personnel records were reviewed and identified as Employees #1, #2 and #3. The agency’s complaint log from 11/1/2021 through 2/23/2022 was reviewed. Agency policies and procedures were reviewed. The Director of Patient Services, Administrator and clinical staff were interviewed. The agency's reported census is 317. The Complaint was investigated and was found to be un-substantiated. Condition level deficiencies were identified in CoP (Conditions of Participation) 484.110 Clinical Record (G - 1008), Required Items in Clinical Record (G - 1012) and Discharge and Transfer Summaries (G - 1022). Upon review of the clinical records and interviews with staff, it was determined the agency failed to maintain clinical records that include accurate past and current information for all patients, and be available to the physician(s) issuing orders for the home health plan of care. The agency was unable to provide requested documents to include the discharge OASIS, current Plans of Care, current Medical Orders and complete nursing and progress notes. The following deficiencies are being cited: E- 0021 - Emergency Officials Contact Information; G-372 - Encoding and Transmitting OASIS; G - 376 - Transmittal of OASIS DATA; G - 434 - Participate in Care; G - 440 - Payment From Federally Funded Program; G - 484 - Document Complaint and Resolve; G - 514 - RN Performs Assessments; G - 550 - At Discharge; G - 572 - Plan Of Care G-574 - Plan of Care Must Include the Following; G - 578 - Conformance with Physician Orders; G - 580 - Only As Ordered By a Physician; G - 588- Reviewed, revised by physician every 60 days; G-590- Promptly Alert physician; G-726 - Nursing Services Supervised by Registered Nurse; G - 1008 - Clinical Records; G - 1012 - Required Items in the Clinical Record; G- 1022 - Discharge and Transfer Summaries;

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 record review and staff interview, the agency failed to ensure that OASIS data was encoded and transmitted to Centers for Medicare and Medicaid System (CMS). This was evident for one (1) of thirteen (13) clinical records reviewed. (Patient #12) Failure to ensure transmittal of OASIS data place patients at risk for negative outcomes. The finding is: Patient #12 has a start of care date of 9/15/21. The record documents a nursing OASIS re-assessment was completed on 1/12/21 on paper. The record lacks documented evidence the OASIS was encoded and transmitted to CMS. During an interview on 11/24/22 at 2:30 PM with the Director of Patient Services (DPS), the DPS stated that "they were not locked and submitted".

Transmittal of OASIS data CFR(s): 484.45(c) Standard: Transmittal of OASIS data. An HHA must- This STANDARD is not met as evidenced by: Based on record review and staff interview, the agency failed to ensure that OASIS data was transmitted to Centers for Medicare and Medicaid System (CMS). This was evident for thirteen (13) of thirteen (13) clinical records reviewed. (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12 and #13). Failure to ensure transmittal of OASIS data has the potential for negative patient outcomes. The findings are: 4. Patient #6 has a start of care (SOC) date of 9/13/2018. The last "Recertification Follow-up assessment" (OASIS) is dated 12/22/2021. There is no documented evidence the Recertification Follow-up assessment dated 12/22/2021 was transmitted to the CMS data system. 5. Patient #7 has a start of care date of 1/7/20. The " Recertification Follow-up assessment" (OASIS) is dated 12/22/2021. There is no documented evidence the Recertification Follow-up assessment dated 12/22/2021 was transmitted to the data system as of 2/24/2022 . 6. Patient #8 has a start of care date of 3/10/2016. The Recertification Follow-up assessment ( OASIS) is dated 12/8/21. There is no documented evidence the Recertification Follow-up assessment dated was transmitted to the data system as of 2/24/2022. 7.Patient #9 has a start of care date of 4/25/19. The Recertification Follow-up assessment ( OASIS) is dated 12/9/21. There is no documented evidence the Recertification Follow-up assessment dated 12/9/21 was transmitted to the data system as of 2/24/2022. 8. Patient #10 has a start of care date of 6/27/08. The Recertification Follow-up assessment ( OASIS) is dated 12/16/21. There is no documented evidence the Recertification Follow-up assessment dated dated12/16/21 was transmitted to the CMS data system as of 2/24/2022. On 2/24/2022 at 4:00PM the Director of Clinical Services was interviewed and did not provide an explanation. 9. Patient #1 has a start of care date of 11/26/2014, with diagnosis that include Bipolar Disorder, Episode Mixed with Psychiatric Features, Essential Hypertension, Alcohol Dependence Uncomplicated as documented on the “Home Health Certification and Plan Of Care" for the Certification Period of 10/20/2021 to 12/18/2021. The record document a " Recertification Follow-up Assessment" ( OASIS) dated 12/15/2021 for the Certification Period of 11/30/2021 to 1/9/2022. There is no documented evidence the assessment was transmitted as of 2/24/2022 10. Patient #2 has a start of care date of 8/10/2010. Two (2) "Recertification/Follow-up Assessments" were conducted on 12/14/21: A "Recertification/ Follow-up Assessment" (OASIS) dated 12/14/2021 for the Certification Period of 11/28/21 to 1/6/22. There is no documented evidence the assessments were transmitted as of 2/24/2022. 11. Patient #3 has a start of care date of 10/21/2020. Two (2) "Recertification/ Follow-up Assessments" were conducted on 12/14/21: A Recertification / Follow-up Assessment ( OASIS) dated 12/14/21 for the Certification Period of 11/24/21 to 1/12/22 . A Recertification/ Follow-up Assessment ( OASIS) dated 12/14/2021 for the Certification Period of 12/15/2021 to 2/12/2022 . There is no documented evidence the assessments were submitted as of 2/24/2022. 12. Patient #4 has a start of care date of 9/9/2017. Two (2) "Recertification/ Follow-up Assessments" were conducted on 12/14/22: A" Recertification/ Follow-up Assessment" (OASIS) dated 12/14/21 for the Certification Period 11/30/21 to 1 /11/22. A "Recertification/ Follow-up Assessment" ( OASIS) dated 12/14/2021 for the certification Period of 12/17/2021 to 2/14/2022 . There is no documented evidence the assessments were transmitted as of 2/24/2022 13. Patient #5 has a start of care date of 9/19/2017 . Two (2) "Recertification/ Follow-up Assessments" were conducted on 12/22/21: A "Recertification Follow-up Assessment" ( OASIS dated 12/22/21 for the Certification Period of 12/1/21 to 1/3/22. A "Recertification Follow-up Assessment" ( OASIS) dated 12/22/2021 for the Certification Period of 12/27/2021 to 2/24/2022. There is no documented evidence the assessments were transmitted as of 2/24/2022. A request was made for the last OASIS transmission. The agency provided a validation report dated 10/25/21. There is no documented evidence of OASIS transmission after 10/25/21. On 2/24/22 at 2:30 PM, the Director Of Clinical Services was interviewed and did not provide an explanation. 1. Patient #11 has a start of care date of 3/20/19. The record documents a re-certification assessment and Plan of Care were completed on 11/4/21. The record lacks documented evidence of an OASIS assessment was submitted to CMS. 2. Patient #12 has a start of care date of 9/15/2. The last OASIS submission date was 11/10/21. The record documents a nursing re-assessment was completed on 1/12/22. There is no documented evidence of OASIS submission after 11/10/21. 3. Patient #13 has a start of care date of 6/14/13. The record documents an OASIS nursing re-assessment was performed on 12/27/21. The record lacks documented evidence of the assessment being transmitted to CMS. During an interview on 2/24/22 at 2:30 PM with the Director of Administrator (DPS), the DPS stated that "they were not locked and submitted".

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on record reviews and interview, the agency failed to inform patients of the frequency of the services they would be receiving. This was evident for six (6) of thirteen (13) clinical records reviewed. (Patients #3, # 4, #5, #11, #12 and #13) Failure to ensure that patients are informed in writing of specific services they would be receiving and the frequencies has the potential for patients to be unaware of their rights which may prevent them from making informed decisions. The findings are: 4. Patient #3 has a start of care date of 10/21/2020. The "Admission Consent " form dated 10/21/2020 lacks documented evidence the Patient was informed of the frequency of services. 5. Patient #4 has a start of care date of 5/11/2018. The "Conditions Of Admission" form dated 5/11/2018 lacks the documented evidence the Patient was informed of the frequency of services. 6. Patient #5 has a start of 9/19/2017. The "Conditions Of Admission "form dated 9/19/2017 lacks the documented evidence the Patient was informed of the frequency of services. There is no documented evidence the Patients were informed of the frequency of services. During an interview with the Administrator on 3/16/22 at 2:00 PM, the Administrator did not provide an explanation for the findings 1. Patient #11 has a start of care date of 3/20/2019. The Admission Consent form dated 3/20/19 documents the Patient is to receive Skilled Nursing services. The form does not document the frequency for the nursing visits. 2. Patient #12 has a start of care date of 9/15/2021. The agency provided six (6) pages and document on page 32 the form was signed on 12/2/2020. Page #38 documents a signature and is dated 1/8/21. The consent forms document the Patient is to receive nursing services. The pages lack documented evidence of the the frequency for the nursing visits. 3. Patient #13 has a start of care date of 6/14/2013. The record documents a Conditions of Admission form that was signed on 4/20/18. A second form titled Admission Consent was signed on 3/20/2019. Both consent forms document the Patient is to receive Skilled Nursing services. The form does not document the frequency for the nursing visits. During an interview with the Administrator on 3/16/22 at 2:00 PM, the Administrator did not provide an explanation for the findings.

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: Based on record reviews and interview, the agency failed to inform patients of the cost (if any) for their services the Patients would be receiving. This was evident for two (2) of thirteen (13) clinical records reviewed. (Patients # 11 and #13) Failure to ensure that patients are informed in writing of cost of services has the potential for negative patient outcomes. The findings are: 1. Patient #11 has a start of care date of 3/20/2019. The Admission Consent form dated 3/20/19 documents the Patient is to receive Skilled Nursing services. The forms do not document the cost, if any, for the nursing services. 2. Patient #13 has a start of care date of 6/14/2013. The record documents a Conditions of Admission form that was signed on 4/20/18. A second form titled Admission Consent was signed on 3/20/2019. Both consent forms document the Patient is to receive Skilled Nursing services. The forms do not document the cost, if any, for the nursing services. During an interview with the Director of Patient Services (DPS) on 2/24/21 at 2:30 PM, the DPS did not provide an explanation for the above.

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 record reviews and staff interviews, the agency failed to document the receipt of, investigation and resolution of all complaints received by the agency. This was evident for one (1) of thirteen (13) patients.( Patient #12) Failure to provide complete documentation, investigation and resolution of all complaints received by the agency has the potential for negative patient outcomes. The findings are: Patient #12 has a start of care date of 9/15/21 with diagnoses of Post Traumatic Stress Syndrome and Schizophrenia as documented on the Home Health Certification and Plan of Care dated 11/14/21 through 1/12/22. The Home Health Certification and Plan of Care dated 11/14/21 through 1/12/22 documents the Patient is to receive a Skilled Nurse weekly for medication pre-pours. The record documents that the Patient called the agency on 1/5/22 and "was upset that the nurse would not be coming today but would go tomorrow". The note does not document whether the Patient has a sufficient amount of medication until the next day. The agency's complaint log from 11/1/21 through 2/23/22 was requested and reviewed. The above complaint was not documented in the log. During an interview with the DPS on 2/23/22 at 3:00 PM the DPS did not provide an explanation for the above.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the development of an updated comprehensive assessment at discharge to include a summary of the patient's progress in meeting the care plan goals. This was evident in one (1) of two (2) discharged records. (Patient #11) Failure to development of an updated comprehensive assessment at discharge to include a summary of the patient's progress in meeting the care plan goals has the potential for negative patient outcomes. The finding is: Patient #11 has a start of care date of 3/20/19 with diagnoses of Schizo-affective Disorder and Lymphedema as documented on the Home Health Certification and Plan of Care dated 11/4/21 through 1/2/22. A Coordination note dated 12/22/21 documents the Patient was transferred to the hospital on 12/21/21. There is no documented evidence of a Resumption of Care or nursing visits after 12/21/21. The record lacks documented evidence of an OASIS discharge summary developed to include all aspects required including an updated comprehensive assessment at discharge to include a summary of the patient's progress in meeting the care plan goals. During an interview with the Director of Patient Services (DPS) on 2/24/22 at 2:30 PM, the DPS 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 record review and interview, the Governing Authority failed to ensure that all patients receive services as outlined in the written Plan of Care. This was evident in six (6) of thirteen (13) Clinical records reviewed. (Patients #1, #2, #3, #4, #10 and #12). Failure to ensure that all patients receive services as outlined in the written Plan of Care, has the potential for negative patient outcomes. The findings are: 2. Patient #1 has a start of care has a start of care date of 11/26/2014 with diagnosis that include Bipolar Disorder, Episode Mixed with Psychiatric Features, Essential Hypertension, Alcohol Dependence Uncomplicated as documented on the “Home Health Certification and Plan Of Care" for the Certification Period of 10/20/2021 to 12/18/2021. The record document the following nursing visits: 12/29/21, 1/12/22 and 1/26/22. There is no documented evidence of a written Plan Of Care after the Certification Period ending 12/18/21. 3. Patient #2 has a start of care date of 8/10/2010 with diagnosis that include Bipolar Disorder, Panic Disorder, Personal History of Pulmonary Embolism, Congenital malformation Of Brain, Personal History Of Other Venous Thrombosis and Embolism as documented on the “ Home Health Certification and Plan Of Care” for the Certification Period of 12/18/21 to 2/15/22. The record document the following nursing visit dated : 2/22/22 " Scheduled Skilled Nurse Visit. Intervention: Observation / Assessment, Medication Box Set- Up. Medication sleeve reflect compliance. Medication pre- pour done by Writer". . There is no documented evidence of a written Plan Of Care after the Certification Period of 12/18/21 to 2/15/22. 4. Patient #3 has a start of care date of 10/21/20 with diagnosis that include Bipolar Disorder, Memory deficit Following Cerebral Infarction, Vascular Dementia with Behavioral Disturbances, Type II Diabetes Mellitus Without Complications, Long term Use Of Oral Hypoglycemic Agents as documented on the “Home Health Certification and Plan Of Care” for the Certification Period of 12/15/21 to 2/12/2022. The record document the following nursing visits: 2/16/22 and 2/23/22. There is no documented evidence of a written Plan Of Care after the certification period ending of 12/15/21 to 2/12/2022. 5. Patient #4 has a start of care date of 9/9/2017 with diagnosis that include Schizophrenia, Anxiety Disorder, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting The Right Dominant Side, History Of Falling as documented on the " Home Health Certification and Plan Of Care" for the Certification Period of 12/17/21 to 2/14/22. The record document the following nursing visits: 2/15/22 and 2/22/22. There is no documented evidence of a written Plan Of Care after the certification Period of 12/17/21 to 2/14/22. 6. Patient #10 has a start of care date of 6/27/08 and a discharge date of 11/27/21 with diagnosis of schizophrenia, major depressive disorder, anxiety, and alcohol abuse documented on the Home Health Certification and Plan of Care for certification period 12/16/21 to 2/13/22. The record documents a nursing visit was made on 2/16/22. The record lacks documented evidence of an active/current Plan of Care after 2/13/22. There is no documented evidence that all patients received services as per a written individualized Plan of Care. During an interview with the Director of Patient Services (DPS) on 2/24/22 at 3:00 PM, the DPS did not provide an explanation for the above. 1. Patient #12 has a start of care date of 9/15/21 with diagnoses of Post Traumatic Stress Syndrome and Schizophrenia as documented on the Home Health Certification and Plan of Care dated 11/14/21 through 1/12/22. The record documents nursing visits were made on 2/2/22 and 2/23/22. The record documents an OASIS re-assessment was completed on 1/12/22. There is no documented evidence of a written Plan of Care developed after 1/12/22.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record reviews and interview, the agency failed to develop complete and comprehensive Plans of Care. This was evident for five (5) of thirteen (13) clinical records reviewed. (Patient #6, #7, #10, #12 and #13). Failure to develop complete and comprehensive Plans of Care has the potential for negative patient outcomes. The findings are: 3. Patient #6 has a start of care date of 9/13/2018 with diagnoses of Bipolar Disorder, Panic Disorder, Atherosclerotic Heart Disease, Hypertensive Heart Disease Diabetes Mellitus Type 2 and Chronic Obstructive Pulmonary Disease documented on the Home Health Certification and Plan of Care for certification period 12/26/21 to 2/23/22. The Home Health Certification and Plan of Care for certification period 12/26/21 to 2/23/22 documents, “RN visit 8 visits for one certification period starting 12/26/21; skilled nursing to provide assessment observation every visit; assess/observe patient’s compliance with treatment and medications" The skilled nursing visit notes dated 1/26/22, 2/2/22, 2/9/22, 2/16/22, and 2/23/22 documents, " Med (medication) pre pour done". The Plan of Care lacks documented evidence of the frequency for skilled nursing visits and the nurse is to pre-pour medications. 4. Patient #7 has a start of care date of 1/7/20 with diagnoses of Bipolar II Disorder, Borderline Personality, Post Traumatic Stress Disorder, Hypothyroidism, Hyperlipidemia, Generalized Anxiety Disorder, and Obesity documented on the Home Health Certification and Plan of Care for certification period 12/21/21 to 2/24/22. The Home Health Certification and Plan of Care for certification period 12/21/21 to 2/24/22 documents, “RN visit 4 visit for one Certification period starting 12/27/21; Skilled Nursing (SN) to assess/observe patient's Compliance with treatment and medication”. The Skilled Nursing visit notes dated 12/22/21 and 12/27/21 document, "pre-pour done by writer". The Plan of Care lacks documented evidence the nurse is to pre-pour medications. 5. Patient #10 has a start of care date of 6/27/08 with diagnoses of schizophrenia, major depressive disorder, anxiety, and alcohol abuse documented on the Home Health Certification and Plan of Care for certification period 12/16/21 to 2/13/22. The Home Health Certification and Plan of Care for certification period 12/16/21 to 2/13/22 documents, “skilled nursing (SN) 8 visits for one certification period starting 12/16/21; SN to assess/observe cognitive functioning; provide system assessment/observation every visit; assess/observe patient compliance with treatment and medications” The Skilled Nursing visits dated 2/2/22, 2/9/22, and 2/16/22 documents, "Med (medication) pre pour done". The Plan of Care lacks documented evidence for the nurse to pre-pour medications. There is no documented evidence all patients plans of care are complete. On 2/23/2022 at 4:00PM the Director of Clinical Services was interviewed and did not provide an explanation. 1. Patient #12 has a start of care date of 9/15/21 with diagnoses of Post Traumatic Stress Syndrome and Schizophrenia as documented on the Home Health Certification and Plan of Care dated 11/14/21 through 1/12/22. The record documents an OASIS re-assessment was completed on 1/12/22; Patient received nursing visits on 1/25/22, 2/2/22 and 2/23/22 to pre-pour medications. There is no documentation of a Plan of Care developed after 1/12/22. 2. Patient #13 has a start of care date of 7/9/19 with diagnoses of Bipolar Disorder, Diabetes Type Two and Hypertension as documented on the the Home Health Certification and Plan of Care dated 12/29/21 through 2/26/22. The Home Health Certification and Plan of Care dated 12/29/21 through 2/26/22 documents: Skilled Nurse (SN) weekly visits; SN to pre-pour medications; Novolog Flex-pen sliding scale- 110 to 140-3 units, 141 to 180 -5 units; 181 to 220 - 7 units, 221 to 260 - 9 units, 261 to 300 - 11 units, 301 to 36- - 13 units, over 361 call physician; Toujeo Max 10 units three (3) times a day; Mental status is depressed, anxious, cognitive deficits, poor insight and judgement. The Plan of Care lacks documented evidence of the frequency the Patient is to have the blood glucose monitored. There is no documented evidence all patients plans of care are complete. During an interview with the Registered Nurse on 2/24/22 at 2:17 PM, the Nurse stated "the blood glucose is monitored three times a day after eating".

