Every finding on record at Nursing Sisters Home Care, Inc.

The following statement of deficiencies represents the results of a re-certification survey of Catholic Home Care Certified Home Health Agency, located at 110 Bi-County Blvd, Farmingdale, New York 11735, conducted on 04/07/2025 through 04/15/2025, to evaluate the Agency’s compliance with Federal Conditions of Participation and State requirements. A standard re-certification survey was initiated on 04/07/2024. Deficient practices were identified within Level 1 standards in Conditions 484.60 (Care Planning) and 484.55 (Comprehensive Assessment of Patient) resulting in a partial extended survey. The Agency reported an active patient census of 2,835 at the entrance conference on 04/07/2025. The survey consisted of a review of seventeen (17) clinical records including seven (7) observational home visits, five (5) discharge records, nineteen (19) personnel records and two (2) contracts. The survey included a review of pertinent policies and procedures, Quality Improvement meeting minutes for the past 12 months, agency Admission Packet, the Emergency Preparedness Plan, and Complaint Log. Pre-survey activities consisted of review on 04/04/25 of the agency’s Health Commerce System, Home Care Worker Registry, Criminal History Record Check, Internet Quality Improvement and Evaluation System (IQIES) reports for the period 01/01/2024 – 12/31/2024, and the agency’s compliance with report submission for the statistical report and Department of Health Emergency Drills. The Director of Patient Services, Director of Performance Improvement, Assistant Vice President and Director of Human Resource and staff were interviewed on 04/14/25 at 2.08PM. Findings were reviewed at the exit conference on 04/15/2025. The following deficiencies are identified as a result of the survey: Federal Deficiencies: G0534 Patient's needs G0536 Review of all current medications G0572 Plan of Care G0574 Plan of Care must include the following G0580 Only as ordered by a Physician G0590 Prompt alert of Physician G0608 Coordinate care delivery G0984 In accordance with current clinical practice G1012 Required items in clinical record State Deficiencies: J1156 Governing Authority R1034 Responsibilities of the providers

Patient's needs CFR(s): 484.55(c)(4) The patient's medical, nursing, rehabilitative, social, and discharge planning needs; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview the Governing Authority failed to ensure a complete assessment of patient needs and referral for other skill services. This was evident in one (1) of seventeen (17) clinical records reviewed (Patient #4). Failure to ensure the assessment of all patient needs and services has the potential for negative patient outcomes. Findings are: 1) Patient #4 has a start of care date of 03/15/2025 with diagnoses of “Malignant Neoplasm of Esophagus, Partial Intestinal Obstruction, Pleural Effusion and Benign Prostatic Hyperplasia" as documented on the “Home Health Plan of Care" for certification period of 3/15/2025 to 5/13/2025. The “Home Health Plan of Care" for certification period of 03/15/2025 to 05/13/2025 documents orders for "Skilled Nursing 6 to 7 visits every week for 2 weeks (six to seven visits every week for two weeks), 6 to 7 visits every week for 1 weeks (six to seven visits every week for one week). Functional Limitations- endurance, ambulation. Durable Medical Equipment - standard wheelchair, wheeled walker". The referral for services dated 03/14/2025 documents "assess for Physical Therapy needs". The "Start of Care" comprehensive assessment dated 03/15/2025, the Skilled Nurse/Registered Nurse documents "Musculoskeletal problems: muscle weakness, ambulation - standby assist, transfer - standby assist. Functional Limitations- endurance, ambulation". The clinical record lacks documented evidence of Physical Therapy referral, evaluation to assess the patient's need related to muscle weakness, ambulation assist, transfer assist, poor endurance, and usage of the Durable Medical Equipment. Survey findings were reviewed with the Director of Patient Services and Assistant Vice President on 04/10/2025 at 03:50PM. An Interview was conducted on 04/14/2025 at 11:15 AM with the Assistant Vice President, no explanation was provided.

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 clinical record reviews, home visit observation and staff interview, the Governing Authority failed to ensure the review of all medications the patient is currently using to identify any potential adverse effects and drug interaction. This was evident in one (1) of seventeen (17) clinical records reviewed (Patient #3). Failure to review all medications the patient is currently using to identify any potential adverse effects and drug interaction has the potential for negative patient outcomes. The findings are: 1) Patient #3 has a start of care date of 03/30/2025 with diagnoses including “Unspecified open wound to Right Lower Leg, Peripheral Vascular Disease, Unspecified Atrial Fibrillation, Rheumatoid Arthritis, Pan lobular Emphysema, Essential Hypertension, Age-related Osteoporosis, and Long-term use of anticoagulants” as documented on the “Home Health Plan of Care” for certification period 03/30/2025 to 05/28/2025. The "Home Health Plan of Care” for certification period 03/30/2025 to 05/28/2025 document orders for “Medical Social Worker 1 to 2 visits every month for 2 months, Physical Therapy 1 to 2 visits every week for 3 weeks, Skilled Nursing 2 to 4 visits every week for 3 weeks. Medications include Acidophilus caps – take by mouth, Fluticasone 50 micrograms/ACT nasal spray, Metoprolol succinate 50 milligram 24-hour tablet – take by mouth, Silver sulfadiazine 1% cream – apply to affected area on the leg every day, and Warfarin (Coumadin) 4 milligram tablet take one time daily except 2 milligram every Monday and Fridays”. On 04/08/25, a home visit observation was conducted with the agency Registered Nurse. The following medications were observed in the patient’s home, but were not documented on the Plan of Care updated on 04/03/25: Ammonium Lactate 10% cream apply daily as needed, lacked route and indications for as needed), Blink tears 0.25% - one drop both eyes two times a day, Silver sulfadiazine 1% cream (lacked route and frequency of use), Clobetasol 0.05% cream apply 2 times a day as needed (lacked route and the indications for as needed order), Docusate sodium 100 milligram capsules take 1 capsule two times a day as needed (lacked indication for as needed order), Aspercreme (4% Lidocaine) apply daily as needed, (lacked route and indications for as needed), Fiber Powder 1 application daily as needed, (lacked dosage and indication for the as needed), Pepto Bismol 262 milligram take 1-2 tablets daily as needed, (lacked indication for as needed), Warfarin 4 milligram by mouth one time daily. Take 4 milligram daily except 2 milligram every Monday and Friday. On 04/08/25 at 11:45 AM the patient was interviewed by a surveyor. The patient stated the above “Warfarin dose is not what he/she is taking”. The patient stated, “I am currently taking Warfarin 2 milligram on Saturday and Sunday, 4 milligrams on Monday, 2 milligrams on Tuesday, 4 milligrams on Wednesday, 2 milligrams on Thursday, and 4 milligrams on Friday”. The patient verbalized "a non-agency nurse comes to the home and draws blood to determine if the warfarin dose needs to be adjusted. Per the patient the last blood draw was on 03/25/25. The patient stated the nurse calls the day after the blood draw with the results and instructs the patient on what dose of warfarin to take until the next blood draw. The nurse’s do not physically check the pill bottles or medications in the box every visit”. The clinical record lacks documented evidence of a review of all current medications. On 04/8/2025 the Registered Nurse was interviewed and stated, “The One Source of Truth (patient’s in home medication list) is updated every visit.” On 04/08/25 the Registered Nurse and Director of Clinical Education acknowledged the findings. On 04/08/25 at 4:15 PM the Director of Patient Services, Assistant Vice President and Administrative staff were notified regarding the survey findings. No additional information was provided.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on clinical record review, observational home visits, and staff interviews, the Governing Authority failed to establish a complete individualized Plan of Care that identifies all of the patient's needs. This was evident in two (2) of the seventeen (17) clinical records reviewed (Patient #4 and #5). Failure to ensure a complete individualized Plan of Care is developed for each patient has the potential for negative patient outcomes. The findings are: 1) Patient #4 has a start of care date of 03/15/2025 with diagnoses of “Malignant Neoplasm of Esophagus, Partial Intestinal Obstruction, Pleural Effusion and Benign Prostatic Hyperplasia" as documented on the “Home Health Plan of Care" for certification period of 3/15/2025 to 5/13/2025. The “Home Health Plan of Care" for certification period of 03/15/2025 to 05/13/2025 document orders for "Skilled Nursing 6 to 7 visits every week for 2 weeks (six to seven visits every week for two weeks), 6 to 7 visits every week for 1 weeks (six to seven visits every week for one week). Skilled Nurse to drain chest catheter to right chest daily. Skilled Nurse to evaluate respiratory status. Skilled Nurse to perform dressing change to chest catheter site – cleanse site with alcohol, apply drain sponge, gauze dressing and cover with transparent dressing using sterile technique to location right chest -daily”. The Skilled Nurse visit report dated 03/16/2025 lack documentation of an evaluation of the patient’s respiratory status. There is no documented evidence of an assessment of the patients’ lungs. The "Skilled Nurse routine visit" reports dated 03/17/25, 3/18/25, 03/19/25, 03/31/25, 04/01/25 lacks documentation of dressing change to chest catheter site – "cleanse site with alcohol, apply drain sponge, gauze dressing and cover with transparent dressing using sterile technique to location right chest -daily”. The Agency did not provide services and chest catheter site treatments as ordered in the Plan of Care. Survey findings were reviewed with the Director of Patient Services and Assistant Vice President on 04/10/2025 at 03:50PM. An Interview was conducted on 04/14/2025 at 11:15 AM with the Assistant Vice President, no explanation was provided. 