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 record reviews and interviews, the agency failed to ensure that nursing services are provided in accordance with the physician's orders. This was evident for two (2) of thirteen (13) clinical records reviewed. (Patients #12 and #13) Failure to ensure that patient care is provided in accordance with the physician's orders has the potential for negative patient outcomes. The findings are: 1. Patient #12 has a start of care date of 9/15/21 with diagnoses of Schizophrenia and Post Traumatic Stress Disorder as documented on the Home Health Certification and Plan of Care dated 11/14/21 through 1/12/22. The Home Health Certification and Plan of Care dated 11/14/21 through 1/12/22 documents the Patient is to receive nursing visits every week to pre-pour medications. There is no documented evidence the nurse went to the home to pre-pour medications the week of 1/2/22 through 1/8/22. There is no documented evidence of the nurse conforming to the physician's orders. 2. Patient #13 has a start of care date of 6/14/13 with diagnoses of Bipolar Disorder, Diabetes Mellitus Type Two and Hypertension as documented on the Home Health Certification and Plan of Care date documents d 12/29/21 through 2/26/22. The Home Health Certification and Plan of Care dated 12/29/21 through 2/26/22 documents Skilled Nursing (SN) visits weekly to pre-pour medications, monitor for medication compliance, parameters for physician notification blood glucose readings and assess/observe Diabetic status; Novolog Insulin as needed on a sliding scale as per the finger stick readings. The SN notes dated 1/5/22 through 2/16/22 lack documented evidence as to whether the Patient is compliant with finger sticks, the readings obtained since last visit and whether the Novolog is being administered. There is no documented evidence of the nurse conforming to the physician's orders. In an interview with the Registered Nurse (RN) and the Director of Patient Services (DPS) on 2/24/22 at 2:17 PM, the RN and DPS did not provide an explanation for the above.

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 record reviews and staff interview, the agency failed to ensure services, drugs and treatments are administered only as ordered by Physicians . This was evident for five (5) of thirteen (13) clinical records reviewed. (Patients #1, #2, #3, #4 and #12) Failure ensure services, drugs and treatments are administered only as ordered by physicians has the potential for negative patient outcomes. The findings are: 1. Patient #1 has a start of care has a start of care date of 11/26/2014 with diagnosis that include Bipolar Disorder, Episode Mixed with Psychiatric Features, Essential Hypertension, Alcohol Dependence Uncomplicated as documented on the “Home Health Certification and Plan Of Care" for the Certification Period of 10/20/2021 to 12/18/2021. The “ Home Health Certification and Plan Of Care” for the Certification Period of 10/20/2021 to 12/18/21 document:” Skilled Nurse (SN) effective 10/31/2021 once a week for one week, once every 2 weeks for six weeks. SN to prefill planner device every week, instruct patient/ caregiver on how to prefill medication planner. SN to continue to educate and stress to patient hazards of alcohol abuse and her medication”. Medications: Aspirin 81 mg tablet delayed release one tablet oral every morning, Lisinopril 2.5 mg tablet one tablet every morning oral, Lithium Carbonate 300 mg capsule one capsule oral twice a day, Primidone 50 mg tablet 2 tablets oral three times a day, Risperidone 2 mg tablet one tablet oral twice a day." The record document the following nursing visits: 12/29/21, 1/12/22 and 1/26/22. The " Nursing progress Note" dated 12/29/21 documents: " Observation/ Assessment, Compliant with medication regimen, Medication count reflects compliance." The " Nursing Progress Note dated document: "1/12/22, Mental Health and Physical Assessment, Medication pre-pour completed with the oversight of Skilled Nurse. Medication education/reconciliation completed." The Nursing Progress Note dated 1/26/22 documents: "Scheduled Skilled Nurse Visit, Observation/ Assessment, Medication sleeve reflect compliance, Patient pours medication herself." There is no documented evidence of a written Plan Of Care/Physician's Orders after the Certification Period ending 12/18/21. There is no documented evidence the drugs, the nursing services/Treatments were ordered by a Physician. 2. Patient #2 has a start of care date of 8/10/2010 with diagnosis that include Bipolar Disorder, Panic Disorder, Personal History of Pulmonary Embolism, Congenital malformation Of Brain, Personal History Of Other Venous Thrombosis and Embolism as documented on the “ Home Health Certification and Plan Of Care” for the Certification Period of 12/18/21 to 2/15/22. The " Home Health Certification and Plan Of Care” for the Certification Period of 12/18/21 to 2/15/22 document: "Treatment Orders: Registered Nurse ( RN) Visit 11 visits for one certification Period starts week of 12/18/21; OASIS Recertification Visit one hour Certification Period starts week of 12/18/21. Licensed Practical Nurse 8 Visit certification for one Certification Period starts 12/18/21. Medications: Polyethylene Glycol 3350 oral packet once a day as directed by Physician, Percocet oral tablet 5-325 mg 2 tablets oral every 4 hours for pain, Oxycodone- Acetaminophen oral tablet 5-325 mg 1-2 tablet as needed three times a day for pain, Nystatin external ointment 1000000 unit/gm small amount topical as needed every 4hours for rash, small amount on affected areas, Lamotrigine oral tablet 25 mg three tablets twice a day, Ibuprofen oral tablet 800 mg , one tablet every 8 hours as needed for pain, Fexofenadine HCL oral tablet 180 mg one tablet oral once a day, Duloxetine HCL oral capsule sprinkle 60 mg one capsule once a day take with 20 mg of Duloxetine, Duloxetine HCL oral capsule sprinkle 20 mg one capsule once a day in addition with 60 mg of Duloxetine, Calcium 600 + D oral tablet 600- 200 mg -unit one tablet oral once a day, Aspirin Acetaminophen Caffeine 250-250-65 mg two tablets oral as needed once a day for migraine, Aspirin oral tablet delayed release 81 mg tablet oral once a day, Arthritis Pain relief oral tablet extended release 650 mg one tablet oral as needed every 8 hours as needed for pain, Aripiprazole oral tablet 5 mg one tablet oral once a day." The record document the following nursing visit dated : 2/22/22, " Scheduled Skilled Nurse Visit. Intervention: Observation / Assessment, Medication Box Set- Up. Medication sleeve reflect compliance. Medication pre- pour done by Writer". There is no documented evidence of a written Plan Of Care/ Medical Orders after the Certification Period of 12/18/21 to 2/15/22. There is no documented evidence the drugs and nursing services/ treatments were ordered by a Physician. There is no documented evidence of conformance to Physician's Orders. 3. Patient #3 has a start of care date of 10/21/20 with diagnosis that include Bipolar Disorder, Memory deficit Following Cerebral Infarction, Vascular Dementia with Behavioral Disturbances, Type II Diabetes Mellitus Without Complications, Long term Use Of Oral Hypoglycemic Agents as documented on the “Home Health Certification and Plan Of Care” for the Certification Period of 12/15/21 to 2/12/2022. The " Home Health certification and Plan Of Care for the Certification Period of 12/15/21 to 2/12/22 document:” Skilled Nurse Orders: Frequency/ Duration: 1 time a week for one certification period. RN ( Registered Nurse) 8 Visit Certification Period Period start week of 12/15/21. OASIS Recertification Visit weekday one Visit Certification period starts week of 12/14/21, Skilled Nurse to assess / observe diabetic status ( Schedule). Vital Signs and Parameters. Skilled Nurse to provide System Assessment/ Observation every visit. Medications: Zebutal oral capsule50-325-40 mg one tablet as needed (PRN) twice a week for cerebral headaches, Topiramate oral tablet 25 mg / 3 tabs oral at bedtime, Thiamine HCL tablet 100 mg one tablet oral once a day, Sertraline HCL oral 100 mg tabs 2 tablets once a day, Pantoprazole Sodium oral delayed release 20 mg/ one tablet once a day, Mirtazapine 15 mg tablet one tablet oral at night, Metformin HCL ER one tablet extended release 500 mg once a day, Levetiracetam 750 mg tablet 2 tabs twice a day, Depakote oral tablet extended release 250 mg one tablet twice a day, Clonazepam oral tablet 1 mg tablet twice a day”. The record document the following nursing visits: 2/16/22 and 2/23/22. The " Nursing Progress Note " dated 2/16/22 document: "Scheduled Skilled Nurse Visit. Intervention: Observation/ Assessment, Medication box set-up. Medication sleeve reflects compliance. Medication pre- pour done by writer" The " Nursing Progress Note " dated 2/23/22 document: "Scheduled Skilled Nurse Visit. Intervention: Observation/ Assessment, Medication box set-up. Medication sleeve reflects compliance. Medication pre- pour done by writer" There in no documented evidence of a written Plan Of Care/ Physician's Orders after the Certification Period of 12/18/21 to 2/15/22. There is no documented evidence the drugs, nursing services/ treatments were ordered by a Physician. There is no documented evidence the drugs and nursing services/ treatments were ordered by a Physician. 4. Patient #4 has a start of care date of 9/9/2017 with diagnosis that include Schizophrenia, Anxiety Disorder, Hemiplegia Following Cerebral Infarction Affecting Right Dominant Side as documented on the Side, History Of Falling as documented on the " Plan Of Care" for the Certification Period of 12/17/21 to 2/14/22. The “ Plan Of Care” for the certification Period of 12/17/21 to 2/14/22 document:” Registered Nurse 8 Visit Certification Period starts week of 12/17/21. OASIS Recertification Visit weekday one hour Certification Period. Skilled Nurse order: Seen weekly for medication pre-pour throughout Certification Period. Medications: Tylenol 8 hour oral tablet Extended Release 650 mg one tablet oral as needed every 8 hours for generalized pain, Trazodone HCL oral tablet 150 mg one tablet oral at bedtime, Seroquel oral tablet 400 mg one tablet oral twice a day, Omeprazole oral capsule Delayed release 20 mg once capsule oral twice a day, Multivitamin oral tablet one tablet oral once a day, Olanzapine oral tablet 2.5 mg one tablet oral at bedtime, Hydrocortisone Acetate External cream 1% per instructions topical twice a day, apply to face, Fluticasone Propionate Nasal Suspension 50 mcg /act one spray nasal once a day, Benztropine Mesylate oral tablet 2 mg one tablet oral at bedtime, Aspirin oral tablet Delayed Release 81 mg one tablet oral once a day." The record document the following nursing visits: 2/15/22 and 2/22/22. The "Nursing Progress Note" dated 2/15/22 document:" Observation/ Assessment , Medication Box Set- Up. Medication sleeve reflects compliance. Medication pre- pour done by the writer." The "Nursing Progress Note" dated 2/22/22 document:" Observation/ Assessment , Medication Box Set- Up. Medication sleeve reflects compliance. Medication pre- pour done by the writer." There is no documented evidence of a written Plan Of Care / Physician Orders after the Certification Period ending 2/14/22. There is no documented evidence the drugs and nursing services and treatments were ordered by a Physician. There is no documented evidence the drugs and nursing services/ treatments were ordered by a Physician. 5. Patient #12 has a start of care date of 9/15/21 with diagnoses of Post Traumatic Stress Syndrome and Schizophrenia as documented on the Home Health Certification and Plan of Care dated 11/14/21 through 1/12/22. The record documents the Patient is receiving nursing services every week (1/25/22, 2/2/22 and 2/23/22) for evaluation and medication pre-pours. The record lacks documented evidence of a Pan of Care/Medical Orders developed after 1/12/22 to include nursing visits and medication pre-pours. There is no documented that all Patients receive services , drugs and treatments only when ordered by the Physicians On 2/24/22 at 4:00 PM, the Director Of Clinical Services was interviewed and did not have an explanation for the above.

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on record reviews and staff interviews, the agency failed to ensure that the Patients' individualized Plan of Care are reviewed and revised as the patient's condition or need require but no less frequently than once every 60 days. This was evident for five (5) of thirteen (13) clinical records reviewed. ( Patients #1, #2, #3, #4 and #12). Failure to ensure that Patient's individualized Plan Of Care are reviewed and revised as the patient's condition or need require but no less frequently than once every 60 days has the potential for negative patient outcomes. The findings are: 5. Patient #12 has a start of care date of 9/15/21. The record documents a Home Health Certification and Plan of Care dated 11/14/21 through 1/12/22 documents the Patient is to receive weekly nursing visits to evaluate and pre-our medications. The record documents a nursing recertification assessment was completed on 1/12/22. There is no documented evidence of a Plan of Care developed after 1/12/22. During an interview with the Director of Patient Services (DPS) on 2/24/22 at 2:00 PM, The DPS did not provide an explanation. 1. Patient #1 has a start of care has a start of care date of 11/26/2014 with diagnosis that include Bipolar Disorder, Episode Mixed with Psychiatric Features, Essential Hypertension, Alcohol Dependence Uncomplicated as documented on the “Home Health Certification and Plan Of Care for the Certification Period of 10/20/2021 to 12/18/2021. The record document the following nursing visits: 12/29/21, 1/12/22 and 1/26/22. There is no documented evidence of a written Plan Of Care / Physician Orders after the Certification Period ending 12/18/21. There is no documented evidence the Plan Of Care was reviewed and revised by a Physician as frequently no less than every 60 days. 2. Patient #2 has a start of care date of 8/10/2010 with diagnosis that include Bipolar Disorder, Panic Disorder, Personal History of Pulmonary Embolism, Congenital malformation Of Brain, Personal History Of Other Venous Thrombosis and Embolism as documented on the “ Home Health Certification and Plan Of Care” for the Certification Period of 12/18/21 to 2/15/22. The record document the following nursing visit dated : 2/22/22, " Scheduled Skilled Nurse Visit. Intervention: Observation / Assessment, Medication Box Set- Up. Medication sleeve reflect compliance. Medication pre- pour done by Writer". There is no documented evidence of a written Plan Of Care after the Certification Period of 12/18/21 to 2/15/22. There is no documented evidence the Plan Of Care was reviewed and revised by a Physician as frequently no less every 60 days. 3. Patient #3 has a start of care date of 10/21/20 with diagnosis that include Bipolar Disorder, Memory deficit Following Cerebral Infarction, Vascular Dementia with Behavioral Disturbances, Type II Diabetes Mellitus Without Complications, Long term Use Of Oral Hypoglycemic Agents as documented on the “Home Health Certification and Plan Of Care” for the Certification Period of 12/15/21 to 2/12/2022. The record document the following nursing visits: 2/16/22 and 2/23/22. There is no documented evidence of a written Plan Of Care after the Certification Period of 12/18/21 to 2/15/22. There is no documented evidence the Plan Of Care was reviewed and revised by a Physician as frequently no less every 60 days. 4. Patient #4 has a start of care date of 9/9/2017 with diagnosis that include Schizophrenia, Anxiety Disorder, Hemiplegia Following Cerebral Infarction Affecting Right Dominant Side as documented on the Side, History Of Falling as documented on the " Plan Of Care" for the Certification Period of 12/17/21 to 2/14/22. The record document the following nursing visits: 2/15/22 and 2/22/22. There is no documented evidence of a written Plan Of Care after the Certification Period ending 2/14/22. There is no documented evidence the Plan Of Care was reviewed and revised as frequently no less every 60 days by a Physician.

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 reviews and interview, the agency failed to promptly notify the physician of changes in patients' status which may require alteration in the Plans of Care. This was evident for three (3) of thirteen (13) clinical records reviewed. (Patients #8, #9 and #11) Failure to notify the physician of the patient's change in status has the potential of negative patient outcomes. The findings are: 2. Patient #8 has a start of care date of 3/10/2016 with diagnosis of Major Depressive Disorder, Diabetes Mellitus Type 2, Hypertensive Heart Disease, Congestive Heart Failure, and Hypothyroidism as documented on the Home Health Certification and Plan of Care for certification period 10/10/21 to 12/8/21. The Home Health Certification and Plan of Care for certification period 10/10/21 to 12/8/21 documents, “skilled nursing (SN) one x week/ for 9 weeks; SN to evaluate and develop Plan of Care, may use telehealth to provide services; skilled nurse to prefill planner device every 7 days”. A nursing recertification visit dated 12/8/21documents: "entered client’s home to complete recertification visit; became agitated and yelling, house is dirty, disorganized and unsafe; patient is a hoarder, apartment is unsanitary and is a high risk for falls/fires; I spoke with physician to form the physician that I was unable to pour medications and the condition of the apartment; I was informed that she (the physician) was fired from the practice; called Psychiatrist and patient was no longer follows up there”. There is no documented evidence the patient is receiving follow up care/ Psychiatric monitoring after 12/8/21 from a physician and/or a physician was notified that the patient is unsafe and disorganized. There is no follow-up to determine the name of a physician that will be managing the Patient's care and Plan of Care. 3. Patient #9 has a start of care date of 4/25/19 with diagnosis of Schizophrenia, Hypertension, Chronic Obstructive Pulmonary Disease, Diabetes Mellitus Type 2, Nicotine Dependence, and History of falling as documented on the Home Health Certification and Plan of Care for certification period 12/10/21 to 2/7/22. The Home Health Certification and Plan of Care for certification period 12/10/21 to 2/7/22 documents, “frequency/duration of visit one visit x one week; skilled nursing (SN) to evaluate patient and develop plan of care; may use telehealth and telecommunication to provide services, SN to prefill planner device every week; instruct patient/caregiver on how to prefill medication planner; Mental Status: Depressed, Anxious, poor insight and judgment”. The RN note dated 1/4/22 documents the Patient stated that he fell on Sunday (1/2/22) when he was walking outside to smoke”; The nursing note dated 1/14/22 documents, “legs are slightly swollen which improved from last time; client's vision has rapidly decrease; states fell outside about a week ago”. There is not documented evidence the physician was notified of the client vision; swelling to legs and the fall. On 2/23/2022 at 4:00PM the Director of Clinical Services was interviewed and did not provide an explanation. 1. Patient #11 has a start of care date 3/20/19 with diagnoses of Schizoaffective Disorder and Lymphedema as documented on the Home Health Certification and Plan of Care dated 11/4/21 through 1/2/22. The Home Health Certification and Plan of Care dated 11/4/21 through 1/2/22 documents: Skilled Nurse (SN) visits weekly to pre-pour medications and evaluate Patient and report pain greater than 6 on a scale of 0 to 10. The POC lacks documented evidence of pain medications and/or modalities to reduce pain. The SN note dated 11/1/21 documents the Patient has generalized pain and it is rated 7. There is no documented evidence of communication with the physician regarding the Patient's pain for possible pain medications and/or modalities to reduce pain and possible revision to the Plan of Care. The nursing visit note dated 1/26/21 documents: "positive for auditory hallucinations and delusional thought, yelling outburst through visit, able to be re-directed for brief intervals; patient refuses to see dermatologist ; Psoriasis is increasing with peeling of skin and thick crusted areas, skin bright red; Patient's partner is not able to assist client because Patient becomes abusive; Psoriasis has gotten worse since she ran out of medication; physician refuses to order medication until Patient is seen". The nursing visit note dated 12/1/21 documents: Patient refuses to leave her apartment, refuses to go to the doctor despite Psoriasis condition is worse, Client's hygiene is poor, body odor is notable, hair is dirty with thick skin peeling; Odor in the apartment from peeling skin on the floor; medication sleeves reflect slow progress of improved medication compliance. The note does not document which medications the Patient has not been compliant. There is no documented evidence of communication with the physician regarding the above. During an interview with the Director of Patient Services (DPS) on 2/24/22 at 2:30 PM, the DPS did not provide an explanation.