2) Patient #5 has a start of care date of 03/29/2025 with diagnoses of “Encounter for change or removal of non-surgical wound dressing, Pressure Ulcer of sacral region: stage 4, Alzheimer’s Disease, Dementia, Chronic Atrial Fibrillation, and Essential Hypertension” as documented on the “Home Health Plan of Care” for certification period 03/29/2025 to 05/27/2025. The “Home Health Plan of Care” for certification period 03/29/2025 to 05/27/2025 document orders for “Medical Social Worker 1 to 2 visits every month for 2 months, Skilled Nursing 1 visit every day for 1 day, 1 to 2 visits every week for 4 weeks, 2 visits as needed for CV (Cardiovascular), CP (Cardiopulmonary), wound complications, monitor the patient’s weight”. The plan of care lacks documented evidence of the frequency, the parameters, and the interventions to obtain and monitor the patient’s weight. Survey findings were conducted with the Director of Patient Services and Assistant Vice President on 04/14/2025 at 10:30 AM. An Interview was conducted on 04/14/2025 at 12:30 PM with Director of Patient Services, no explanation was provided.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record review, observational home visits, and staff interviews, the Governing Authority failed to establish a comprehensive Plan of Care that include all diagnoses, all medications, treatments and supplies based on the patient's needed home care services. This was evident in eight (8) of the seventeen (17) clinical records reviewed (Patients #3, #4, #7, #8, #11, #10, #12 and #16). Failure to ensure a complete Plan of Care is developed for each patient has the potential for negative patient outcomes. The findings are: 6) Patient #3 has a start of care date of 03/30/2025 with diagnose including “Unspecified open wound to Right Lower Leg, Peripheral Vascular Disease, Unspecified Atrial Fibrillation, Rheumatoid Arthritis, Pan lobular Emphysema, Essential Hypertension, Age-related Osteoporosis, and Long-term use of anticoagulants” as documented on the “Home Health Plan of Care” for certification period 03/30/2025 to 05/28/2025. The Home Health Plan of Care” for certification period 03/30/2025 to 05/28/2025 document orders for “Medical Social Worker 1 to 2 visits every month for 2 months, Physical Therapy 1 to 2 visits every week for 3 weeks, Skilled Nursing 2 to 4 visits every week for 3 weeks. Medications include Acidophilus caps – take by mouth, Fluticasone 50 micrograms/ACT nasal spray, Metoprolol succinate 50 milligram 24-hour tablet – take by mouth, Silver sulfadiazine 1% cream – apply to affected area on the leg every day, and Warfarin (Coumadin) 4 milligram tablet take one time daily except 2 milligram every Monday and Fridays”. On 4/8/25, a home visit observation was conducted with the agency Registered Nurse. The following medications were observed in the patient’s home, but were not documented on the Plan of Care updated on 4/3/25: Ammonium Lactate 10% cream apply daily as needed, lacked route and indications for as needed), Blink tears 0.25% - one drop both eyes two times a day, Silver sulfadiazine 1% cream (lacked route and frequency of use), Clobetasol 0.05% cream apply 2 times a day as needed (lacked route and the indications for as needed order), Docusate sodium 100 milligram capsules take 1 capsule two times a day as needed (lacked indication for as needed order), Aspercreme (4% Lidocaine) apply daily as needed, (lacked route and indications for as needed), Fiber Powder 1 application daily as needed, (lacked dosage and indication for the as needed), Pepto bismol 262 milligram take 1-2 tablets daily as needed, (lacked indication for as needed), Warfarin 4 milligram by mouth one time daily. Take 4 milligram daily except 2 milligram every Monday and Friday. On 4/8/25 at 11:45 AM the patient was interviewed by a surveyor. The patient stated the above “Warfarin dose is not what he/she is taking”. The patient stated, “I am currently taking Warfarin 2 milligram on Saturday and Sunday, 4 milligrams on Monday, 2 milligrams on Tuesday, 4 milligrams on Wednesday, 2 milligrams on Thursday, and 4 milligrams on Friday”. The Plan of Care lacks an order for all medications dosage, route and frequency, bleeding precautions, anticoagulant precautions, and blood clotting testing International Normalized Ratio (INR) related to prolonged use of anticoagulant. Survey findings were reviewed with the Director of Patient Services and Assistant Vice President on 04/14/2025 at 10:15 AM. An Interview was conducted on 04/14/2025 at 02:05 PM with Director of Patient Services, no explanation was provided. 7) Patient #4 has a start of care date of 03/15/2025 with diagnoses of "Malignant Neoplasm of Esophagus, Partial Intestinal Obstruction, Pleural Effusion and Benign Prostatic Hyperplasia" as documented on the “Home Health Plan of Care" for certification period of 3/15/2025 to 5/13/2025. The “Home Health Plan of Care" for certification period of 3/15/2025 to 5/13/2025 documents orders for "Skilled Nursing 6 to 7 visits every week for 2 weeks (six to seven visits every week for two weeks), 6 to 7 visits every week for 1 weeks (six to seven visits every week for one week). Functional Limitations- endurance, ambulation. Durable Medical Equipment - standard wheelchair, wheeled walker". The addendum to the Plan of Care dated 04/02/2025 documents an order for "Skilled Nurse 6 to 7 visits every week for 1 weeks (six to seven visits every week for one week)". The referral for services dated 03/14/2025 documents "assess for Physical Therapy needs". The Plans of Care lacks an order for Physical Therapy services to evaluate and treat. The Agency did not establish an individualized Plan of Care to include Physical Therapy services to meet the patient's needs related to functional limitations, muscle weakness, ambulation assist, transfer assist, poor endurance, and Durable Medical Equipment’s. Survey findings were reviewed with the Director of Patient Services and Assistant Vice President on 04/10/2025 at 03:50PM. An Interview was conducted on 04/14/2025 at 11:15 AM with the Assistant Vice President, no explanation was provided. 