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on record reviews and staff interviews, the Home Health agency failed to ensure that LPNs are assigned to the care of patients in accordance with their licensure, their training, orientation and demonstrated skills. This was evident for one (1) of thirteen (13) patient care records reviewed. (Patient #9). Failure to ensure that staff are assigned to the care of patients in accordance with their licensure, their training, orientation and demonstrated skills have the potential for negative patient outcomes. The findings are: Patient #9 has a start of care date of 4/25/19 and a discharged date of 12/10/21 with diagnosis of Schizophrenia, Hypertension, Chronic Obstructive Pulmonary Disease, Diabetes Mellitus Type 2, Nicotine Dependence, and History of falling documented on the Home Health Certification and Plan of Care for certification period 12/10/21 to 2/7/22. The Home Health Certification and Plan of Care for certification period 12/10/21 to 2/7/22 documents, “frequency/duration of visit one visit x one week; skilled nursing (SN) to evaluate patient and develop plan of care; may use telehealth and telecommunication to provide services, SN to prefill medication planner device every week; instruct patient/caregiver on how to prefill medication planner; Mental Status: Depressed, Anxious, poor insight and judgment”. The Skilled Nursing note document titled: "Visit Note Report" with sections titled "Assessment" dated 1/14/22 was completed by an LPN. There is no documented evidence the LPN is assigned to the care of patients in accordance with their licensure, and functioning in the Scope of Practice of Licensed Practical Nurses which clarifies that assessment is not within the privilege of an LPN. On 2/24/2022 at 4:00PM the Director of Clinical Services was interviewed and did not provide an explanation.

Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This CONDITION is not met as evidenced by: Based on record review, discharged patient roster and interview, the agency failed to maintain clinical records that include accurate past and current information for all patients, and be available to the physician(s) issuing orders for the home health plan of care. This was evident for twelve (12) of thirteen (13) records reviewed. (Patients #1, #2, #3, #4, #5, #6, #8, #9, #10, #11, #12 and #13) Failure to maintain clinical records that include accurate past and current information for all patients, and has the potential to result in negative patient outcomes. The findings are: 1. Patient #1 has a start of care has a start of care date of 11/26/2014 with diagnosis that include Bipolar Disorder, Episode Mixed with Psychiatric Features, Essential Hypertension, Alcohol Dependence Uncomplicated as documented on the “Home Health Certification and Plan Of Care for the Certification Period of 10/20/2021 to 12/18/2022. The “ Home Health Certification and Plan Of Care” for the Certification Period of 10/20/2021 to 12/18/21document:” Skilled Nurse (SN) effective 10/31/2021 once a week for one week, once every 2 weeks for six weeks. SN to prefill planner device every week, instruct patient/ caregiver on how to prefill medication planner. SN to continue to educate and stress to patient hazards of alcohol abuse and her medication”. A document titled: “ Discharge/ Transfer Summary Report" dated 12/2/21 document:” Discharged/ Transferred to a home under care of organized Home Health Service organization in anticipation of covered skilled care. Reason: No longer meets eligibility requirements: Independent in the home." A “Coordinated Notes Report” document:” As of 12/21/21 Patient record can be accessed in the Continulink EMR ( Electronic Medical Record)”. The record document the following skilled nursing visit dates after the discharge: 12/29/21, 1/12/21, 1/26/22 and 2/9/22. There is no documented evidence of an " actual discharge of the Patient". There is no documented evidence of a written Plan Of Care/ Physician Orders after the Certification Period ending 12/18/21. There is no documented evidence the drugs, the nursing services/Treatments were ordered by a Physician. There is no documented evidence the Plan Of Care/ Physician's Orders was reviewed and revised by the Physician as frequently no less than 60 days. There is no documented evidence of conformance to Physician's Orders There is no documented evidence the clinical record include accurate past and current information. 2. Patient #2 has a start of care date of 8/10/2010 with diagnosis that include Bipolar Disorder, Panic Disorder, personal History of Pulmonary Embolism, Congenital malformation Of Brain as documented on the “ Home Health Certification and Plan Of Care” for the Certification Period of 10/19/21 to 12/17/21. The “ Home Health Certification and Plan Of Care” for the Certification Period of 10/19/21 to 12/17/21. Document :” Skilled Nurse effective 10/24/21 once a week for eight weeks, 1 as needed for medication or behavior changes. Skilled Nurse to prefill planner device every week. Skilled Nurse to evaluate patient and develop plan of care in coordination with Physician”. A "Discharge / Transfer Summary Report" dated 12/5/21 document: “ Discharged/ transferred to a home under care of organized home health service organization in anticipation of covered skilled care/ reason: no longer meet eligibility requirements/ condition: independent in the home”. A Coordination Notes Report dated 12/21/21 document:” As of 12/5/21 patient record can be accessed in the ContinulinkEMR”. A" Plan of Care" dated 12/18/21 to 2/15/22 document : “RN 11 visit certification Period. LPN 8 Visit Certification period. Oasis Recertification Visit weekday 1 hour Certification Period starts 12/18/21; LPN visit 8 Certification Period for 1 Certification Period starts 12/18/21.Client seen for medication pre pour throughout Certification Period”. The record document the following nursing visits: 12/7/21, 12/14/21, 12/21/21, 12/28/21, 1/4/22, 1/18/22, 1/25/22, 2/8/22, 2/22/22. There is no documented evidence of a written Plan Of Care/ Physician Orders after the Certification Period ending 2/15/22. There is no documented evidence the drugs, the nursing services / Treatments were ordered by a Physician. There is no documented evidence on an " actual discharge of the Patient". There is no documented evidence the Plan Of Care/ Physician's Orders was reviewed and revised by the Physician as frequently no less than 60 days. There is no documented evidence of conformance to Physician's Orders There is no documented evidence the clinical record include accurate past and current information. 3. Patient #3 has a start of care date of 10/21/2020 with diagnosis that include Schizoaffective Disorder, Bipolar Disorder, Vascular Dementia with Behavioral Disturbance as documented on the “ Home Health Certification and Plan Of Care" for the Certification Period of 10/16/21 to 12/14/21. The "Home Health Certification and Plan Of Care" for the Certification Period of 10/16/21 to 12/14/21 document:” Skilled Nurse effective 10/17.21 once a week for nine weeks. SN to prefill planner device every week. Instruct patient / caregiver how to prefill medication planner”. A document titled:" Discharge Summary Report dated 12/2/21 document: “ Discharge to Home or self care / reason no longer meets eligibility requirements/ conditions: Independent in the home. A coordinated Notes Report dated 12/21/21 document:” As of 12/2/21 Patient record can be accessed in the ContinulinkEMR:” The record document a " Plan Of Care " dated 12/15/21 for the Certification Period of 12/15/21 to 2/12/22 document :" Registered Nurse (RN) Visit Certification Period for one Certification Period starts week of 12/15/21. OASIS Recertification Visit Weekday one Visit Certification Period starts week of 12/14/21." The record document the following nursing visits : 12/8/21, 12/22/21, 12/28/21, 1/5/22, 1/26/22, 2/16/22 and 2/23/22. There is no documented evidence of a written Plan Of Care/ Physician Orders after the Certification Period ending 2/12/22. There is no documented evidence of an " actual discharge of the Patient". There is no documented evidence the drugs, the nursing services / Treatments were ordered by a Physician. There is no documented evidence the Plan Of Care/ Physician's Orders was reviewed and revised by the Physician as frequently no less than 60 days. There is no documented evidence of conformance to Physician's Orders. There is no documented evidence the clinical record include accurate past and current information. 4. Patient #4 has a start of care date of 9/9/2017 with diagnosis that include Schizophrenia, Anxiety Disorder, Hemiplegia Following Cerebral Infarction Affecting Right Dominant Side as documented on the Side, History Of Falling for the Certification Period of 10/18/21 to 12/16/21. The “ Home Health Certification and Plan Of Care” for the certification Period of 10/18/21 to 12/18/21 document :”Skilled Nurse once a week for nine weeks, 1 as needed for medication or behavioral changes. Skilled Nurse to prefill planner device every week , instruct patient/ caregiver on how to prefill medication planner." The record document a " Discharge Transfer Summary Report" dated 12/3/21:” Discharged/ transferred to a home under organized home health service organization in anticipation of covered skilled care/ Reason: no longer meets eligibility requirements. Condition: Unstable." A "Coordination Notes Report" dated 12/21/21 Document:” As of 12/3/21 the patient record can be accessed in the ContinulinkEMR”. The record document a " Plan Of Care" dated 12/17/21 to 2/14/22 document: " RN 8 Visit certification Period for one certification Period starts week of 12/17/21. OASIS Recertification Visit weekday one hour certification Period starts week of 12/17/21." The record document the following nursing visits : 12/10/21, 12/21/21, 12/28/21, 1/18/22, 2/1/22, 2/15/22 and 2/22/22. There is no documented evidence of an " actual discharge of the Patient". There is no documented evidence of a written Plan Of Care/ Physician Orders after the Certification Period ending 2/14/22. There is no documented evidence the drugs, the nursing services / Treatments were ordered by a Physician. There is no documented evidence the Plan Of Care/ Physician's Orders was reviewed and revised by the Physician as frequently no less than 60 days. There is no documented evidence of conformance to Physician's Orders There is no documented evidence the clinical record include accurate past and current information. 5. Patient #5 has a start of care date of 9/19/2017 with diagnosis that include Bipolar Disorder, Anxiety, Parkinson’s Disease, Hypertensive Heart Disease with Heart Failure, Chronic Obstructive Pulmonary Disease as documented on the “ Home Health Certification and Plan Of Care” for the Certification Period of 10/28/21 to 12/26/21. The Home Health Certification and Plan Of Care for the Certification Period of 10/28/21 to 12/26/21 document:” Skilled Nurse to prefill planner device every week. Instruct patient / caregiver on how to prefill medication planner. Skilled Nurse for administration of B12 IM/ SUBQ every month. RN visit 8 Certification Period for 1 Certification period starting 10/28/21. OASIS Recertification t visit weekday 1 visit Certification period for 1 Certification Period starts 10/28/21.” A “ Discharge / Transfer Summary Report” dated 11/24/21 document:’ Discharged/ transferred to a home under organized home health service organization in anticipation of covered skilled care/ Reason: no longer meets eligibility requirements. Condition: Independent in the Home.” A Coordination Notes Report dated 12/21/21 document:” As of 11/27/21 Patient record can be accessed through the ContinulinkEMR’. The record document a "Plan Of Care" for the Certification Period of 12/27/21 to 2/24/22 document:" OASIS Recertification Visit Weekday one hour Certification period. RN Visit 8 Visit Recertification Period for one Certification Period starting 12/27/21. There is no documented evidence of an " actual discharge of the Patient". The record document the following nursing visits : 11/30/21, 12/7/21, 12/14/21,1/4/22, 1/18/22,2/1/22, 2/8/22 and 2/22/22. There is no documented evidence the clinical record include accurate past and current information. 6. Patient #6 has a start of care (SOC) date of 9/13/2018 with diagnosis of Bipolar Disorder, Panic Disorder, Atherosclerotic Heart Disease, Hypertensive Heart Disease Diabetes Mellitus Type 2 and Chronic Obstructive Pulmonary Disease as documented on the Home Health Certification and Plan of Care for certification period 12/26/21 to 2/23/22. The record document :"Discharge/ Transfer summary dated 12/5/21.: Discharged/transferred to a home under care of organized home health service organization in anticipation of covered skilled care/ Reason: no longer meets eligibility requirements/condition: independent in the home". The record documents the following skilled nursing visits "12/22/21, 12/29/21, 1/5/22, 1/19/22, 1/26/22, 2/2/22, 2/9/22, and 2/16/22. There is no documented evidence of a " actual discharge of the Patient. There is no documented evidence the clinical record include accurate past and current information. 7. Patient #8 has a start of care (SOC) date of 3/10/2016 with diagnosis of Major Depressive Disorder, Diabetes Mellitus Type 2, Hypertensive Heart Disease, Congestive Heart Failure, and Hypothyroidism documented on the Home Health Certification and Plan of Care for certification period 10/10/21 to 12/8/21. The record document a " Discharge/ Transfer summary dated 12/4/2021" Discharge Information: Discharge to home or self care/ Reason: no longer meets eligibility requirements/condition: independent in the home; Patient Disposition/Status: Discharged, Date: 12/4/21; Discharged to home or self care”. The Skilled Nursing assessment dated 12/8/21 documents, "Resumption of Care: 12/8/21". The record documents the following nursing visit 12/8/21. There is no documented evidence of an " actual discharge of the Patient". There is no documented evidence the clinical record include accurate past and current information. 8. Patient #9 has a start of care date of 4/25/19 with diagnosis of Schizophrenia, Hypertension, Chronic Obstructive Pulmonary Disease, Diabetes Mellitus Type 2, Nicotine Dependence, and History of falling documented on the Home Health Certification and Plan of Care for certification period 2/8/22 to 4/8/22. The record document:" Discharged/Transferred to a home under care of organized home health service organization in anticipation of covered skilled care/ Reason: Home Health-Transition/DC to HCBS; Condition: independent with use of assistive device; Patient Disposition/Status: Discharged, Date: 12/5/21; Discharged/Transferred to a home under care of organized home health service organization in anticipation of covered skilled care”. The clinical record documents the following skilled nursing visits "1/4/22 , 1/14/22, 1/16/22, 2/10/22 , and 2/15/22. There is no documented evidence of an " actual discharge of the Patient". The RN note dated 1/4/22 documents, "patient reported that he fell on 1/2/22". A request was made for the Incident/Accident report. No document received. There is no documented evidence of a skilled nursing assessment post fall. There is no documented evidence of physician notification of the fall. There is no documented evidence the clinical record include accurate past and current information. 9. Patient #10 has a start of care date of 6/27/08 and a discharge date of 11/27/21with diagnosis of schizophrenia, major depressive disorder, anxiety, and alcohol abuse documented on the Home Health Certification and Plan of Care for certification period 12/16/21 to 2/13/22. The record document: "Discharge Information: Discharged/Transferred to a home under care of organized home health service organization in anticipation of covered skilled care/ Reason: no longer meets eligibility requirements/ Condition: independent in the home; Patient Disposition/Status: Discharged, Date: 12/5/21; Discharge Reason: Discharged/Transferred to a home under care of organized home health service organization in anticipation of covered skilled care”. The clinical record documents the following nursing visit, 12/16/21 and 2/9/22. There is no documented evidence of an " actual discharge of the Patient". There is no documented evidence the clinical record include accurate past and current information. On 2/23/2022 at 4:00PM the Director of Clinical Services was interviewed and did not provide an explanation. 9. Patient #11 has a start of care date of 3/20/19 with diagnoses of Schizoaffective Disorder and Lymphedema as documented on the Home Health Certification and Plan of Care dated 11/4/21 through12/20/21. The record documents a discharge/Transfer summary documenting the Patient was discharged on 12/6/21. The discharge summary is not signed and dated. The record documents nursing visits were made on 12/7/21, 12/14/21 and 12/21/21. There is no documented evidence of an actual discharge for the Patient. A Coordination note dates 12/22/21 documents the Patient was admitted to the hospital on 12/21/21. During an interview with the Registered Nurse (RN) on 2/24/22 at 2:15PM, the RN stated the Patient had vaginal bleeding and was transferred to the hospital. There is no documented evidence of a Transfer summary developed and sent to the physician. There is no documented evidence of a OASIS transfer summary. The record lacks documented evidence as to the Patient's status after being transferred to the hospital. There is no Resumption of Care or nursing visits after 12/22/21. There is no documented evidence of an OASIS Discharge/Transfer comprehensive assessment. The record lacks documented evidence of complete past, current and accurate information. 10. Patient #12 has a start of care date of 9/15/21 with diagnoses of Post Traumatic Stress Syndrome and Schizophrenia as documented on the Home Health Certification and Plan of Care dated 11/14/21 through 1/12/22. The record documents a Discharge/Transfer Summary documents the Patient was discharged on 11/28/21. The nursing notes document visits were made on 12/2/21, 1/8/22, 1/12/22, 1/25/22, 2/2/22, and 2/23/22. A Discharge roster that was printed on 2/23/22 documents the Patient was discharged on 1/13/22 and was "discharged to home or self care/reason is care of another Home Health". There is no documented evidence of an "actual" discharge on 11/28/21 and 1/13/222. The record documents a Home Health Certification and Plan of Care is dated 11/14/21 through 1/12/22. There is no documented evidence the Plan of Care/medical orders were renewed every 60 days. There is no documented evidence of current medical orders/Plan of Care after 1/12/22. The record lacks documented evidence of complete past, current and accurate information. 11. Patient #13 has a start of care date of 6/14/13 with diagnoses of Bipolar Disorder, Diabetes Mellitus Type Two and Hypertension as documented on the Home Health Certification and Plan of Care dated 10/30/21 through 12/28/21. A Discharge Report dated 2/23/22 documents the Patient was discharged from the agency on 2/2/22 to "another home care agency". A “Coordinated Notes Report” documents: "As of 2/2/22 the Patient record can be accessed in the Continulink EMR ( Electronic Medical Record)”. The record documents the Patient received nursing visits on 2/2/22, 2/9/22 and 2/16/22. There is no documented evidence of an "actual discharge of the Patient". The record lacks documented evidence of complete past, current and accurate information. There is no documented evidence the clinical records contain accurate past and current information and are available to staff and physicians as needed. During an interview with the Director of Patient Services (DPS) on 2/24/22 at 2:00 PM, the DPS did not provide an explanation for the above.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure that the clinical records contain all required items. This was evident for seven (7) of thirteen (13) records reviewed. (Patients #1, #2, #3, #4, #9, #11 and #12) Failure to ensure clinical records contain all required items has the potential for negative patient outcomes. The findings are: 3. Patient #1 has a start of care has a start of care date of 11/26/2014 with diagnosis that include Bipolar Disorder, Episode Mixed with Psychiatric Features, Essential Hypertension, Alcohol Dependence Uncomplicated as documented on the “Home Health Certification and Plan Of Care for the Certification Period of 10/20/2021 to 12/18/2021. The record document the following nursing visits: 12/29/21, 1/12/22, 1/26/22 and 2/9/22. There is no documented evidence of a current written Plan Of Care /Physician Orders after the Certification Period ending 12/18/21. There is no documented evidence the Plan Of Care was reviewed and revised by a Physician as frequently no less than every 60 days. There is no documented of a completed discharge summary. There is no documented evidence the clinical record contains the current Plan Of Care/ Physician Orders for the delivery of care and services to the Patient. 4. Patient #2 has a start of care date of 8/10/2010 with diagnosis that include Bipolar Disorder, Panic Disorder, Personal History of Pulmonary Embolism, Congenital malformation Of Brain, Personal History Of Other Venous Thrombosis and Embolism as documented on the “ Home Health Certification and Plan Of Care” for the Certification Period of 12/18/21 to 2/15/22. The record document the following nursing visit dated : 2/22/22. There is no documented evidence of a current written Physician's Orders after the Certification Period ending 2/15/22 . There is no documented evidence the Plan Of Care was reviewed and revised by a Physician no less than every 60 days. There is no documented evidence the clinical record contains the current Plan Of Care and Physician Orders for the delivery of care and services to the Patient. 5. Patient #3 has a start of care date of 10/21/20 with diagnosis that include Bipolar Disorder, Memory deficit Following Cerebral Infarction, Vascular Dementia with Behavioral Disturbances, Type II Diabetes Mellitus Without Complications, Long term Use Of Oral Hypoglycemic Agents as documented on the “Home Health Certification and Plan Of Care” for the Certification Period of 12/15/21 to 2/12/2022. The record document the following nursing visits: 2/16/22 and 2/23/22. There is no documented evidence of a current written Plan Of Care/ Physician's Orders after the Certification Period ending 2/15/22. There is no documented evidence the Plan Of Care / Physician's Order was reviewed and revised by a Physician as frequently no less every 60 days. There is no documented evidence the clinical record contains the current Plan Of Care and Physician order for the delivery of care and services to the Patient. 6. Patient #4 has a start of care date of 9/9/2017 with diagnosis that include Schizophrenia, Anxiety Disorder, Hemiplegia Following Cerebral Infarction Affecting Right Dominant Side as documented on the Side, History Of Falling as documented on the " Plan Of Care" for the Certification Period of 12/17/21 to 2/14/22. The record document the following nursing visits: 2/15/22 and 2/22/22. There is no documented evidence of a current written Plan Of Care/Physician's Orders after the Certification Period ending 2/14/22. There is no documented evidence the Plan Of Care was reviewed and revised as frequently no less every 60 days by a Physician. There is no documented evidence the clinical record contains the current Plan Of Care / Physician order for the delivery of care and services to the Patient. 7. Patient #9 has a start of care date of 4/25/19 and a discharged date of 12/10/21 with diagnosis of Schizophrenia, Hypertension, Chronic Obstructive Pulmonary Disease, Diabetes Mellitus Type 2, Nicotine Dependence, and History of falling documented on the Home Health Certification and Plan of Care for certification period 12/10/21 to 2/7/22. The Home Health Certification and Plan of Care for certification period 12/10/21 to 2/7/22 documents, “frequency/duration of visit 1 (visit) x 1 (week); skilled nursing (SN) to evaluate patient and develop plan of care; may use telehealth and telecommunication to provide services". 1/4/22 RN documents, “Patient had dropped his meds on the floor; patient stated that he fell on Sunday 1/2/22 when he was walking out to smoke”. The Incident/Accident report was requested on 2/23/22 at 11:00 AM for the fall. No report was provided. There is is no documented evidence of a clinical assessment/clinical note post fall, intervention to prevent additional falls and/or physician notification. There is no documented evidence that all required items are in each Patient's clinical records. On 2/23/2022 at 4:00PM the Director of Clinical Services was interviewed and did not provide an explanation. 1. Patient #11 has a start of care date of 3/20/19 with diagnoses with diagnoses of Schizoaffective Disorder and Lymphedema as documented on the Home Health Certification and Plan of Care dated 11/4/21 through 1/2/22. The Coordination note dated 12/22/22 documents the Patient was transferred to the hospital on 12/21/22. The record lacks documented evidence of a progress note documenting the reason for the discharge and the status of the Patient after being transferred to the hospital. In an interview with the Registered Nurse (RN) on 2/24/22 at 2:30 PM, the RN stated the Patient had vaginal bleeding". A nursing visit note dated 11/1/21 documents the Patient has pain of a 7 on a scale of 0 to 10. The record lacks documented evidence of notification to the physician regarding the Patient's increased pain for possible changes in pain relieving modalities. 2. Patient #12 has a start of care date of 9/15/21 with diagnoses of Post Traumatic Stress Syndrome and Schizophrenia as documented on the Home Health Certification and Plan of Care dated 11/14/21 through 1/12/22. The Home Health Certification and Plan of Care is dated 11/14/21 through 1/12/22 and documents skilled nursing visits weekly for evaluation and medication pre-pour. The record lacks documented evidence of: There is no written Plan of Care developed after 1/12/22; A nursing visit for the week of 1/2/22. During an interview with the Director of Patient Services (DPS) on 2/24/22 at 2:00 PM, the DPS did not provide an explanation for the above.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record reviews and staff interviews, the Agency failed to develop complete discharge and/or transfer summaries within 5 days from discharge or 2 days from transfer and include the care provided and communication with the patient/caregiver and Physician regarding the discharge/transfer who will be responsible for providing services to the Patient after discharge from the agency. This was evident in two (2) of two (2) discharge records reviewed. (Patients #1 and #11) Failure to consult all persons involved in the Plan Of Care and ensure a safe discharge/transfers and complete summaries are completed within the approved time frames has the potential for negative patient outcomes. The findings are: 3. Patient #1 has a start of care date of 11/26/2014 and a discharge date of 2/16/ 22. On 2/24/21 at 1:30 PM, a request was made for the discharge summary. A document dated 2/16/22 titled" Discharged from agency , Status Not Started" was provided. The document lacks the following elements: The Physician responsible for the Plan of Care; Type of services and frequency of services; Patient condition at discharge; Medication the patient is on at the time of discharge; Patient outcomes in meeting the goals in Plan Of Care; Patient Discharge Instructions. The last documented nursing visits were: 1/26/22 and 2/9/22. There is no documented evidence a completed discharge summary was sent to the Physician . On 2/24/22 at 2: 45 PM the Clinical Director was interviewed and stated the patient is discharged as of 2/16/22 and the summary is in progress. No further explanation was provided. 1. Patient #11 has a start of care date of 3/20/19 with diagnoses of Schizo-affective Disorder and Lymphedema as documented on the Home Health Certification and Plan of Care dated 11/4/21 through 1/2/22. The Home Health Certification and Plan of Care dated 11/4/21 through 1/2/22 documents the Patient is to receive SN visits every week for medication pre-pours and to evaluate and instruct the Patient. A Coordination note dated 12/22/21 documents the Patient was transferred "to an in patient facility on 12/21/21". There is no documented evidence of a complete transfer summary was developed to include the following: Type of services provided and frequency of services; the physician responsible for home health plan of care; Medications the patient is on at the time of transfer; Patient's condition at time of transfer; Patient outcomes in meeting the goals in the plan of care; the reason for the transfer; the name of the in patient facility the patient was transferred to; and the communication with the physician regarding the transfer and the summary was sent to the physician. During an interview with the Registered Nurse (RN) on 2/24/22 at 2:15 PM, the RN stated the Patient "had vaginal bleeding and was transferred to the hospital". During an interview with the Director of Patient Services (DPS) on 2/24/22 at 2:30 PM, the DPS did not provide an explanation for the above.