8) Patient #7 has a start of care date of 02/27/2025 with diagnoses of "Encounter for change or removal of drains, Aftercare following surgery for Neoplasm, Malignant Pleural Effusion, Malignant Neoplasm of unspecified part of Right Bronchus or Lung, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Hypothyroidism, and Atherosclerotic Heart Disease, Native Coronary without Angina Pectoris" as documented on the "Home Health Plan of Care” for certification period 02/27/2025 to 04/27/2025. The "Home Health Plan of Care” for certification period 02/27/2025 to 04/27/2025 documents orders for "Skilled Nursing 1 visit every day for 21 days (one visits every day for twenty-one days), 1 to 3 visits (one to three visits) as needed to assess for any issues chest drain. Skilled Nurse to drain a maximum amount of 1000 ml (milliliters) from chest drain daily". The addendum to the Plan of Care dated 03/18/2025 documents an order for "Skilled Nurse 1 visit every day for 38 days (one visits a day for thirty-eight days), effective 03/21/2025. The Plans of Care lack orders for wound care dressing change to the chest drain site. Survey findings were reviewed with the Director of Patient Services and Assistant Vice President on 04/10/2025 at 03:30PM. An Interview was conducted on 04/14/2025 at 11:15 AM with the Assistant Vice President, no explanation was provided. 1) Patient # 8 has a start of care date of 06/06/2024 with diagnoses of "Hypertensive Heart and Chronic Kidney Disease with Heart Failure, End Stage Renal Disease and Type II Diabetes" as documented on the “Home Health Plan of Care” for certification period of 04/02/2025 to 05/31/2025. The “Home Health Plan of Care” certification period 04/02/2025 to 05/31/2025 documents orders for “Skilled Nursing 1 to 2 visits every month for 2 months and 1 to 3 visits as needed for Foley complications, infection or falls, safety measures as- adequate lighting, nutritional requirements: renal diet, Oxygen inhale 2 liters per minute and the durable medical equipment (DME): wheelchair cushion and walker”. The “Skilled Nurse recertification” dated 03/31/2025 documents “Foley catheter 16 French 10cc balloon in place with 100ml clear yellow urine in drainage bag, poor appetite on diabetic diet”. The Plan of Care lacks documented evidence of the safety measures of oxygen precautions, the nutritional requirements of diabetic diet, and durable medical equipment of oxygen concentrator and Foley catheter supplies. Interview conducted with the Director of Patient Services and acknowledges findings, an updated list including the oxygen concentrator and Foley catheter supplies provided on 04/14/2025. The survey findings were reviewed with the Director of Patient Services (DPS), Assistant Vice President, Director of Clinical Education (DCE), and Director of Performance Improvement on 4/14/2025 at 4:00PM. The team acknowledged findings, no further explanation was given. 2) Patient # 10 has a start of care date of 05/10/2024 with diagnoses of “Pressure Ulcer of right hip: stage 4, Lumbar Spina Bifida, Paraplegia, Type II Diabetes, Essential Hypertension, Gastro-esophageal Reflux, Sleep Apnea, and Depression” as documented on the “Home Health Plan of Care” for certification period of 03/06/2025 to 05/04/2025. The “Home Health Plan of Care” for certification period 03/06/2025 to 05/04/2025 documents orders for “Skilled Nursing 3 visits every week for 8 weeks and 4 visits as needed for wound complications and dressing changes, under discharge plans:(not documented). Medication: Bupropion (Wellbutrin XL) 150mg 24-hour tablet: 150mg every morning for depressive disorder, and Polyethylene glycol 17 grams per scoop: Take 17 grams by mouth daily as needed". The Plan of Care lacks documented evidence of the patient’s discharge plans. The Plan of Care lacks the medication route for Bupropion 150mg and the indication for the Polyethylene glycol 17 grams “as needed” order. The Governing Authority failed to maintain a comprehensive plan of care. Interview conducted with the Assistant Vice President on 04/14/2025 at 4:00pm and acknowledges findings, stated “a ticket was entered to the Information Technology (IT) department to address the issue”. The survey findings were reviewed with the Director of Patient Services (DPS), Assistant Vice President, Director of Clinical Education (DCE), and Director of Performance Improvement were interviewed on 04/14/2025 at 4:00PM. The team acknowledged findings, no further explanation was given. 