A standard re-certification survey and focused COVID-19 infection conntrol survey of Willcare CHHA at 700 Corporate Boulavard, Newburgh NY 12550 was initiated on 2/22/21 and exited 3/2/21. Deficient practices were identified within high priority standards in Plan of Care resulting in a partial extended survey. Seventeen (17) clinical records were reviewed and are identified as Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16 and #17. Six (6) Home Visits (HV) were conducted with Patients #11, #12, #13, #15, #16 and #17. Eleven (11) personnel records were reviewed and are identified as Employees #1, #2, #3, #4, #5, #6, #7, #8, #9, #10 and #11. Policies and procedures for Emergency Preparedness Plan, Health Commerce System, Home Care Registry, Criminal History Record Check, Infection Control and Influenza Vaccination policy were reviewed. OBQI Adverse Event Outcome Report was reviewed for the period of 12/2019 - 11/2020. The agency's Complaint log was reviewed for the years 2020 and 2021. Two Complaints were investigated. Complaints #NY00252291 and #NY00263371 . Complaint #NY00252291 and #NY00263371 were investigated and found to be substantiated. Administrative and clinical staff were interviewed. The agency's Quality Improvement meeting minutes were reviewed for 2020 and 2021. The following deficiencies are cited: G - 434 - Participate in Care; G - 440 - Payment From Federally Funded Programs; G - 464 - Advise the Patient of Discharge for Cause; G - 470 - Document Efforts to Resolve Problems; G - 536 - A Review of All Current Medications; G- 574 - Plan of Care Must Include the Following; G - 578 - Conformance with Physician's Orders; G - 590 - Promptly Alert Relevant Physician of Changes; G - 598 - Discharge Plans Communication; G - 608 - Coordinate Care Delivery; G - 702 - Services By Skilled Professionals; G - 1022 - Discharge and Transfer Summary; J - 1128, 1140, 1156, 1184, 1260 & 1276 - Governing Authority; J - 1426 - 1476 - Personnel; J - 1520 & 1476 - Records and Reports; L - 0001 - Unacceptable Infection Control Procedures; W - 0407 - General Requirements W - 614 - Responsibilities Of Home Care Services Entities; R - 504 & 510 - General Requirements; R - 1024 - Responsibilities Of Providers; Required Notification

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on record reviews, policy review and interview, the governing authority failed to inform Patients of the services the Patient is to receive and the frequency for the services and any related charges. This was evident for seventeen (17) of seventeen (17) clinical records reviewed. (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16 and #17) Failure to ensure that patients are informed in writing of rights has the potential for patients to be unaware of rights which may prevent them from making informed decisions. The findings are: The agency's admission packet was requested on 2/22/21. The admission packet was reviewed and documents a form titled Standard Charge Rates For Medicare and Non-Medicare Visits and dated 5/17 at the bottom of the form. The form documents the rates for the following services: Skilled Nursing, Physical Therapy, Occupational Therapy, Speech Therapy, Medical Social Worker and Home Health Aide. The form has spaces for the disciplines/frequency of visits and the cost, if any, for the services. A review of the clinical records for Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16 and #17 lack documented evidence of the Standard Charge Rates For Medicare and Non-Medicare Visits forms that documents the services and frequencies the patients are to recieve completed and signed at the start of care. During an interview with the Administrator on 2/25/21 at 11:00 AM ,the Administrator did not provide an explanation from the above.

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: Based on record reviews, policy review and interview, the governing authority failed to inform Patients of any related charges for the services they are to recieve from the agency. This was evident for seventeen (17) of seventeen (17) clinical records reviewed. (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16 and #17) Failure to ensure that patients are informed in writing of rights has the potential for patients to be unaware of rights which may prevent them from making informed decisions. The findings are: The agency's admission packet was requested on 2/22/21. The admission packet was reviewed and documents a form titled Standard Charge Rates For Medicare and Non-Medicare Visits and dated 5/17 at the bottom of the form. The form documents the rates for the following services: Skilled Nursing, Physical Therapy, Occupational Therapy, Speech Therapy, Medical Social Worker and Home Health Aide. The form has spaces for the disciplines/frequency of visits and the cost, if any, for the services. A review of the clinical records for Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16 and #17 lack documented evidence of the Standard Charge Rates For Medicare and Non-Medicare Visits forms with the services/frequency/costs completed and signed at the start of care. During an interview with the Administrator on 2/25/21 at 11:00 AM ,the Administrator did not provide an explanation from the above.

Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) issuing orders for the home health plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) that a discharge for cause is being considered; This ELEMENT is not met as evidenced by: Based on record reviews and staff interviews , the agency failed to advise the patient and the Physician that a discharge is being considered for non compliance to psychiatric medications. This was evident for one (1) of five discharge records reviewed.( Patient# 3). Failure to advise the Patient and the Physician hat a discharge is being considered for non compliance to psychiatric medications has the potential for negative patient outcomes. The finding is: Patient # 3 has a start of care date of 11/13/2017 with diagnosis that include Bipolar Disorder, Type II Diabetes Mellitus, Long term use of Hypoglycemic drugs, Hypertension, Benign Prostatic Hyperplasia as documented on the " Home Health Certification and Plan Of Care for the certification period of 7/6/2019 to 9/3/2019. The " Home Health Certification and Plan Of Care" for the certification period of 7/6/19 to 9/3/19 documents: " Skilled Nurse (SN) effective 7/14/2019 one time a week for one week, one time every two weeks for six weeks; Discipline and treatments: " SN to evaluate and develop plan of care in coordination of physician; SN to instruct on Hypertension to include disease process, signs and symptoms, complications and management; SN to instruct on Diabetes to include disease process; the patient is receiving Home Care due to the need for medication pre pour, medication management, diabetic teaching, symptom management, supportive counseling and teaching related to coping skills. Medications include: Accu check guide test once daily, Aspirin oral 81mg one tablet daily, Calcium Carbonate D3 oral, one tablet daily, Donnatal oral one tablet three times daily, Hydrocodone- Acetaminophen 5-325 mg four times daily as needed, Magnesium Oxide oral one tablet daily, Metformin oral 500 mg one tablet twice daily, Methylphenidate HCL oral one tablet three times a day, Pantoprazole oral 40 mg one tablet daily, Resistor oral 150 mg three times a day, Ropinirole oral 1 mg one tablet four times a day, Tab a Vite oral one tablet once daily, Tamsulosin oral 4 mg one tablet at bedtime, Tizanidine 4 mg oral one or two tablets three times a day as needed, Ventolin HFA inhalation one inhalation every six hours via mouth as needed, Zinc oral 50 mg one tablet daily and Zolpidem oral 10 mg at bedtime". The "Home Health Certification and Plan of Care" for the certification period of 9/4/2019 to 11/12/2019 documents: " Skilled nurse to pre-fill planner device every two weeks, instruct patient/ caregiver on how to pre-fill medication planner. The "Client Coordination Note Report" dated 7/21/19 documents: " Medication reconciliation, medication completed pour by writer, client not independent with medication management." The " Client Coordination Note Report" dated 8/21/19 documents: "Team case Conference: Team reviewed the episode detail report and discussed the following, client lives with wife who also has several disabilities; he has limited insight, speech is pressured, though he is pleasant; Skilled Nurse does medication pre-pour as client is unable to to perform this task. Based on discussion the recommendation of the teams is Recertification, anticipated disciplines recerting, behavioral Skilled Nurse." The record documents the last "visit note report" is dated 8/31/2019. On 2/11/2020, the patient complained that the agency stopped services on 9/4/2109, because "the agency claimed that he was non-complaint with his psychiatric medications. Thee patient was never on any psychiatric medications". On 2/24/21, during the survey, a review of the medications lack documented evidence the patient was prescribed antipsychotic medications. The "Client Coordination Note Report" dated 8/31/19 documents: " Client is seen every other week for skilled nursing assessment, compliant with current medication regimen with prompts and education, mental status at baseline with moderate to severe anxiety, hypervigilance, and periods of hypomania; Utilize Home Health Aide for ADLs, continue to have poor tolerance for stress; Home Health services continued for medication management, pre pour medication, medication reconciliation each visit; assess compliance efficacity, side effects, teach and reinforce existing medications; Intervene early to minimize hospitalization risk, case management, crisis intervention as necessary, teach and reinforce coping skill; Requesting Skilled nursing every other week. On 2/26/2021 at 11:15 AM, the Administrator was interviewed and stated the patient has been discharged. A request was made on 2/26/21 and 3/2/21 for the date of discharge and documentation of the discharge. This information was not provided. On 3/2/21 at 12:00 PM, the Administrator was interviewed and stated the patient went to the hospital on 9/5/19, he was placed on hold on 9/6/19. He was discharged. There is no documented evidence of the patient's date of hospitalization, return from the hospital and reasons for discontinuation of services. There is no documented evidence the Managed Long Term Care Plan was notified of the discharge. There is no documented evidence of a completed discharge summary, notification of the physician, reasons for the discharge, date of discharge, summary of care given, and patient's progress. There is no documented evidence the patient's rights were respected that a discharge for non compliance to psychiatric medications were being considered On 3/2/21 at 1:30 PM, the Administrator was interviewed and did not provide further explanation for the above findings.