3) Patient #11 has a start of care date of 07/05/2024 with diagnoses of "Pressure Ulcer right buttocks stage 4, Paraplegia, Neuralgia and Neuritis, complete lesion at the Thoracic (T11-T12), Epilepsy and Colostomy" as documented on the “Home Health Plan of Care” for the certification period of 03/02/2025 to 04/30/2025. The "Home Health Plan of Care” for certification period 03/02/2025 to 04/30/2025 documents orders for "Skilled Nurse visits every week for 8 weeks and 3 to 4 visits as needed for additional wound care due to increased drainage when caregiver unavailable”. The "Skilled Nurse Oasis" start of care assessment dated 02/28/2025 documents “Patient independent with colostomy care and intermittently urinary catheterization every 2-3 hours”. The Plan of Care lacks documented evidence of complete orders for genitourinary self-catheterization, colostomy care and care planning with intervention and goals. On 4/11/25 at 12:45 pm the Assistant Vice President was interviewed and stated, “You were accurate in your findings”, no additional information was provided. On 4/11/25 at 4:10 pm the survey findings were reviewed with the administrative team including the Director of Patient Services and Assistant Vice President. No explanation or additional information was provided. 4) Patient #12 has a start of care with diagnoses of "Diabetes type 2 with foot ulcer, Chronic ulcer of the left foot, Osteomyelitis left ankle, Atherosclerosis of the native arteries with intermittent claudication, Neuropathy Arthropathy, Charcot’s joint, left ankle and foot, Hypertension and Hypercholesterolemia" as documented on the “Home Health Plan of Care” for certification period of 03/04/2025 to 05/02/2025. The “Home Health Plan of Care” for certification period of 03/04/2025 to 05/02/2025 documents orders for “Skilled Nursing: one (1) visit every week for one (1) week, one to three (1 to 3) visits every week for three (3) weeks for cardiovascular, cardiopulmonary assessment and wound complications, one to two (1 to 2) visits every week for eight (8) weeks”. The “Skilled Nurse Recertification” dated 02/28/2025 documents “Peripheral inserted central catheter (PICC line) double lumen placed 01/20/2025 to left arm, dressing clean dry and intact, reason: Antibiotics”. The Plan of Care lacks documented evidence of who is responsible for the care of the Peripheral inserted central catheter, dressing change and flushing to maintain patency. An interview conducted with the Assistant Vice President on 04/10/2025 at 11:27AM acknowledges findings and stated, “spoke to nurse, central line is being manage by another agency”. Surveyor was provided with an Interim order sent on 04/09/2025 to provider. 5) Patient #16 has a start of care date of 6/17/2024 and discharge date 12/18/2024 with the diagnoses of "Acute on Chronic Systolic Congestive Heart Failure, permanent Atrial Fibrillation, Spondylosis, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease, Atherosclerotic Heart Disease of native Coronary Artery, Obstructive Sleep Apnea, long-term use of Anticoagulants, and long-term use of Aspirin" as documented on the “Home Health Plan of Care” for certification period of 11/15/2024 to 01/13/2025. The "Home Health Plan of Care” for certification period 11/15/2024 to 01/13/2025 documents orders for “Skilled Nursing 1 to 2 visits every week for 4 weeks and 1 to 3 visits as needed for Cardiopulmonary assessments, home safety and falls prevention. Physical Therapy one visit every two weeks for two weeks. Skilled clinicians to instruct patient and caregiver causes and prevention of skin breakdown. Under Intervention: Respiratory device- BIPAP machine”. The Plan of Care lacks documented evidence of the settings for the BIPAP machine. The Plan of Care lacks documented evidence of a complete order for the equipment and supplies required. The “Skilled Nurse Oasis” start of care assessment dated 11/15/2024 documents “Patient has Stage 2 pressure ulcer on left buttocks measuring 0.5 cm x 0.5 cm x 0.1 cm. Picture sent to Wound Ostomy Certified Nurse (WOCN) who recommended that wound be cleaned with wound cleanser and patted dry, apply Triad cream to wound daily and as needed (prn)”. The Plan of Care lacks documented evidence of the pertinent diagnosis of the stage 2 pressure ulcer. The Plan of Care lacks documented evidence of a complete order for wound care and supplies required. On 4/10/25 at 3:55 pm the survey findings were reviewed with the administrative team including the Director of Patient Services and Assistant Vice President, no explanation provided. On 4/11/25 at 12:45 pm the Assistant Vice President was interviewed and stated, “You were accurate in your findings”, no additional information was provided.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interviews, the Governing Authority failed to ensure that treatment and services are administered in accordance with the orders of the patient's primary care provider. This was evident in one (1) of the seventeen (17) clinical records reviewed (Patient #15). Failure to ensure treatment and services are administered in accordance with the orders of the patient's primary care provider has the potential for negative patient outcomes. Findings are: Patient # 15 has a start of care date of 01/10/2024 and discharge date of 01/23/2025 with diagnoses of "Pressure Ulcer of sacral region: stage 4, Dementia, Type II Diabetes, Nonrheumatic Mitral valve insufficiency, Barrett’s Esophagus, Atrioventricular Block, Ventricular Block, and Hyperlipidemia" as documented on the “Home Health Plan of Care” for certification period of 01/02/2025 to 03/02/2025. The “Home Health Plan of Care” for certification period of 01/02/2025 to 03/02/2025 documents orders for “ skilled nursing: one visit every week for one week, one visit day for one day, 2 to 4 visits every week for three weeks, 1 to 2 visits as needed for wound care 2-4 visits every week for two weeks 2 to 4 every week for 7 weeks for cardiovascular and cardiopulmonary assessment, weekly wound measurements, nutritional requirements: diabetic diet, low cholesterol diet, low fat diet, and low sodium diet and under (Discharge Plans) documents: discharge plans not documented”. The "Skilled Nurse visit" notes dated 01/13/2025 and 01/15/2025 lacks documented evidence that the patient’s wound was measured the week of 01/13/2025. Interviewed conducted on 04/14/2025 at 4:00PM with the Assistant Vice President and acknowledged findings. The survey findings were interviewed on 04/14/2025 at 4:00PM with the Director of Patient Services, Assistant Vice President (AVP), Director of Clinical Education, and Director of Performance Improvement. The team acknowledged the survey findings and no further explanation provided.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interviews, the Governing Authority failed to ensure that treatment and services are administered in accordance with the orders of the patient's primary care provider. This was evident in one (1) of the seventeen (17) clinical records reviewed (Patient #16). Failure to ensure treatment and services are administered in accordance with the orders of the patient's primary care provider has the potential for negative patient outcomes. Findings are: Patient #16 has a start of care date of 6/17/2024 and discharge date of 12/18/2024 with diagnoses of "Acute on Chronic Systolic Congestive Heart Failure, Permanent Atrial Fibrillation, Spondylosis, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease, Atherosclerotic Heart Disease of native coronary artery, Obstructive Sleep Apnea, long-term use of anticoagulants, and long-term use of aspirin" as documented on the “Home Health Plan of Care” for certification period of 11/15/2024 to 1/13/2025. The “Home Health Plan of Care” for certification period 11/15/2024 to 1/13/2025 documents orders for “Skilled Nursing 1 to 2 visits every week for 4 weeks and 1 to 3 visits as needed for Cardiopulmonary assessments, home safety and falls prevention. Physical Therapy one visit every two weeks for two weeks. Skilled clinicians to instruct patient and caregiver causes and prevention of skin breakdown. Under Intervention: Respiratory device- BIPAP machine”. The Skilled Nurse home visit note dated 11/21/24 documented, “Patient has additional stage 2 pressure sore on sacrum – wound #1 measures 1.0 cm x 0.25 cm x 0.1 cm and wound #2 measures 0.5 cm x 0.25 cm x 0.1 cm. Caregiver instructed to turn and reposition patient every 2 hours. All pressure sores including pressure sore on left buttock were cleaned with wound cleanser and patted dry. Applied Triad cream to wounds and left open to air.” The record lacks documented evidence the physician was promptly notified regarding the additional stage 2 pressure ulcer. On 4/11/25 at 12:45 pm the Assistant Vice President was interviewed and stated, “You were accurate in your findings”. No additional information was provided. On 4/11/25 at 3:55 pm the survey findings were reviewed with the administrative team including the Director of Patient Services and Assistant Vice President. No explanation or additional information was provided.

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 the coordination of care and services to meet the needs of the patients. This was evident in six (6) of seventeen (17) clinical records reviewed (Patients #3, #4, #5, #9, #12 and #15). Failure to ensure coordination of care, has the potential for negative patient outcomes. Findings are 3) Patient #3 has a start of care date of 03/30/2025 with diagnose including “Unspecified open wound to Right Lower Leg, Peripheral Vascular Disease, Unspecified Atrial Fibrillation, Rheumatoid Arthritis, Pan lobular Emphysema, Essential Hypertension, Age-related Osteoporosis, and Long-term use of anticoagulants” as documented on the “Home Health Plan of Care” for certification period 03/30/2025 to 05/28/2025. The Home Health Plan of Care” for certification period 03/30/2025 to 05/28/2025 document orders for “Medical Social Worker 1 to 2 visits every month for 2 months, Physical Therapy 1 to 2 visits every week for 3 weeks, Skilled Nursing 2 to 4 visits every week for 3 weeks. Warfarin (Coumadin) 4 milligram tablet take one time daily except 2 milligram every Monday and Fridays”. The Skilled Nurse visit reports dated 04/01/2025 and 04/02/2025 lack documented evidence of patient education for Coumadin precautions, bleeding precautions, and anticoagulant therapy monitoring. On 04/08/25 at 11:45 AM the patient was interviewed by a surveyor. The patient stated the above “Warfarin dose is not what I am taking". The patient stated, “I am currently taking Warfarin 2 milligram on Saturday and Sunday, 4 milligrams on Monday, 2 milligrams on Tuesday, 4 milligrams on Wednesday, 2 milligrams on Thursday, and 4 milligrams on Friday. The patient verbalized a non-agency nurse comes to the home and draws blood to determine if the warfarin dose needs to be adjusted. Per the patient the last blood draw was on 03/25/25. The patient stated the nurse calls the day after the blood draw with the results and instructs the patient on what dose of Warfarin to take until the next blood draw. The nurse’s do not physically check the pill bottles or medications in the box every visit”. The clinical record lacks documented evidence of coordination with the Physician for blood testing and Warfarin dosage adjustments. The Agency did not coordinate care delivery involving the patient's health needs. Survey findings were conducted with the Director of Patient Services and Assistant Vice President on 04/14/2025 at 10:15 AM. An Interview was conducted on 04/14/2025 at 02:05 PM with Director of Patient Services, no explanation was provided. 4) Patient #4 has a start of care date of 03/15/2025 with diagnoses of “Malignant Neoplasm of Esophagus, Partial Intestinal Obstruction, Pleural Effusion and Benign Prostatic Hyperplasia" as documented on the “Home Health Plan of Care" for certification period of 03/15/2025 to 05/13/2025. The “Home Health Plan of Care" for certification period of 03/15/2025 to 05/13/2025 documents orders for "Skilled Nursing 6 to 7 visits every week for 2 weeks (six to seven visits every week for two weeks), 6 to 7 visits every week for 1 weeks (six to seven visits every week for one week). The “Routine Licensed Practical Nurse” visit reports dated 03/18/2025, 03/27/2025, 03/31/25, 04/01/25, and 04/03/25 lack documented evidence of coordination with the Registered Nurse. The Agency did not coordinate care delivery involving the patient's needs. Survey findings were reviewed with the Director of Patient Services and Assistant Vice President on 04/10/2025 at 03:50PM. An Interview was conducted on 04/14/2025 at 11:15 AM with the Assistant Vice President, no explanation was provided. 