Document efforts to resolve problems CFR(s): 484.50(d)(5)(iv) (iv) Document the problem(s) and efforts made to resolve the problem(s), and enter this documentation into its clinical records; This ELEMENT is not met as evidenced by: Based on record review, complaint log review and interview, the agency failed to maintain a complaint log to document the receipt, investigation and resolution of all complaints. This was evident for the complaint log and one clinical record. (Patient #1) Failure to document, investigate and resolve complaints has the potential for patient complaints to not be addressed. The findings are: The agency's complaint log for 2020 and 2021 was requested on 2/22/21. 1. The complaint log for 2020/2021 documents a total of sixteen 16 complaints were received. Thirteen (13) complaints that were received lack documented evidence of either complete investigations and/or resolutions. 2. A review of the clinical record for Patient# 1 documents a Physical Therapy note dated 8/28/20 documents the Patient's spouse was upset about PT ending. On 2/23/21 at 10:45 AM, the Physical Therapy Supervisor was interviewed and stated that she had spoken to the spouse regarding the complaint but cannot find the complaint in the computer complaint log. The Supervisor stated that the spouse wanted Long Term PT and that the Supervisor referred her to a Long Term Rehabilatation program. During an interview with the Administrator 2/23/21 at 2:00 PM, the Administrator did not provide an explanation to the above.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record reviews and staff interview the agency failed to review all medications the Patient is currently using in order to identify any potential adverse effects and drug interaction. This was evident for four (4) of seventenn (17) patient care records reviewed. (Patients #1, #8, #15 and #17). Failure to review all medications the patient is currently using in order to identify any potential adverse effects and drug interaction may have negative patient outcomes. The findings are: 1. Patient #15 has a start of care date of 12/19/2020, the Home Health Care Certification and Plan of Care" dated "12/17/2021 to 4/17/2021" with diagnosis of Parkinson's Disease, Obstructive Sleep Apnea, Age-Related Osteoporosis, Major Depressive Disorder, Hyperlipidemia, Dependence on Supplemental Oxygen, History of Falls. The "Home Health Care Certification and Plan of Care" dated 12/17/2021 to 4/17/2021 documents "Medication: Gabapentin 100 mg 1 capsule 3 x daily, hydrocodone 5 mg -Acetaminophen 325 mg 2 x daily/PRN." During the home visit conducted on 2/25/21 at 12:00 PM the patient complained of lower back pain, multiple falls, and states that she is taking a new dose of Hydrocodone/Acetaminophen 7.5/325 mg I tablet a day. The medication bottle documents date filled of 2/5/2021 and 40 tablets were dispensed. The agency staff (OT) counted 14 tabs left in the bottle. There is no documented evidence of medication reconciliation. The Plan of Care lacks parameters for pain monitoring and safe administration of Hydrocodone/Acetaminophen. 2. Patient #17 has a start of care date of 9/29/2020, the Home Health Care Certification and Plan of Care" dated "1/27/2021 to 3/27/2021" with diagnosis of Type 2 Diabetes Mellitus with Foot Ulcer, Hypertension, History of Falling. The "Home Health Care Certification and Plan of Care" dated 1/27/2021 to 3/27/2021 documents "Medications: Caltrate 600 plus D chewable tablet, Gabapentin 300 mg capsule, Januvia 50 mg, Multivitamin 50 Plus, Tramadol 50 mg, Amlodipine 5 mg, Aspirin 81 mg delayed release, Buprenorphine 5 mcg/hour weekly transdermal patch" During the home visit conducted on 2/26/21 at 11:00 AM the following medication discrepancies were noted: Amlodipine 10 mg (new dosage ) was filled on 1/27/21; Hydroxyurea 500 mg capsules 1 alternate with 2 daily filled on 1/27/21 not listed on the current physician order, and Buprenorphine 5 mcg/hour weekly transdermal patch was not in the home. There is no documented evidence the nurse performed medication review and reconcile medication list during visits. During an interview with the Administrator 2/26/21 at 2:40 PM, the Administrator did not provide an explanation to the above.3. Patient #1 has a start of care date of 8/4/20 and a discharge date of 9/10/20 with diagnoses of Alzheimer's Disease, Hypertension, Pain in Right Ankle and Joints of Right Foot and Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms as documented on the Home Health Certification and Plan of Care dated 8/4/20 through 10/2/20. The Home Health Certification and Plan of Care dated 8/4/20 through 10/2/20 documents the Patient is to receive the following: Physical Therapy (PT) visits two times a week for two weeks, then 1 time a week for three weeks; Occupational Therapy (OT) one time one week; Speech Therapy (ST) one time a week for one week; PT to monitor and provide instruction regarding pain control methodologies including pharmacologic and non-pharmacologic methods. The Plan of Care does not document any pharmacological medications for pain. The OT note dated 9/1/20 documents the Patient has pain to he right shoulder, the pain is rated a 6 on a scale of 0 to 10 and the Patient is using prescription and over the counter medications for pain relief. The POC/medication profile does not document any pain medications. During an interview with the Adminstrator on 2/23/21 at 12:00 PM, the Administrator did not provide an explanation for the above. 4. Patient #8 has a start of care date of 9/20/20 with diagnoses of Chronic Obstructive Pulmonary Disease, Chronic Pain and Hypertension as documented on the Home Health Certification and Plan of Care dated 1/18/21 through 3/18/21. The Home Health Certification and Plan of Care dated 1/18/21 through 3/18/21 documents: SN visits wekly for eight weeks, Lidocaine patch every twelve hours, Nitroglycerine 0.4 mgsublingual as needed. The Lidocaine patch does not specify the location the patch is to be placed; the Nitroglycerine does not document the reason for use and the frquency it is to taken. During an interview with the Adminstrator on 2/25/21 at 1:30 PM, the Administrator did not provide an explanation for the above.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record reviews and interview, the agency failed to develop/revise complete and comprehensive Plans of Care. This was evident for twelve (12) of seventeen (17) clinical records reviewed. (Patients #1, #2, #4, #5, #6, #7, #8, #9, #12, #14, #15 and #17) Failure to develop complete and comprehensive Plans of Care places patients at risk for not having needs met and negative patient outcomes. The findings are: 1. Patient #1 has a start of care date of 8/4/20 and a discharge date of 9/10/20 with diagnoses of Alzheimer's Disease, Dementia, Hypertension, Pain in Right Ankle and Joints of Right Foot and Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms as documented on the Home Health Certification and Plan of Care dated 8/4/20 through 10/2/20. The Home Health Certification and Plan of Care dated 8/4/20 through 10/2/20 documents the Patient is forgetful, and is to receive the following: Physical Therapy (PT) visits two times a week for two weeks, then 1 time a week for three weeks; Occupational Therapy (OT) one time one week; Speech Therapy (ST) one time a week for one week; PT to monitor and provide instruction regarding pain control methodologies including pharmacological and non-pharmacological methods. The medications include Lisinopril (antihypertensive) 10 mg daily. The Plan of Care does not document any pharmacological medications for pain. The PT notes dated between 8/4/20 through 9/10/20 document the Patient's pulse and blood pressure is taken on each visit; the OT notes dated between 8/10/20 through 9/15/20 document the OT is taking the Patient's pulse and blood pressure on each visit. The POC lacks documentation to include safety measures of parameters for pulse and blood pressure for physician notification The OT documents on 9/1/20 Patient has "pain to the right shoulder, is rated a 6 and that prescription and over the counter medications are used to relieve pain". The note and the POC do not document the medications the Patient is taking. The POC does not document any prescribed or over the counter medications for pain. 2. Patient #2 has a start of care date of 11/3/19 and a discharge date of 1/28/21 with diagnoses of Schizoaffective Disorder, Bipolar Type, Diabetes Mellitus Type Two, Cardiac Disease, Chronic Kidney Disease and Parkinson's Disease as documented on the Home Health Certification and Plan of Care dated 1/2/20 through 3/1/20. The Home Health Certification and Plan of Care (POC) dated 1/2/20 through 3/1/20 document the following: SN visits weekly visits for eight (8) weeks; medications include: Lopressor (antihypertensive) 50 mg two times a day; Tradjenta (antidiabetic) 5mg daily; Farxiga (antidiabetic) 10 mg daily. A SN note dated 11/4/20 documents: Patient "is a poor historian, forgetful and non-compliant with medications and diabetic treatments, is a functional quadriplegic with diagnoses of Schizoaffective Disorder, Bipolar Type, lives alone in a boarding house, has a glucometer, random check shows 130, unknown how often Patient is checking Blood Sugar". A SN note dated 12/8/20 documents the Patient is to montor blood sugar daily. The POC lacks documented evidence to include the Patient is to monitor the Blood Sugar daily and safety measures to include parameters for Blood Sugar and Blood Pressure for physician notification. 3. Patient #4 has a start of care date of 12/4/19 and a discharge date of 3/17/20 with diagnoses of Pressure Ulcer to the Right Heel, Hypertension, Diabetes Mellitus Type Two, Chronic Kidney Disease and Atrial Fibrillation as documented on the Home Health Certification and Plans of Care dated 12/4/19 through 2/1/20 . The Home Health Certification and Plan of Care (POC) dated 12/4/19 and 2/2/20 document: SN visits 2 times a week for three weeks then one time a week for six weeks; PT 2 times a week for three weeks; OT two times a week for three weeks; ST one time a week for two weeks then every other week times two; Metformin (antidiabetic) 500 mg at bedtime, Norvasc (antihypertensive) 10 mg daily, Pioglitazone (antidiabetic) 30mg daily, Lasix (antihypertensive) 20 mg daily. The SN notes documents the Patient's pulse readings - 2/19/20- 58, 2/21/20- 55, 3/5/20 - 50, 3/11/20 -52 weak and thready, 3/17/20 - 50. The POC lacks documented evidence to include the frequency the Patient is to monitor the Blood Sugar and safety measures to include parameters for Blood Sugar, pulse and Blood Pressure for physician notification, The PT and the ST notes document the Patient has pain to the ankles and rates the pain as a four on a scale of 0 to 10. The ST note dated 2/13/20 documents the Patient is not able to wear the shoes due to the pain. The POC 2/2/20 through 4/1/20 does not document pain modalities and parameters for blood sugar, pulse and blood pressure were developed. 4. Patient #7 has a start of care date of 12/27/20 with diagnoses of Cardiac Disease, Diabetes Mellitus Type Two, Atrial Fibrillation and Chronic Pain as documented on the Home Health Certification and Plans of Care dated 12/27/20 through 2/24/21. The Home Health Certification and Plan of Care (POC) dated 12/27/21 through 2/24/20 documents: SN visits two times a week for one week then one time a week for eight weeks; SN may perform up to two as needed visits for chest pain, Dyspnea, increase leg edema, increase of weight within 5 pounds in one week, increase in systolic blood pressure greater than 20 mm/hg or brady/tachycardia; "SN to instruct Patient on blood glucose (BG) testing, frequency for blood glucose testing. Patient's therapuetic BG (blood glucose) range is mg/DL to MG/DL"; medications include: Januvia (antidiabetic) 100 mg daily, Amlodipine (anti-hypertensive) 10 mg daily, Baclofen (pain reliever) 5 mg two times a day, Clonidine (antihypertensive) 0.2 mg two tablets a day, Coreg (antihypertensive) 25 mg two times a day, Hydralazine (antihypertensive) 25 mg two times a day. The POC does not document any prescribed or over the counter medications for pain. The SN notes document the Patients blood pressure readings are as follows: 12/27/20- 180/100, 12/29/20 - 185/100, 1/12/21 - 190/110 and Pulse is 91, 2/3/21 - 176/100, 2/9/21 - 190/100, 1/4/21 - 160/80. The POC lacks documented evidence to include the frequency the Patient is to monitor the Blood Sugar and weights and safety measures to include parameters for Blood Sugar, pulse and Blood Pressure for physician notification. 5. Patient #8 has a start of care date of 9/20/20 with diagnoses of Chronic Obstructive Pulmonary Disease, Chronic Pain and Hypertension as documented on the Home Health Certification and Plan of Care dated 1/18/21 through 3/18/21. The Home Health Certification and Plan of Care dated 1/18/21 through 3/18/21 documents: SN visits weekly for eight weeks, SN to monitor pain and instruct/reinforce Patient regarding pharmacological and non-pharmacological pain control; Acetaminophen ER 650 mg every 6 hours as needed; Oxycodone 15 mg every 4 hours as needed for pain; Lidocaine 5% (pain relief) patch topically every 12 hours as needed; Amlodipine (antihypertensive) 5 mg daily, Coreg (antihypertensive) 12.5 mg two times a day, Lasix (antihypertensive) 20 mg daily. The POC lacks documented evidence to include the frequency the Patient is to monitor the Blood Sugar and weights and safety measures to include parameters for Blood Sugar, pulse and Blood Pressure for physician notification. The initial nursing assessment dated 9/20/20 documents the Patient's adult child is pre-pouring the Patient's medications. The SN note dated 2/3/21 documents the Patient is forgetful. The POC does not document the manner in which the "as needed" medications are administered. 6. Patient #9 has a start of care date of 10/27/20 with a discharge date of 2/23/21 has diagnoses of Diabetes Mellitus Type Two, Decubitus Ulcers and Hypertension as documented on the Home Health Certification and Plan of Care dated 12/26/20 through 2/23/21. The Home Health Certification and Plan of Care dated 12/26/20 documents: SN one time a week for one week, 3 times a week for 8 weeks, one time a week for one week; PT and OT visits; SN to monitor pain and instruct/reinforce Patient regarding pharmacological and non-pharmacological pain control; Oxycodone Acetaminophen 5mg/325 mg every 6 hours for pan as needed, Methocarbamol (restless Leg Syndrome) 500 mg every 6 hours as needed; Lasix (antihypertensive) 80 mg daily. The POC lacks documented evidence to include safety measures to include parameters for pulse and Blood Pressure for physician notification. 7. Patient #14 has a start of care date of 4/24/20 with diagnoses of Pressure Ulcer, Paraplegia, Hypertension and Dementia as documented on the Home Health Certification and Plan of Care dated 12/19/20 through 2/17/21 . The Home Health Certification and Plan of Care dated 12/19/20 through 2/17/21 and 2/18/21 through 4/18/21 document the Patient is to receive SN, PT and OT visits; Amlodipine (antihypertensive) 2.5 mg daily. The POC lacks documented evidence to include safety measures to include parameters for pulse and Blood Pressure for physician notification. The recertification POC dated from 2/18/21 through 4/18/21 lacks documented evidence to include safety measures to include parameters for pulse and Blood Pressure for physician notification. During an interview with the Administrator on 3/1/21 at 12:30 PM, the Administrator did not provide an explanation for the above.8. Patient #5 has a start of care date of 1/27/ 2021 with diagnosis that include Atherosclerotic Heart Disease, Old Myocardial Infarction, Hypertensive Chronic Kidney Disease Of Native Coronary Artery without Angina Pectoris , Hyperlipidemia, Chronic kidney Disease Stage 3 as documented on the " Home Health Certification And Plan Of Care" for the certification period of 1/27/21 to 3/27/21. The " Home Health Certification and Plan Of Care" for the certification period of 1/27/21 to 3/27/21 document: " Order of Discipline and Treatments: Skilled Nurse twice a week for one week, once a week for eight weeks; Skilled Nurse to instruct on new and changed medications, those with assessed knowledge deficit, high risk medications and any applicable drug interactions; Skilled Nurse to instruct on Hypertension to include disease process, signs and symptoms, complications and management. Medications include: Enalapril Maleate (Cardiovascular Therapy Agent) 2.5 mg tablet daily oral, Fenofibrate Micronized 200 mg capsule (Cardiovascular Therapy Agent) oral one capsule daily". The "Coordination Note" dated 1/27/21 documents: "Vital Signs parameters ordered for this patient. Internal reporting parameters established". There is no documented evidence the Plan Of Care includes Blood Pressure parameters and safety measures to report to the Physician when Blood Pressure falls outside the established Blood Pressure Parameters by the agency. There is no documented evidence the Plans Of Care are complete. 9. Patient # 12 has a start of care date of 1/25/2021 with diagnosis that include Fistula of Intestine, Anxiety Disorder, Unspecified Asthma, Personal History of Malignant Neoplasm of Breast as documented on the "Home Health Certification and Plan Of Care" for the certification period of 1/25/21 to 3/25/21. The "Home Health Certification and Plan Of Care" for the certification period of 1/25/21 to 3/25/21 documents: " Skilled Nurse twice a week for nine weeks; Skilled Nurse to perform pulse oximetry every visit on room air to monitor patient's respiratory status; notify Physician if O2 saturation is less than 90; Nutritional requirement: Heart healthy diet. Medications include: Metoprolol Succinate Extended Release (Cardiovascular Therapy Agent) oral 24 hour, take one tablet daily for High Blood Pressure". There is no documented evidence the Plan of Care includes Blood Pressure Parameters and safety measures to report to the Physician when Blood Pressure falls outside the parameters established by the agency. There is no documented evidence the Plans of Care are complete. On 3/2/2021 at 1:15 PM, the Administrator was interviewed and did not provide an explanation for the above findings.10. Patient #6 has a start of care date of 11/16/2020, the Home Health Care Certification and Plan of Care" dated "1/15/2021 to 3/15/2021" documents diagnoses of Type 2 Diabetes Mellitus, Venus Insufficiency, Hypertensive Heart Disease, Chronic Diastolic (Congestive) Heart Failure, and Chronic Atrial Fibrillation. The "Home Health Care Certification and Plan of Care" dated 1/15/2021 to 3/15/2021 documents medications include "Digoxin 125 mcg one tablet orally daily, Furosemide 40 mg one orally tablet daily, Metoprolol Succinate ER 100 mg one tablet daily, Humalog mix 75-25 16 units subcutaneous with breakfast, 20 units with supper, Metformin 500 mg one tablet in AM and 2 tablets in PM; Skilled Nursing one time weekly for 7 weeks". The "Visit Note Report" documents skilled nursing (SN) visits on 1/18/2021, and 1/21/2021. There is no documented evidence of a physician order for SN visits twice weekly. There is no documented evidence of blood glucose parameters for safe administration of insulin and when to notify the physician. There is no documented evidence of include safety measures to include parameters for pulse and Blood Pressure for physician notification. There is no documented evidence the Plans Of Care are complete During an interview with the Administrator/Director of Patient Services (DPS) on 2/26/2021 at 2:40 PM. the Administrator did not provide an explanation. 11. Patient #15 has a start of care date of 12/19/2020, the Home Health Care Certification and Plan of Care" dated "12/17/2021 to 4/17/2021" with diagnosis of Parkinson's Disease, Obstructive Sleep Apnea, Age-Related Osteoporosis, Major Depressive Disorder, Hyperlipidemia, Dependence on Supplemental Oxygen and History of Falls. The "Home Health Care Certification and Plan of Care" dated 12/17/2021 to 4/17/2021 documents the medications include: Gabapentin 100 mg one capsule 3 times a day, Hydrocodone 5 mg -Acetaminophen 325 mg 2 time a day as needed; Treatments: Occupational Therapy 1 weekly x 4 week, one every 2 weeks for 2 weeks; one time a week for 3 weeks; Home Health Aide 2 times a week for 9 weeks up to 2 hours per visit; Occupational Therapy to monitor and provide instruction regarding pain, perform pulse oximetry 1-2 times per session" During the home visit conducted on 2/25/21 at 12:00 PM, the patient complained of lower back pain, multiple falls, and states that she is taking a new dose of Hydrocodone. The bottle was viewed and documents Hydrocodone/Acetaminophen 7.5/325 mg I tablet a day and the date the medication was filled is 2/5/2021 and 40 tablets were dispensed. The agency staff (OT) counted 14 tabs left in the bottle. The "Client Coordination Note Report" documents the following: 2/8/2021 - "patient called service last night at 12:14 am stating that she fell and could not get up"; 2/15/21 - "patient has history of falling and has had 1-3 falls. The record lacks documented evidence of physician order for Hydrocodone/Acetaminophen 7.5/325 mg. There is no documented evidence the Plan of Care was revised to meet the needs of the patient related to falls prevention The Plan of Care lacks pain parameters for monitoring and safe administration of the Hydrocodone/Acetaminophen. There is no documented evidence the Plans Of Care are complete During an interview with the Administrator/Director of Patient Services (DPS) on 2/26/2021 at 2:40 PM. the Administrator /DPS did not provide an explanation. 12. Patient #17 has a start of care date of 9/29/2020, the Home Health Care Certification and Plan of Care" dated "1/27/2021 to 3/27/2021" with diagnosis of Diabetes Mellitus Type 2 with Foot Ulcer, Hypertension and History of Falling. The "Home Health Care Certification and Plan of Care" dated 1/27/2021 to 3/27/2021 documents the following medications: Caltrate 600 plus D chewable tablet, Gabapentin 300 mg capsule, Januvia 50 mg, Multivitamin 50 Plus, Tramadol 50 mg, Amlodipine 5 mg, Aspirin 81 mg delayed release, Buprenorphine 5 mcg/hour weekly transdermal patch; Treatments: skilled nurse to instruct on Diabetes to include Diabetes management; Patient perform finger stick once daily; skilled nurse to monitor pain". During the home visit conducted on 2/26/21 at 11:00 AM, the surveyor observe the medication "Hydroxyurea 500 mg capsules one alternate with 2 daily filled on 1/27/2021" in the home that is not listed on the active medication profile order. The Plan of Care lacks documented evidence of Hydroyurea Capsules and reason for treatment. The Plan of Care lacks documented evidence of the frequency the patient is to perform fingersticks; parameters for safe administration of Januvia and when to notify the physician. On 2/26/2021 at 2:45 PM, the Administrator was interviewed and did not provide an explanation for the above findings