5) Patient #5 has a start of care date of 03/29/2025 with diagnoses of “Encounter for change or removal of non-surgical wound dressing, Pressure Ulcer of sacral region: stage 4, Alzheimer’s Disease, Dementia, Chronic Atrial Fibrillation, and Essential Hypertension” as documented on the “Home Health Plan of Care” for certification period 3/29/2025 to 5/27/2025. The “Home Health Plan of Care” for certification period 03/29/2025 to 05/27/2025 document orders for “Medical Social Worker 1 to 2 visits every month for 2 months, Skilled Nursing 1 visit every day for 1 day, 1 to 2 visits every week for 4 weeks, 2 visits as needed for CV (Cardiovascular), CP (Cardiopulmonary), wound complications, monitor the patient’s weight". The “Initial Medical Social Worker” visit report dated 04/03/2025 documents the patient has “severe Intellectual impairment, oriented to person, place, time, situation, and has no memory loss". The clinical record lacks documentation of an accurate assessment of the patient’s mental health status. The “Routine Licensed Practical Nurse” visit report dated 04/07/25 documents the patient’s daughter is “overwhelmed with patient care as she is the primary care giver”. Case Manager notified. The clinical record lacks documentation of social work intervention to address the patient’s primary caregivers’ patient care needs. The clinical record lacks the frequency, the parameters, and the interventions to obtain and monitor the patient’s weight. The Agency did not coordinate care delivery involving the patient/caregiver needs. Survey findings were conducted with the Director of Patient Services and Assistant Vice President on 04/14/2025 at 10:30 AM. An Interview was conducted on 04/14/2025 at 12:30 PM with Director of Patient Services, no explanation was provided. 6) Patient #9 has a start of care date of 11/02/2024 with diagnoses of "Encounter for attention to colostomy, Diverticulosis large intestines, Hypertensive Chronic Kidney Disease, Type 2 Diabetes Mellitus, Chronic Kidney Disease and Encounter for fitting and adjustment of urinary devices" as documented on the “Home Health Plan of Care” for certification period 02/06/2025 to 04/06/2025. The “Home Health Plan of Care” for certification period 02/06/2025 to 04/06/2025 documents orders for "Skilled Nurse 1 to 2 visits every week for 4 weeks (one to two visits a week for four weeks), 1 to 4 visits as needed for Ostomy issues, Cardiovascular, and falls". The "Routine Registered Nurse" visit report dated 02/05/2025 documents "Patient unable to urinate after procedure,14 French,10 cubic centimeter balloon (Foley catheter) in place". The “Routine Licensed Practical Nurse” visit report dated 02/09/25 documents "Foley Catheter removed by Urologist with no further issues". There is no documented evidence that the Registered Nurse was notified of the change in patient's Foley catheter removal. The Agency did not coordinate care delivery involving the patient's needs. Survey findings were conducted with the Director of Patient Services on 04/14/25 at 02:30 P.M. An Interview was conducted on 04/15/2025 at 12:45 PM with Director of Patient Services, no explanation was provided. 1) Patient #12 has a start of care with diagnoses of "Diabetic type 2 with foot ulcer, Chronic ulcer of the left foot, Osteomyelitis left ankle, Atherosclerosis of the native arteries with intermittent claudication, Neuropathy Arthropathy, Charcot’s joint, left ankle and foot Hypertension, Hypercholesterolemia" as documented on the “Home Health Plan of Care” for certification period of 03/04/2025 to 05/02/2025. The “Home Health Plan of Care” for certification period of 03/04/2025 to 05/02/2025 documents orders for “Skilled Nursing: one (1) visit every week for one (1) week, one to three (1 to 3) visits every week for three (3) weeks for wound complications, one to two (1 to 2) visits every week for eight (8) weeks”. The “Licensed Practical Nurse home visit” reports dated 01/01/2025,01/13/2025, 01/27/2025, 02/14/2025, 03/14/2025, 02/24/2025 03/14/2025, 03/21/2025, 03/31/2025 and 04/04/2025 lacked documented evidence of coordination with the Registered Nurse. An Interview conducted with the Director of Patient Services on 04/09/2025 at 02:53 PM and acknowledges issue, stated “Licensed Practical Nurses should be coordinating with Registered Nurse/Team Manager of daily visits. We are in the process of implemented a new future on Epic for Licensed Practical Nurses to submit visit notes to Registered Nurse/Team Manager for review”. 2) Patient # 13 has a start of care date of 09/28/2024 and discharged date of 01/29/2025 with diagnoses of "Laceration right lower leg, Alzheimer’s Disease, Dementia, Hypertension, Thoracic Aortic Aneurysm and Neuromuscular dysfunction of the bladder" as documented on the “Home Health Plan of Care” for certification period of 01/03/2025 to 03/03/2025. The “Home Health Plan of Care” for certification period of 01/03/2025 to 03/03/2025 documents orders for “Skilled Nursing; one (1) visit every week for one (1) week, one to two (1 to 2) visits every week for three (3) weeks”. The “Licensed Practical Nurse home visit” reports dated 10/07/2024, 10/09/2024, 10/15/2024, 10/18/2024, 11/27/2024, 11/29/2024, 12/06/2024, 01/20/2025 and 01/24/2025 lacked documented evidence of coordination with the Registered Nurse. An Interview conducted with the Director of Patient Services on 04/09/2025 at 02:53 PM and acknowledges issue, stated “Licensed Practical Nurses should be coordinating with Registered Nurse/Team Manager of daily visits. We are in the process of implemented a new future on Epic for Licensed Practical Nurses to submit visit notes to Registered Nurse/Team Manager for review”. Survey findings were reviewed with the Director of Patient Services and the Assistant Vice President on 4/09/2025 at 4:00 PM, no additional explanation was provided.