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician orders. This STANDARD is not met as evidenced by: Based on observations, record reviews and interviews, the agency failed to ensure that services are provided in accordance with the Plans of Care (POC). This was evident for eight(8) of seventeen (17) clinical records reviewed. (Patients #1, #3, #4, #5, #8, #9, #14 and #15) Failure to ensure that patient care is provided in accordance with the Plans of Care has the potential for patients to receive poor care and health care needs to go unmet. The findings are: The agency's policy titled "Pain Assessment" with a revision date of 1/1/20 documents the following: A pain treatment plan will be developed based on the patient's clinical condition, past medical history and pain management goals. The clinician assesses pain in the cognitively impaired or non-communicative adult using the Checklist of nonverbal Pain Indicators scale. 1. Patient #1 has a start of care date of 8/4/20 and a discharge date of 9/10/20 with diagnoses of Alzheimer's Disease, Dementia, Hypertension, Pain in Right Ankle and Joints of Right Foot and Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms as documented on the Home Health Certification and Plan of Care dated 8/4/20 through 10/2/20. The Home Health Certification and Plan of Care dated 8/4/20 through 10/2/20 documents the Patient is forgetful, and to receive the following: Physical Therapy (PT) visits two times a week for two weeks, then 1 time a week for three weeks; Occupational Therapy (OT) one time one week; Speech Therapy (ST) one time a week for one week; PT to monitor and provide instruction regarding pain control methodologies including pharmacological and non-pharmacological methods. The medications include Lisinopril (antihypertensive) 10 mg daily. The Plan of Care does not document any pharmacological medications for pain. The OT documents on 9/1/20 Patient has "pain to the right shoulder, is rated a 6 and that prescription and over the counter medications are used to relieve pain". The note and the POC does not document the medications the Patient is taking. The SN, PT, OT and ST notes lack do not document the Patient's pain is being assessed using the Checklist of nonverbal Pain Indicators scale. The POC documents the Patient is to recieve seven (7) home visits. The record documents the PT made visits on 8/4/20, 8/7/20, 8/14/20, 8/19/20, 8/28/20 and 9/10/20 for a total of six (6) visits. A visit dated 8/21/20 documents the PT called the home because the PT was "running late" and the Patient's significant other refused the visit. The PT did not make all seven visits before discharging the Patient. During an interview with the Administrator on 2/23/21 at 12:00 PM, the Administrator did not provide an explanation for the above. 2. Patient #4 has a start of care date of 12/4/19 and a discharge date of 3/17/20 with diagnoses of Pressure Ulcer to the Right Heel, Hypertension, Diabetes Mellitus Type Two, Chronic Kidney Disease and Atrial Fibrillation as documented on the Home Health Certification and Plans of Care dated 2/2/20 through 4/1/20. The Home Health Certification and Plans of Care (POC) dated 12/4/19 and 2/2/20 document: SN visits 2 times a week for three weeks then one time a week for six weeks; PT 2 times a week for three weeks; SN to performed pulse oximetry every visit. The SN notes dated 2/21/20, 2/29/20 and 3/17/20 lack documented evidence of Oxygen saturations checked at the time of the visit. 3. Patient #8 has a start of care date of 9/20/20 with diagnoses of Chronic Obstructive Pulmonary Disease, Chronic Pain and Hypertension as documents on the Home Health Certification and Plan of Care dated 1/18/21 through 3/18/21. The Home Health Certification and Plan of Care dated 1/18/21 through 3/18/21 documents: SN visits weekly for eight weeks, SN to monitor pain and instruct/reinforce Patient regarding pharmacological and non-pharmacological pain control; Acetaminophen ER 650 mg every 6 hours as needed; Oxycodone 15 mg every 4 hours as needed for pain; Lidocaine 5% (pain relief) patch topically every 12 hours as needed. The SN notes dated between 1/20/21 through 2/24/21 lack documented evidence of the amount of Acetaminophen and/or Oxycodone the Patient is using and the amount/frequency/ effectiveness of the medications. The notes lack documented evidence as to whether the Lidocaine patch is being used, and if so, the place of the patch(s). The PT notes document the following: 1/21/21 - back pain 6, 1/28/21 back pain prior to session 4 post treatment 5, 2/5/21 abdominal pain 6, 2/11/21 pain to the right knee 5. The OT notes document the following: 1/22/21- pain to back, left and right knees rated a 5, over the counter (OTC) and prescription medications used; 1/25/21 pain to the back and legs 7, prescription and OTC medications used; 2/5/21 abdominal pain 6, prescription medication used. The OT and PT notes do not document which medications the Patient is taking to relieve pain and the amount, frequency and effectiveness of the pain medications. 4. Patient #9 has a start of care date of 10/27/20 with a discharge date of 2/23/21 has diagnoses of Diabetes Mellitus Type Two, Decubitus Ulcers and Hypertension as documented on the Home Health Certification and Plan of Care dated 12/26/20 through 2/23/21. The Home Health Certification and Plan of Care dated 12/26/20 through 2/23/21 documents: SN one time a week for one week, 3 times a week for 8 weeks, one time a week for one week; PT and OT visits; SN to monitor pain and instruct/reinforce Patient regarding pharmacological and non-pharmacological pain control; Oxycodone Acetaminophen 5mg/325 mg every 6 hours for pan as needed, Methocarbamol (restless Leg Syndrome) 500 mg every 6 hours as needed. The SN notes document the following: 12/28/20- neck and back pain-9, 12/30/20 - back and bilateral lower extremities 7, 1/2/21 - back and shoulder pain 7, 1/4/21 - back pain 7 and OTC medication used, 1/6/21 - back pain 8 prescription pain medication used, 1/8/21 - generalized pain prescription pain medication used, 1/11/21 - neck pain 8, 1/13/21 - pain 8 to right arm, 1/15/21 - neck and both shoulders pain 7; 1/22/21 - neck pain 8; 1/25/21 - neck and shoulder pain 8; 1/25/21 - pain right arm pain 8; 1/27/21 - right arm 7; 1/31/21 - generalized and right shoulder pain 8. The PT notes document the Patient has pain on 12/31/20, 1/14/21, 1/25/21 and 2/10/21 rated a 5. The OT notes document the following: 12/29/20 - pain to neck, right shoulder and elbow; 1/5/21 - neck, shoulder and elbow pain 7, 1/19/21 - pain rated a 9 to the right elbow, wrist /hand and parathesia in right arm,; 1/26/21 - pain 7,; 2/3/21 - pain 6; 2/9/21 - pain 8; 2/15/21 - pain 8; 2/27/21 - pain 7. The SN, PT and OT notes lack documented evidence of which medications the Patient is taking to relieve pain and the amount, frequency and effectiveness of the pain medications. 5. Patient #14 has a start of care date of 4/24/20 with diagnoses of Pressure Ulcer, Paraplegia, Hypertension and Dementia as documented on the Home Health Certification and Plans of Care dated 12/19/20 through 2/17/21. The Home Health Certification and Plans of Care dated 12/19/20 through 2/17/21 and 2/18/21 through 4/18/21 documents the Patient is to receive SN, PT and OT visits; Patient goals include: pain control methodologies as evidenced by a score of 3 on a scale of 0 to 10 and/or increased participation in ADL's (activities of daily living); Oxycontin 10 mg three times daily as needed ; Percocet 5mg/325 mg three times daily, Pregaabalin (pain reliever) 50 mg two times daily; Aleve (pain reliever) 220 mg at bedtime as needed. The SN, PT and OT notes document the Patient has pain to the lower extremities. The notes do not document which pain medications the Patient is using to relieve and pain and the amount, frequency and effectiveness for the medications. 6. Patient # 3 has a start of care date of 11/13/2017 with diagnosis that include Bipolar Disorder, Type II Diabetes Mellitus, Long term use of Hypoglycemic Agents as documented on the " Home Health Certification and Plan Of Care" for the certification period of 7/6/19 to 9/3/2019. The " Home Health Certification and Plan Of Care" for the certification period of 7/6/19 to 9/3/19 document: " Skilled Nurse to instruct on Diabetes to include disease process, signs and symptoms of exacerbation, complications and management. Glucose check daily via glucometer by patient. Medication: Metformin 500 mg one tablet oral twice a day. When vital signs are obtained licensed professional to report vital signs falling outside the following established parameters: Pulse 100 Respiration 29 Systolic Blood Pressure (B/P) 165 Diastolic B/P 110 Fasting Blood Sugar 350 Oxygen (O2) Saturation <90. Accucheck Guide one use test once daily." A review of the " Vital Signs report " from 7/4/2019 to 8/31/2019 document : Vital Signs Reading 7/4/2019 Blood Sugar : 114 Fasting Point Of Care." The Record document the " visit note report" on the following dates: 7/4/19, 7/20/19, 7/31/19, 8/17/19 and 8/31/19. On 7/31/19 The " visit note report" document: " No fasting Blood Sugar as client is waiting for new glucometer. Medication pre pour done as client is too disorganized to complete. Medication reconciled changes found, MDO ( Physician Order) done". There is no documented evidence of Blood Sugar readings on 7/20/19, 7/31/19, 8/17/19, 8/31/19. There is no documented evidence of the reasons the blood sugar readings were not present. There is no documented evidence of follow-up as the patient was awaiting for a new glucometer. On 3/2/21 at 12:00PM, the Administrator was interviewed and did not provide an explanation for the above findings. 7. Patient # 5 has a start of care date of 1/27/21 with diagnosis that include Congestive Obstructive Pulmonary Disease, Cerebral Vascular Accident, Hypertension, Cancer of the Breast, Type II Diabetes, as documented on the " Home health Certification and Plan Of Care" for the Certification period of 1/27/21 to 3/27/21. The " Home Health Certification and Plan Of Care" for the certification period of 1/27/21 to 3/27/21 document: Skilled Nursing twice a week for one week, once a week for eight weeks, Physical Therapy once a week for one week, Nutrition once for one week." Skilled Nurse to obtain weight every visit and notify Registered Nurse ( RN)/ Physician ( MD) of weight gain or loss of 5 pounds, instruct patient/ caregiver on importance of obtaining weight and keeping a weight log". The record document " Visit Note Report" on the following dates: 1/27/21, 2/6/21, 2/16/21, 2/22/21. The " visit note report" documented the weights on 2/6/21/191 pounds, 2/13/21 /191 pounds . There is no documented evidence of weights on 2/16/21 and 2/22/21. There is documented evidence of the review of the weight log by the nurse. There is no documented evidence the nurse reported to the RN and the MD the reasons weights were not taken or documented. On 2/22/21, the "Coordination Note " document: "Completed medical reconciliation, Tizanide was discontinued because it made patient very lethargic, ordered remedy Phytoplex, Zinc Oxide, and ordered speech therapy for patient complaining of difficulty swallowing." On 2/23/21, the Coordination Note" document: "Patient being seen, lying in bed for skilled. nursing visit for status post hospitalization for diarrhea related to chemotherapy. Significant event/ problem, patient complaint of sore throat, pain and difficulty swallowing". On 2/26/21, the "Coordination Note" document : There is no authorization for a speech evaluation." There is no documented evidence of physician notification for the speech evaluation not being performed. There is no documented evidence of a communication to the patient of the reasons the speech therapy was not ordered. On 3/2/21 at 12:00PM, the Administrator was interviewed and did not provide an explanation for the above findings.8. Patient #15 has a start of care date of 12/19/2020, the Home Health Care Certification and Plan of Care" dated "12/17/2021 to 4/17/2021" with diagnosis of Parkinson's Disease, Obstructive Sleep Apnea, Age-Related Osteoporosis, Major Depressive Disorder, Hyperlipidemia, Dependence on Supplemental Oxygen, History of Falls. The "Home Health Care Certification and Plan of Care" dated 12/17/2021 to 4/17/2021 documents "Medication: Gabapentin 100 mg 1 capsule 3 x daily, Hydrocodone 5 mg -Acetaminophen 325 mg two times daily as needed; Treatments: Occupational Therapy 1 weekly x 4 week, 1 every 2 weeks x 2; 1 week x 3; Home Health Aide 2 x week x 9 weeks up to 2 hours per visit; Occupational Therapy to monitor and provide instruction regarding pain, perform pulse oximetry 1-2 times/ session" The "Client Coordination Note Report" documents the following: 2/8/2021- The patient called the on-call service last night at 12:14 am stating that she fell and could not get up"; an email was sent to the case manager for follow-up. The agency's policy titled "Patient Fall Reduction Program: has a revision date of 1/1/21 documents the following: For un-witnessed, staff witnessed, or non-staff witnessed falls, the Patient Care Manager will be contacted regarding the need for a Registered Nurse (RN), Physical Therapist (PT), or Occupational Therapist (OT) to perform an on-site assessment. Upon being made aware of the fall, the Patient Care Manager will coordinate the appropriate assessment, care, and/or modifications to the plan of care, as directed. There is no documented evidence the Case Manager contacted either an RN, the PT or the OT to go to the home to perform a post fall assessment. The record documents a PT visit was made to the home on 2/9/21 and the PT discharged the Patient from PT services. OT was still in the home providing OT services. The PT note does not document the Patient fell on 2/8/2, does not document the Patient was assessed regarding the fall to include any injuries and possible reason(s) for the fall in order to prevent further falls. The record documents the OT made a visit to the home on 2/15/21. The note documents "Patient has a history of falls and has 1 to 3 falls within the last month". There is no documented evidence the OT assessed the Patient with regards to the fall that occurred on 2/8/21. The record documents that the patient was discharge from nursing services on 12/9/2020. During the home visit conducted on 2/25/21 at 12:00 PM, the patient complained of lower back pain, multiple falls, and states that she is taking a new dose of Hydrocodone/Acetaminophen 7.5/325 mg I tablet a day, may take up to two tablets a day, the medication bottle documents the medication was dispensed on 2/5/2021 for 40 tablets. The Occupational Therapist counted 14 tablets were left in the bottle. The Hydrocodone was increased from 5 mg to 7.5 mg. There is no documentation the Patient was assessed to determine whether the increase in the Hydrocodone was a possible reason for the fall. On 2/25/21 at 3:00 PM, the Administrator was interviewed and did not provide an explanation for the above findings.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(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 observation, clinical record reviews and interview, the agency failed to promptly notify the physician of changes in patients' status which may require alteration in Plans of Care. This was evident for eleven (11) of seventeen (17) clinical records reviewed. (Patients #1, #2, #3, #4, #5, #7, #8, #9, #10, #14 and #17) Failure to notify the physician of the patient's status has the potential for patients to not receive interventions which may result in negative outcomes. The findings are: 1. Patient #1 has a start of care date of 8/4/20 and a discharge date of 9/10/20 with diagnoses of Alzheimer's Disease, Hypertension, Pain in Right Ankle and Joints of Right Foot and Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms as documented on the Home Health Certification and Plan of Care dated 8/4/20 through 10/2/20. The Home Health Certification and Plan of Care dated 8/4/20 through 10/2/20 documents the Patient is to receive Physical Therapy (PT), Occupational Therapy (OT and Speech Therapy (ST). The ST note dated 8/10/20 documents the Patient has pain to the left knee and is rated a 5 on a scale of 0-10. The OT note dated 9/1/20 documents the Patient has pain to the right shoulder, the pain is rated a 6 and the Patient is using prescription and over the counter medications for pain relief. There is no documented evidence of communication with the physician regarding the Patient's pain for possible pain interventions. During an interview with the Adminstrator on 2/23/21 at 12:00 PM, the Administrator did not provide an explanation for the above. 2. Patient #2 has a start of care date of 11/3/19 and a discharge date of 1/23/20 with diagnoses of Schizoaffective Disorder, Bipolar Type, Diabetes Mellitus Type Two, Cardiac Disease, Chronic Kidney Disease and Parkinson's Disease as documented on the Home Health Certification and Plans of Care dated 11/3/20 through 1/1/20 and 1/2/20 through 3/1/20. The Home Health Certification and Plans of Care dated 11/3/19 through 1/1/20 and 1/2/20 through 3/1/20 document the following: SN visits weekly visits for eight (8) weeks. The POC dated 11/3/20 documents medications include: Glimepride (antidiabetic) 2 mg daily; Lopressor (antihypertensive) 50 mg two times a day. The POC dated 1/2/20 documents medications include: Tradjenta (antidiabetic) 5mg daily; Farxiga (antidiabetic) 10 mg daily. A SN note dated 11/4/20 documents: Patient "is a poor historian, forgetful and non-compliant with medications and diabetic treatments, is a functional quadriplegic with diagnoses of Schizoaffective Disorder, Bipolar Type, lives alone in a boarding house, has a glucometer, random check shows 130 , unknown how often Patient is checking Blood Sugar. The POC dated 11/3/19 has a summary note documenting: "Patient handed me four different bags of medications, they had numerous psych medications which are not listed on the current list of medications. The note documents the Patient had a medication planner box that was filled for the week. The Patient stated that a person from another organization comes to the home to pre-pour the medications. Call placed to the case manager at this organization and "unable to do medication reconciliation as Patient is missing half of his medications; will call physician tomorrow to figure out Plan of Care". The record documents the SN was not able to make visits to home on 11/5/20, 11/7/20, 11/15/20, 11/16/20 and 11/30/20 due to either the Patient is not home or did not answer the door. The SN notes document the following: 12/6/20 - the Patient has not been checking the blood sugar and, during the visit, the Patient's blood sugar was 59 and went to the Emergency room; 12/8/20 - Hypoglycemic medications (Metformin and Glimiperide) were discontinued " left message with physician regarding finger sticks"; A Coordination note dated 1/15/20 and written by the Registered Nurse documents: Client called ambulance last night because his glucometer was too high to read; told the nurse his sugar was over 500 in ER (emergency room), was treated and sent home; has an appointment with his physician on Monday; blood sugar was 180 at visit before dinner; states he is drinking pineapple juice from concentrate, informed him concentrate has high sugar content; he has been advised repeatedly about his diet. A Coordination note dated 1/23/20 documents the Patient called at 7:40 AM; Patient said his sugar was high and asking if he should go to the hospital. The person that took the call reviewed chart. Call placed to the Registered Nurse asking her if she wanted to make a visit or call Patient's physician; Nurse stated she would follow up and call his care manager. There is no documentation the Nurse communicated with the Patient's physician regarding finger sticks, medications, elevated blood sugar readings and the issues with the Patient's compliance with diet. During an interview with the Administrator on 2/24/21 at 11:00 AM, The Administrator did not provide an explanation for the above. 3. Patient #4 has a start of care date of 12/4/19 and a discharge date of 3/17/20 with diagnoses of Pressure Ulcer to the Right Heel, Hypertension, Diabetes Mellitus Type Two, Chronic Kidney Disease and Atrial Fibrillation as documented on the Home Health Certification and Plans of Care dated 12/4/19 through 2/1/20 and 2/2/20 through 4/1/20. The Home Health Certification and Plans of Care (POC) dated 12/4/19 and 2/2/20 document: SN visits 2 times a week for three weeks then one time a week for six weeks; PT 2 times a week for three weeks; OT two times a week for three weeks; ST one time a week for two weeks then every other week for times two; Metformin (antidiabetic) 500 mg at bedtime, Norvasc (antihypertensive) 10 mg daily, Pioglitazone (antidiabetic) 30mg daily, Lasix (antihypertensive) 20 mg daily. The SN notes document the following: 2/6/20 - 'wound care provided as ordered to the right heel, wound is not healing, left heel noted with suspected deep tissue injury, physician to be notified. A coordination note documents voice mail left for physician on 2/7/20. 2/13/20 - edema plus 2 to the right and left lower extremities; Cardiologist to be notified of increased edema. A Coordination note documents a voice mail was left on 2/14/20 regarding edema. 2/19/20 - pulse 58, pain with a rating of 3 on a scale of 0-10 and Patient is taking "OTC" (over the counter) medications, has swelling to the lower extremities (no measurement), Metalazone 2.5 mg for five days then as needed for edema; 2/21/20 - pulse 55, pitting edema to lower extremities plus one; 3/5/20 - pulse 50, edema plus 2 pitting edema and weeping to right leg, called physician and spoke to RN regarding edema. The note does not document whether the Patient is compliant with the Metalazone; 3/11/20 - pulse 52, edema plus 3, pulse weak and thready. The note does not document whether the Patient is compliant with the Metalazone; The record lacks documented evidence of communication with the physician regarding the pulse, wound to the left heel and edema. 4. Patient #7 has a start of care date of 12/27/20 with diagnoses of Cardiac Disease, Diabetes Mellitus Type Two, Atrial Fibrillation and Chronic Pain as documented on the Home Health Certification and Plans of Care dated 12/27/20 through 2/24/21. The Home Health Certification and Plans of Care (POC) dated 12/27/21 through 2/24/20 documents: SN visits two times a week for one week then one time a week for eight weeks; "SN to instruct Patient on blood glucose (BG) testing, frequency for blood glucose testing. Patient's therapeutic BG range is mg/DL to MG/DL"; medications include: Januvia (antidiabetic) 100 mg daily, Nitro-Dur patch one patch daily (24 hours). The SN note dated 12/27/20 documents the Patient is not testing the Blood Glucose and the blood pressure is 180/100. On 1/27/21, the SN note documents the Patient does not have a glucometer, strips and lancets. The SN note dated 2/9/21 documents the Patient's blood pressure is 190/100, complained of a headache and thought it was a stroke and went to the emergency room. The SN note dated 2/17/21 documents the Patient complained of pain and that the Nitro Dur patch was applied. The SN notes do not document whether the Patient is compliant with using the Nitro-Dur patch daily. The SN note dated 1/4/21 documents the Patient's blood pressure is 160/80 and has pitting edema plus two. The SN notes do not document whether the Patient obtained a glucometer and is testing the blood glucose. The record lacks documented evidence of communication with the physician regarding blood pressure readings, the Patient is not monitoring the blood glucose, and the edema. 5. Patient #8 has a start of care date of 9/20/20 with diagnoses of Chronic Obstructive Pulmonary Disease, Chronic Pain and Hypertension as documented on the Home Health Certification and Plan of Care dated 1/18/21 through 3/18/21. The Home Health Certification and Plan of Care dated 1/18/21 through 3/18/21 documents: SN visits weekly for eight weeks, SN to monitor pain and instruct/reinforce Patient regarding pharmacological and non-pharmacological pain control; PT visits one time a week for 6 weeks; OT one time a week for 5 weeks; Acetaminophen ER 650 mg every 6 hours as needed; Oxycodone 15 mg every 4 hours as needed for pain; Lidocaine 5% (pain relief) patch topically every 12 hours as needed. The PT note dated 2/5/21 documents the Patient had abdominal pain of a 6. The OT note dated 1/22/21 documents 2/5/21 abdominal pain of a 6. The record lacks documented evidence of coordination between the PT, OT and the Registered Nurse (RN) regarding the Patient's abdominal pain and the physician was informed of the Patient's abdominal pain. 6. Patient #9 has a start of care date of 10/27/20 with a discharge date of 2/23/21 with diagnoses of Diabetes Mellitus Type Two, Decubitus Ulcers and Hypertension as documented on the Home Health Certification and Plan of Care dated 12/26/20 through 2/23/21. The Home Health Certification and Plan of Care dated 12/26/20 documents: SN one time a week for one week, 3 times a week for 8 weeks, one time a week for one week; PT and OT visits; SN to monitor pain and instruct/reinforce Patient regarding pharmacological and non-pharmacological pain control; Oxycodone Acetaminophen 5mg/325 mg every 6 hours for pan as needed, Methocarbamol (restless Leg Syndrome) 500 mg every 6 hours as needed, Lasix diuretic and antihypertensive) 80 mg daily. The SN notes regarding pain document the following: 12/28/20- neck and back pain - 9, 12/30/20 - back and bilateral lower extremities 7, 1/2/21 - back and shoulder pain 7, 1/4/21 - back pain 7 and OTC medication used, 1/6/21 - back pain 8 prescription pain medication used, 1/8/21 - generalized pain prescription pain medication used, 1/11/21 - neck pain 8, 1/13/21 - pain 8 to right arm, 1/15/21 - neck and both shoulders pain 7; 1/22/21 - neck pain 8; 1/25/21 - neck and shoulder pain 8; 1/25/21 - pain right arm pain 8; 1/27/21 - right arm 7; 1/31/21 - generalized and right shoulder pain 8. The SN notes dated 1/15/21 and 1/20/21 document the Patient has pitting edema plus two to the lower extremities. The PT notes document the Patient has pain on 12/31/20, 1/14/21, 1/25/21 and 2/10/21 is rated a 5. The OT notes document the following: 12/29/20 - pain to neck, right shoulder and elbow; 1/5/21 - neck, shoulder and elbow pain 7, 1/19/21 - pain rated a 9 to the right elbow, wrist /hand and parathesia in right arm,; 1/26/21 - pain 7,; 2/3/21 - pain 6; 2/9/21 - pain 8; 2/15/21 - pain 8; 2/27/21 - pain 7. There is no documented evidence of evaluation of the amount, frequency and effectiveness of the pain medications being used to relieve pain. There is no documentation of communication with the physician regarding the pain and pitting edema. The agency's policy titled Pain Assessment with a revision date of 1/1/20 documents: "A score of 7 or greater on any pain assessment tool is indicative of severe pain, which will require physician notification and patient appropriate interventions." 7. Patient #10 has a start of care date of 9/18/20 with diagnoses of Pressure Ulcer, Quadriplegia, Chronic Pain, Spinal Stenosis as documented on the Home Health Certification and Plan of Care dated 1/16/21 through 3/16/21. The Home Health Certification and Plan of Care dated 1/16/21 documents: SN visits 3 times a week for 8 weeks then one time a week for one week; SN to monitor pain and instruct/reinforce Patient regarding pharmacological and non-pharmacological pain control; Oxycodone 10 mg 5 tablets a day; Acetaminophen 325 mg two tablets every 6 hours as needed for pain, The SN note dated 2/3/21 documents the Patient "refused to allow the RN to view/assess the PICC line and refuses further visits for wound care; Patient has three wounds which we are treating; right and left coccyx wounds are not healing; Patient annoyed with nurse while trying to ascertain medications the Patient is on". The record documents the Patient refused visits on 1/22/21 and 2/5/21. The SN note dated 2/8/21 documents the Patient refused to allow the nurse to take vital signs and wound treatment. The SN note dated 2/15/21 documents the Patient has pain to the neck and back and is rated a 7, there are no vital signs documented. The SN notes document: 2/17/21 - pain to the neck is an 8; 2/19/21 - pain is a 10; 2/22/21 - pain is a 10. The SN note dated 2/21/21 documents Patient sweating due to pain, pain not under control, reports pain of 10/10, spoke with Patient about Oxycodone, Patient reports he doesn't take it consistently that it does not work, last taken was 2/18/21 and states he has an appointment with the physician. The SN note dated 2/22/21 documents the Patient has pain of a 10 to the wound areas, Patient taking prescribed medications as ordered. There is no documented evidence of communication with the physician regarding the Patient's pain, and the refusal to allow visits and the nurses to perform tasks/treatments, 8. Patient #14 has a start of care date of 4/24/20 with diagnoses of Pressure Ulcer, Paraplegia, Hypertension and Dementia as documented on the Home Health Certification and Plans of Care dated 12/19/20 through 2/17/21. The Home Health Certification and Plans of Care dated 12/19/20 through 2/17/21 and 2/18/21 through 4/18/21 document the Patient is to receive SN, PT and OT visits; Patient goals include pain control methodologies as evidenced by a score of 3 on a scale of 0 to 10 and/or increased participation in ADL's (activities of daily living); patient will demonstrate Oxygen saturation within normal limits; Oxycontin 10 mg three times daily as needed ; Percocet 5mg/325 mg three times daily, Pregaabalin (pain reliever) 50 mg two times daily; Aleve (pain reliever) 220 mg at bedtime as needed. The OT note dated 1/19/21 documents the Patient has pain of a 5 to the right ankle/foot and Patient has a sacral wound. The record lacks documented evidence the OT informed the nurse and physician of the wound and pain. The PT note dated 2/17/21 documents the Patient has edema plus three, Oxygen saturation is 95% and that the Patient has CHF (Congestive Heart Failure) and Dementia. There is no documentation the PT communicated with the Registered Nurse or the physician regarding these findings. During an interview with the Administrator on 3/1/21 on 11:30 AM, the Administrator did not provide an explanation for the above.9. Patient #3 has a start of care of 11/13/2017 with diagnosis that include Bipolar Disorder, Type II Diabetes Mellitus, Long term use of Hypoglycemic drugs, Hypertension, Benign Prostatic Hyperplasia as documented on the " Home Health Certification and Plan Of Care for the certification period of 7/6/2019 to 9/3/2019. The " Home Health Certification and Plan Of Care" for the certification period of 7/6/19 to 9/3/19 documents: " Skilled Nurse (SN) effective 7/14/2019 one time a week for one week, one time every 2 weeks for 6 weeks; Discipline and treatments: "SN to evaluate and develop plan of care in coordination of physician; SN to instruct on Hypertension to include disease process, signs and symptoms, complications and management; SN to instruct on Diabetes to include disease process disease process; the patient is receiving Home Care due to need for medication pre-pour, medication management, diabetic teaching, symptom management, supportive counseling, teaching related to coping skills. On 9/4/2019, the Patient complained the agency stopped services because of "non compliance with psychiatric medications". On 2/24/2021, during the survey, the surveyor reviewed the patient's clinical record for documentation of reasons for discharge and documentation of communication with physician about the discharge. On 2/26/21 at 11:00AM, during an interview with the Administrator, the Administrator stated the patient was discharged. A request was made for date of discharge and the discharge summary. This information was not provided. There is no documented evidence of communication with the physician regarding the patient's non compliance with medications and the patient's discharge from the agency. On 3/2/21 at 1:00PM, the Administrator was interviewed and did not provide an explanation for the above findings. 10. Patient # 5 has a start of care date of 1/27/21 with diagnosis that include Congestive Obstructive Pulmonary Disease, Cerebral Vascular Accident, Hypertension, Cancer of the Breast, Type II Diabetes, as documented on the " Home health Certification and Plan Of Care" for the Certification period of 1/27/21 to 3/27/21. The " Home Health Certification and Plan Of Care" for the certification period of 1/27/21 to 3/27/21 document: Skilled Nursing twice a week for one week, once a week for eight weeks, Physical Therapy once a week for one week, Nutrition once for one week; Skilled Nurse to obtain weight every visit and notify Registered Nurse ( RN)/ Physician (MD) of weight gain or loss of 5 pounds, instruct patient/caregiver on importance of obtaining weights and keeping a weight log". The record documents a "Visit Note Report" that visits were made on the following dates: 1/27/21, 2/6/21, 2/16/21 and 2/22/21. The " visit note report" documented the weights on 2/6/21 - 191 pounds and 2/13/21 -191 pounds. There is no documented evidence of weights on 2/16/21 and 2/22/21. There is documented evidence of the review of the weight log by the nurse. There is no documented evidence the nurse reported to the RN Case Manager and the MD the reasons weights were not taken or documented. On 2/22/21, the "Coordination Note " documents: "Completed medical reconciliation, Tizanide was discontinued because it made patient very lethargic, ordered remedy Phytoplex, Zinc Oxide, and ordered Speech Therapy (ST) as patient is complaining of difficulty swallowing." On 2/23/21, the Coordination Note" documents: "Patient being seen, lying in bed for skilled. nursing visit for status post hospitalization for diarrhea related to chemotherapy; Significant event/ problem, patient complaint of sore throat, pain and difficulty swallowing". On 2/26/21, the "Coordination Note" documents : there is no authorization for a speech evaluation." There is no documented evidence of physician notification for the speech evaluation not being performed. On 3/2/21 at 12:00PM, the Administrator was interviewed and did not provide an explanation for the above findings. 11. Patient #17 has a start of care date of 9/29/2020, the Home Health Care Certification and Plan of Care" dated "1/27/2021 to 3/27/2021" with diagnosis of Type 2 Diabetes Mellitus with Foot Ulcer, Hypertension and History of Falling. The "Home Health Care Certification and Plan of Care" dated 1/27/2021 to 3/27/2021 documents "Medications: Januvia 50 mg; Treatments: skilled nurse to instruct on Diabetes to include Diabetes management; Patient to perform finger stick once daily; skilled nurse to monitor pain". During the home visit conducted on 2/26/21 at 11:00 AM, the Patient reported a blood sugar reading of 324 ml/dl and the blood sugar log was requested. The Patient stated that she was never told to keep a log." The "Visit Note Report" documents the following Blood Pressure results "12/30/20 - 160/70; 1/4/2021- 150/70; 1/6/2021- 150/60; 1/11/21- 160/52; 1/20/2021-160/70; 1/25/2021-150/80; 1/27/2021- 150/80.; 2/10/2021-160/70; 2/8/21-160/60; 2/3/2021-160/90; The record lacks documented evidence of communication with the physician regarding the elevated blood pressure readings. During an interview with the Administrator on 2/25/21 at 12:00 PM, the Administrator did not provide an explanation.

Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient's discharge must be communicated to the patient, representative, caregiver, all physicians issuing orders for the HHA plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any). This ELEMENT is not met as evidenced by: Based on record reviews and staff interviews, the Agency failed to communicate to the patient , caregiver and to the Physician any revisions related to plans for the patient's discharge and who will be responsible for providing services to the Patient after discharge from the agency. This was evident in one (1) of five (5) discharge records reviewed. ( Patient # 3). Failure to consult all persons involved in the Plan Of Care and ensure a safe discharge has the potential for negative patient outcomes. any related plans for discharge have the potential for negative Patient outcomes. The finding is : Patient # 3 has a start of care date of 11/13/2017 with diagnosis that include Bipolar Disorder, Type II Diabetes Mellitus, Long term use of Hypoglycemic drugs, Hypertension, Benign Prostatic Hyperplasia as documented on the " Home Health Certification and Plan Of Care for the certification period of 7/6/2019 to 9/3/2019. The "Home Health Certification and Plan Of Care" for the certification period of 7/6/19 to 9/3/19 documents: " Skilled Nurse (SN) effective 7/14/2019 one time a week for one week, one time every two weeks for six weeks; Discipline and treatments: " SN to evaluate and develop plan of care in coordination of physician; SN to instruct on Hypertension to include disease process, signs and symptoms, complications and management; SN to instruct on Diabetes to include disease process; the patient is receiving Home Care due to the need for medication pre pour, medication management, diabetic teaching, symptom management, supportive counseling and teaching related to coping skills. Medications include: Accu check guide test once daily, Aspirin oral 81mg one tablet daily, Calcium Carbonate D3 oral, one tablet daily, Donnatal oral one tablet three times daily, Hydrocodone- Acetaminophen 5-325 mg four times daily as needed, Magnesium Oxide oral one tablet daily, Metformin oral 500 mg one tablet twice daily, Methylphenidate HCL oral one tablet three times a day, Pantoprazole oral 40 mg one tablet daily, Resistor oral 150 mg three times a day, Ropinirole oral 1 mg one tablet four times a day, Tab a Vite oral one tablet once daily, Tamsulosin oral 4 mg one tablet at bedtime, Tizanidine 4 mg oral one or two tablets three times a day as needed, Ventolin HFA inhalation one inhalation every six hours via mouth as needed, Zinc oral 50 mg one tablet daily and Zolpidem oral 10 mg at bedtime". The "Home Health Certification and Plan of Care" for the certification period of 9/4/2019 to 11/12/2019 documents: " Skilled nurse to pre-fill planner device every two weeks, instruct patient/ caregiver on how to pre-fill medication planner. The "Client Coordination Note Report" dated 7/21/19 documents: " Medication reconciliation, medication completed pour by writer, client not independent with medication management." The " Client Coordination Note Report" dated 8/21/19 documents: "Team case Conference: Team reviewed the episode detail report and discussed the following, client lives with wife who also has several disabilities; he has limited insight, speech is pressured, though he is pleasant; Skilled Nurse does medication pre-pour as client is unable to to perform this task. Based on discussion the recommendation of the teams is Recertification, anticipated disciplines recerting, behavioral Skilled Nurse." The record documents the last "visit note report" is dated 8/31/2019. On 2/11/2020, the patient complained that the agency stopped services on 9/4/2109, because "the agency claimed that he was non-complaint with his psychiatric medications. Thee patient was never on any psychiatric medications". On 2/24/21, during the survey, a review of the medications lack documented evidence the patient was prescribed antipsychotic medications. The "Client Coordination Note Report" dated 8/31/19 documents: " Client is seen every other week for skilled nursing assessment, compliant with current medication regimen with prompts and education, mental status at baseline with moderate to severe anxiety, hypervigilance, and periods of hypomania; Utilize Home Health Aide for ADLs, continue to have poor tolerance for stress; Home Health services continued for medication management, pre pour medication, medication reconciliation each visit; assess compliance efficacity, side effects, teach and reinforce existing medications; Intervene early to minimize hospitalization risk, case management, crisis intervention as necessary, teach and reinforce coping skill; Requesting Skilled nursing every other week. On 2/26/2021 at 11:15 AM, the Administrator was interviewed and stated the patient has been discharged. A request was made on 2/26/21 and 3/2/21 for the date of discharge and documentation of the discharge. This information was not provided. On 3/2/21 at 12:00 PM, the Administrator was interviewed and stated the patient went to the hospital on 9/5/19, he was placed on hold on 9/6/19. He was discharged. There is no documented evidence of the patient's date of hospitalization, return from the hospital and reasons for discontinuation of services. There is no documented evidence the Managed Long Term Care Plan was notified of the discharge. There is no documented evidence of a completed discharge summary, notification of the physician, reasons for the discharge, date of discharge, summary of care given, and patient's progress. On 3/2/21 at 1:30 PM, the Administrator was interviewed and did not provide further explanation for the above findings.

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 Clinical Record review and staff interview the Agency failed to ensure coordinated care delivery to meet the patient's needs and to involve the patient. This was evident for four (4) of seventeen (17) clinical records reviewed. (Patients #1, #8, #9 and #14). Failure to ensure that the patient is involved in the coordinating and the delivery of care has the potential for negative patient outcome. The findings are: 1. Patient #1 has a start of care date of 8/4/20 and a discharge date of 9/10/20 with diagnoses of Alzheimer's Disease, Hypertension, Pain in Right Ankle and Joints of Right Foot and Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms as documents on the Home Health Certification and Plan of Care dated 8/4/20 through 10/2/20. The Home Health Certification and Plan of Care dated 8/4/20 through 10/2/20 documents the Patient is to receive the following services: Physical Therapy (PT), Occupational Therapy (OT and Speech Therapy (ST). A supplemental order dated 8/13/20 documents the Patient is to receive Skilled Nursing (SN). The ST note dated 8/10/20 documents the Patient has pain to the left knee and is rated a 5 on a scale of 0-10. A OT note dated 9/1/20 documents the Patient has pain to the right shoulder, the pain is rated a 6 and the Patient is using prescription and over the counter medications to relieve the pain. There is no documented evidence the other services were informed of the Patient's pain. The ST note dated the Patient had a seizure on 8/14/20 and was admitted to the hospital. There is no documentation the other services were in formed of the admission to the hospital and the Patient had a seizure. The PT note dated 8/14/20 documents that the PT visit was stopped because the Patient became agitated. There is no documentation this was communicated with the other services. 2. Patient #8 has a start of care date of 9/20/20 with diagnoses of Chronic Obstructive Pulmonary Disease, Chronic Pain and Hypertension as documented on the Home Health Certification and Plan of Care dated 1/18/21 through 3/18/21. The Home Health Certification and Plan of Care dated 1/18/21 through 3/18/21 documents: SN visits weekly for eight weeks, SN to monitor pain and instruct/reinforce Patient regarding pharmacological and non-pharmacological pain control; PT visits one time a week for 6 weeks; OT one time a week for 5 weeks; Acetaminophen ER 650 mg every 6 hours as needed; Oxycodone 15 mg every 4 hours as needed for pain; Lidocaine 5% (pain relief) patch topically every 12 hours as needed. The SN notes dated between 1/20/21 through 2/24/21 lack documented evidence as to which medications the Patient is taking to relieve pain and the amount, frequency and effectiveness of the pain medications. The PT notes document the following: 1/21/21 - back pain 6, 1/28/21 back pain prior to session 4 post treatment 5, 2/5/21 abdominal pain 6, 2/11/21 pain to the right knee 5. The OT notes document the following: 1/22/21- pain to back, left and right knees rated a 5, over the counter (OTC) and prescription medications used; 1/25/21 pain to the back and legs 7, prescription and OTC medications used; 2/5/21 abdominal pain 6, prescription medication used. The OT and PT notes do not document which medications the Patient is taking to relieve pain and the amount, frequency and effectiveness of the pain medications. 3. Patient #9 has a start of care date of 10/27/20 with a discharge date of 2/23/21 has diagnoses of Diabetes Mellitus Type Two, Decubitus Ulcers and Hypertension as documented on the Home Health Certification and Plan of Care dated 12/26/20 through 2/23/21. The Home Health Certification and Plan of Care dated 12/26/20 documents: SN one time a week for one week, 3 times a week for 8 weeks, one time a week for one week; PT and OT visits; SN to monitor pain and instruct/reinforce Patient regarding pharmacological and non-pharmacological pain control; Oxycodone Acetaminophen 5mg/325 mg every 6 hours for pan as needed, Methocarbamol (restless Leg Syndrome) 500 mg every 6 hours as needed. The SN notes document the following: 12/28/20- neck and back pain-9, 12/30/20 - back and bilateral lower extremities 7, 1/2/21 - back and shoulder pain 7, 1/4/21 - back pain 7 and OTC medication used, 1/6/21 - back pain 8 prescription pain medication used, 1/8/21 - generalized pain prescription pain medication used, 1/11/21 - neck pain 8, 1/13/21 - pain 8 to right arm, 1/15/21 - neck and both shoulders pain 7; 1/22/21 - neck pain 8; 1/25/21 - neck and shoulder pain 8; 1/25/21 - pain right arm pain 8; 1/27/21 - right arm 7; 1/31/21 - generalized and right shoulder pain 8. The PT notes document the Patient has pain on 12/31/20, 1/14/21, 1/25/21 and 2/10/21 rated a 5. The OT notes document the following: 12/29/20 - pain to neck, right shoulder and elbow; 1/5/21 - neck, shoulder and elbow pain 7, 1/19/21 - pain rated a 9 to the right elbow, wrist /hand and parathesia in right arm,; 1/26/21 - pain 7,; 2/3/21 - pain 6; 2/9/21 - pain 8; 2/15/21 - pain 8; 2/27/21 - pain 7. The SN, PT and OT notes lack documented evidence of which medications the Patient is taking to relieve pain and the amount, frequency and effectiveness of the pain medications. There is no documentation between the SN,PT and OT regarding the Patient's pain. 4. Patient #14 has a start of care date of 4/24/20 with diagnoses of Pressure Ulcer, Paraplegia, Hypertension and Dementia as documented on the Home Health Certification and Plans of Care dated 12/19/20 through 2/17/21 and 2/18/21 through 4/18/21. The Home Health Certification and Plans of Care dated 12/19/20 through 2/17/21 and 2/18/21 through 4/18/21 document the Patient is to receive SN, PT and OT visits; Patient goals include pain control methodologies as evidenced by a score of 3 on a scale of 0 to 10 and/or increased participation in ADL's (activities of daily living); patient will demonstrate Oxygen saturation within normal limits; Oxycontin 10 mg three times daily as needed ; Percocet 5mg/325 mg three times daily,Pregaabalin (pain reliever) 50 mg two times daily; Aleve (pain reliever) 220 mg at bedtime as needed. The OT note dated 1/19/21 documents the Patient has pain of a 5 to the right ankle/foot and Patient has a sacral wound. The record lacks documented evidence the OT informed the nurse of the wound. The PT notes document: 1/27/21 - Patient is forgetful/confused, SOB (Short of Breath) with wheeze, Oxygen saturation is 93%, pain is a 5 to the ankle/foot; 2/12/21- Oxygen saturation is 91%, pain is a 4 and prescription/OTC medication used; 2/17/21- Oxygen saturation 95%, SOB with minimal exertion, pain to the ankle/foot and rated a 4; edema to the lower extremities plus 3, compression machine was ordered to increase circulation and aid in wound heeling, and has a diagnosis of CHF (Congestive Heart Failure) and Dementia. The SN note dated 2/23/21 documents: Oxygen saturation 90%, pain to the right hip/knee, SOB. The SN notes document from 12/29/21 through 2/17/21 that the Patient has pain of a 3. The OT, PT and SN notes lack documented evidence of communication notes regarding pain, edema and Oxygen saturations.

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 review of clinical records, agency policy and interviews with agency staff, the agency failed to ensure agency policy meets NYS codes and regulations and Skilled Nursing Professionals services are delivered and supervised only by health care professionals who meet the qualifications and practice according to the agency's established policies and procedures, with regards to assessments and wound care. This was evident for four (4) of five (5) patients receiving wound care. (Patients #9, 10, 11, #13) Failure to ensure skilled professional services are delivered in accordance to agency policies has the potential to result in poor quality of care and possible negative outcomes. The findings are: 1. The Agency Policy titled " Policy Number 2.2.001 Wound assessment , documentation and photography" with a revision date of 21/2021 document: " Unless otherwise ordered by the physician, the Registered Nurse (RN) or physical Therapist ( PT) will assess wounds at least: weekly for patients receiving negative pressure wound therapy receiving daily wound care by the agency, every other week for patients receiving wound care by the agency at a frequency less than a week. Reassessments will be documented on the Wound Assessment Tool. The assessment includes measurement of the length of the length, width, and depth, undermining and tunneling, wound description, wound edges, exposed tissue types, drainage and condition of the periwound. At each dressing change, the clinician should record the wound bed description, wound edges, exposed tissue types, drainage and condition of the periwound. Individual State Licensure Boards of Nursing will regulate who can measure wounds." New York Codes, Rules and Regulations "Section 6902, of Article 139 of the Education Law does not include nursing diagnosis within the scope of practice of Licensed Practical Nurses. Thus, Licensed Practical Nurses in New York State do not have assessment privileges; they may not interpret patient clinical data or act independently on such data; they may not triage; they may not create, initiate, or alter nursing care goals or establish nursing care plans. Licensed Practical Nurses function by law in a dependent role at the direction of the RN or other select authorized health care providers. Under such direction, Licensed Practical Nurses may administer medications, provide nursing treatments, and gather patient measurements, signs, and symptoms that can be used by the RN in making decisions about the nursing care of specific patients. However, they may not function independent of direction". In an article Wound Wise: Measuring Wounds to Improve Outcomes published in the AJN, American Journal of Nursing August 2013, Volume :113 Number 8, page 60 - 61 the author writes "Wounds must be assessed and monitored to detect important changes, quantify progress, and guide treatment decisions. Assessment covers a variety of variables, such as the amounts of exudate, necrotic tissue, fibrin slough, and granulation tissue; the presence of undermining, tunneling, and epithelium; and the size of the wound." and "Improvement in any of these variables is encouraging and important to document and consider when making decisions about the type of wound-treatment product to choose (which dressing, for instance).1 But merely assessing and documenting these wound variables and tweaking protocols of care over many weeks (or months), hoping a pressure ulcer, venous ulcer, or foot ulcer is going to heal doesn't suffice. Only one of these variables-wound size, as measured over time-provides quantifiable data that can be used to help predict wound outcome. The healing trajectory, evidenced by changes in wound size, of every type of chronic wound can help in the prediction of whether or not that wound is going to heal within a reasonable period of time." Page 61 documents: The measurements are performed weekly, and progress in the wound's healing (or the lack thereof) will emerge after two to four weeks. The agency's policy regarding wound care does not include the NYS codes and Regulations. 2. Patient #9 has a start of care date of 10/27/20 with a discharge date of 2/23/21 has diagnoses of Diabetes Mellitus Type Two, Decubitus Ulcers and Hypertension as documented on the Home Health Certification and Plan of Care dated 12/26/20 through 2/23/21. The Home Health Certification and Plan of Care dated 12/26/20 documents: SN one time a week for one week, 3 times a week for 8 weeks for wound care. The SN note (recertification note) dated 12/26/20 lacks document of wound measurements. The SN notes dated 1/18/21, 1/22/21, 1/25/21, 1/29/21, 1/31/21, 2/5/21, 2/8/21, 2/8/21, 2/11/21 and 2/15/21 document the Patient received a Licensed Practical Nurse (LPN) for wound care. The notes document the LPN checked off that wound assessment was performed. 3. Patient #10 has a start of care date of 9/18/20 with diagnoses of Pressure Ulcer, Quadriplegia, Chronic Pain, Spinal Stenosis as documented on the Home Health Certification and Plan of Care dated 1/16/21 through 3/16/21. The Home Health Certification and Plan of Care dated 1/16/21 documents SN visits 3 times a week for 8 weeks then one time a week for one week; SN to perform right ischium cleanse with normal saline, apply Iodoflex to wound bed and cover with abdominal pad and Allevyn foam dressing; left ischium cleanse with normal saline, pack with Dankin's moistened gauze, cover with Allevyn foam dressing. The SN notes between 1/18/21 through 2/8/21 lack documented evidence of wound measurements. The SN notes dated 1/20/21 and 2/22/21 document the visits were made by an LPN. The notes document the LPN checked off the wounds were assessed.4. Patient # 11 has a start of care date of 7/7/2020 with diagnosis that include Pressure Ulcer sacral region Stage 3, Paraplegia Complete, Epilepsy , Hydrocephalus Disease as documented on the " Home Health Certification and Plan Of Care" for the certification period of 1/3/21 to 3/3/21. The " Home Health Certification and Plan Of Care" for the certification period of 1/3/21 to 3/3/21 document: "Frequency/ Duration of visits ,Skilled Nurse ( SN) 2 WK 8, 1 WK 1. SN to evaluate patient and develop plan of care in coordination with Physician. Skilled Nurse may perform two as needed visits for wound care complications such as increase and / or change in wound drainage, color, foul odor to wound, increased pain to wound site, elevated temperature, signs and symptoms of infection, increase in wound size and/ or staging". The " Physician Order" dated 1/20/21 document: " Skilled Nursing to perform/ instruct/ reinforce to patient procedure of wound care# 1 Stage III pressure ulcer to sacrum every visit, twice weekly. Patient/ caregiver to perform wound care for 30 days. Patient to return to wound care in two weeks. Cleanse wound with 0.9% Normal Saline and sterile 4x4, cover with Prisma AG or equivalent Fibracol Plus, cover with 4x4 Alleyvin foam dressing. Clean technique to be observed". A review of the " Visit Note Report" from 1/3/21 to 2/25/21 document that Licensed Practical Nurse (LPN) performed the assessment and measurements of the pressure ulcer independently on the following dates: 1/4/21, 1/8/21, 1/11/21, 1/15/21, 1/21/21, 1/25/21, 1/29/21, 1/24,21, 2/5/21 and 2/12/21. There is no documented evidence the pressure ulcer measurements were performed under the direction or reviewed by an Registered Nurse in making decision about the nursing care. There is no documented evidence that all staff are assigned according to the patient's needs; staff's licensure and scope of practice. There is no documented evidence of Direction from the Registered Nurse. 5. Patient # 13 has a start date of 12/13/2020 with diagnosis that include Malignant Neoplasm of Lower Lobe Right bronchus or Lung, Anemia Pleural Effusion as documented on the " Home Health Certification and Plan Of Care" for the certification period of 2/11/21 to 4/11/21 document: " Frequency/ Duration of visits :Skilled Nurse effective 2/14/21 1 WK 7, 2 WK 1. Skilled Nurse to evaluate and develop plan of care in coordination with Physician. Skilled Nurse using manufacturer recommended technique drain not more than 1500 cc of pleural fluid via the pleural catheter to right lung every Monday and notify the physician of amount. Skilled Nurse using manufacturer recommended technique to perform catheter site care every time pleural fluid is drained. Cleanse catheter site with alcohol swab, cover with foam dressing 4x4, cover with transparent dressing". A review of the " Visit Note Report" from 12/1320 to 1/31/21 indicated the assessment of the wound and the pleural catheter procedure were performed by Licensed Practical Nurse ( LPN) on the following dates: 12/18/20,12/24/20, 12/31/20, 1/25/20. There is no documented evidence the procedure for the pleural fluid draining and pleural catheter site were performed under the direction of an RN or were reported to a Registered Nurse in making decision about the nursing care. There is no documented evidence that all staff are assigned according to the patient's needs; staff's licensure and scope of practice. There is no documented evidence of Direction from the Registered Nurse. On 3/2/21 at 1:30 PM, the Administrator was interviewed and did not provide an explanation for the above findings.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to document discharge planning, a completed discharge summary , and physician notification for patients no longer receiving services from the agency. This was for one (1) of five (5) discharge records reviewed. (Patient #3) Failure to document discharge planning, discharge summary and physician notification has the potential for negative patient outcomes. The findings are: 1. Patient #3 has a start of care of 11/13/2017 with diagnosis that include Bipolar disorder, Type II Diabetes Mellitus, Long term use of Hypoglycemic drugs, Hypertension, Benign Prostatic Hyperplasia as documented on the " Home Health Certification and Plan Of Care for the certification period of 7/6/2019 to 9/3/2019. The " Home Health Certification and Plan Of Care" for the certification period of 7/6/19 to 9/3/19 document: " Skilled Nurse (SN) effective 7/14/2019 one time a week for one week, one time every two weeks for six weeks; Discipline and treatments: " SN to evaluate and develop plan of care in coordination of physician.; SN to instruct on Hypertension to include disease process, signs and symptoms, complications and management; SN to instruct on Diabetes to include disease process disease process; the patient is receiving Home Care due to need for medication pre pour, medication management, diabetic teaching, symptom management, supportive counseling, teaching R/T coping skills. Medications include: Accu check guide test once daily, Aspirin oral 81mg tablet, one tablet daily,Calcium carbonate D3 oral, one tablet daily, Donnatal oral one tablet three times daily, Hydrocodone- Acetaminophen 5-325 mg four times daily as needed, Magnesium oxide oral one tablet daily, Metformin oral 500 mg one tablet twice daily ( BID), Methylphenidate HCL oral one tablet three times ( TID) a day, Pantoprazole oral 40 mg one tablet daily, Resistor oral 150 mg TID, Ropinirole oral 1 mg one tablet four times a day, Tab a vite oral one tablet once daily, Tamsulosin oral 4 mg one tablet at bedtime, Tizanidine 4 mg oral one or two tablets TID as needed, Ventolin HFA inhalation one puff every six hours via moth as needed, Zinc oral 50 mg one tablet daily, Zolpidem oral 10 mg a bedtime". The " Home Health Certification and Plan of Care " for the certification period of 9/4/2019 to 11/12/2019 documents: " Skilled nurse to prefill planner device every two weeks, instruct patient/ caregiver on how to prefill medication planner. Skilled Nurse does medication prepour as client is unable to perform this task." The " Client Coordination Note Report dated 7/21/19 documents: " Medication reconciliation , medication completed pour by writer, client not independent with medication management." The " Client Coordination Note Report" dated 8/21/19 document: " Team case Conference: Team reviewed the episode detail report and discussed the following, client lives with wife who also has several disabilities . he has limited insight, speech is pressured, though he is pleasantBased on discussion the recommendation of the teams is Recertification, anticipated disciplines recerting, behavioral Skilled Nurse." The record document the last " visit note report" dated 8/31/2019. On 2/11/2020, the patient complained that the agency stopped services on 9/4/2109, because "the agency claimed that he was non complaint with his psychiatric medications, the patient was never on any psychiatric medications". On 2/26/2021 at 11:15 AM, the Administrator was interviewed and stated the patient has been discharged. A request was made on 2/26/21 and 3/2/21 for the date of discharge and documentation of the discharge, this information was not provided. There is no documented evidence of a completed discharge summary, notification of the physician, reasons for the discharge, date of discharge, summary of care given, and patient's progress. On 3/2/21 at 1:30 PM, the Administrator was interviewed and did not provide an explanation for the above findings.