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on a review of clinical records, and staff interviews, the Governing Authority failed to ensure the Registered Nurse follow standard Infection Control practice. This is evident in two (2) of seventeen (17) clinical records reviewed. (Patients #3 and#7). Failure to ensure the Registered Nurse follow standard Infection Control practice places the patient at risk for negative outcomes. Findings are: 1) Patient #3 has a start of care date of 03/30/2025 with diagnose including “Unspecified open wound to Right Lower Leg, Peripheral Vascular Disease, Unspecified Atrial Fibrillation, Rheumatoid Arthritis, Pan lobular Emphysema, Essential Hypertension, Age-related Osteoporosis, and Long-erm use of anticoagulants” as documented on the “Home Health Plan of Care” for certification period 03/30/2025 to 05/28/2025. The Home Health Plan of Care” for certification period 03/30/2025 to 05/28/2025 document orders for "Skilled Nursing 2 to 4 visits every week for 3 weeks. Skilled Nurse to perform wound care dressing change using clean technique: remove old dressing, cleanse with normal saline/wound cleanser, dry with sponge or gauze pad, apply Medi-honey and alginate to wound bed, cover with dry clean dressing, and secure with ace bandage. Change dressing every other day and measure wound length, depth, width weekly". On 04/08/2025 a home visit observation was conducted with the agency's Registered Nurse and Director of Clinical Education. The Surveyor observed the Registered Nurse perform wound care to the Right Lower Leg, the Registered Nurse removed the soiled gloves, sanitized her hands, applied clean gloves, cleansed the wound, and then measured the wound. The Registered Nurse did not remove the potentially soiled gloves and sanitize her hands before applying Medi-honey, alginate, rolled gauze, and Ace wrap to the wound. On 04/08/25 the Registered Nurse and Director of Clinical Education were interviewed, acknowledged the findings and provided no additional information. On 04/08/25 at 4:15 PM the Director of Patient Services, Assistant Vice President, and Administration staff were notified of the survey findings. No additional information was provided. 2) Patient #7 has a start of care date of 02/27/2025 with diagnoses of “Encounter for change or removal of drains, Aftercare following surgery for Neoplasm, Malignant Pleural Effusion, Malignant Neoplasm of unspecified part of Right Bronchus or Lung, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Hypothyroidism, and Atherosclerotic Heart Disease, Native Coronary without Angina Pectoris” as documented the "Home Health Plan of Care” for certification period 02/27/2025 to 04/27/2025. The "Home Health Plan of Care” for certification period 02/27/2025 to 04/27/2025 documents orders for "Skilled Nursing 1 visit every day for 21 days (one visits every day for twenty-one days), 1 to 3 visits (one to three visits) as needed to assess for any issues chest drain. Skilled Nurse to drain a maximum amount of 1000 ml (milliliters) from chest drain daily". The agency’s policy “Chest or Abdominal Drainage" for symptom management of pleural effusion and ascites effective date 2006, most recently revised 6/2014, and last reviewed on 6/2024 documented the following: “Orders will include frequency of dressing change and frequency of drainage. Applying a new dressing: Wash hands, gather equipment, and set-up a clean workspace. Don sterile gloves, cleanse around catheter site with alcohol pad. Handle catheter with clean hand and dressing and supplies with sterile hand. Place the foam catheter pad, or split drain sponge around the catheter”. On 04/08/2025 aa home visit observation was conducted with the agency Registered Nurse and the Director of Clinical Education. The Surveyor observed the Registered Nurse performing wound care to the right chest Pleurex Drain site, at 01:08 pm the nurse removed the soiled dressing, disposed of dressing, removed sterile gloves sanitized her hands, applied clean gloves and attached the plural vacuum. At 01:15 pm the nurse detached the pleural vacuum canister and placed it directly on the floor (without a barrier) while holding the patient end of the tubing in her gloved right hand. At 01:16 pm the Director of Clinical Education intervened. The nurse picked the canister up off the floor, the Director of Clinical Education placed a drape on the floor and then the nurse placed the canister on the drape. At 01:18 pm the nurse removed the potentially soiled gloves, applied new gloves, and dressed the wound. The nurse was not observed to sanitize her hands after removing potentially soiled gloves before applying new clean gloves. On 04/08/25 the Director of Clinical Education observed and acknowledged the findings. On 04/08/25 at 4:15 pm the Director of Patient Services, Assistant Vice President and Administrative staff were notified of the survey findings. No additional information was provided.

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 a review of clinical records, and staff interviews, the Governing Authority failed to ensure the patient current comprehensive assessments includes all assessments and clinical notes. Failure to ensure all content of the comprehensive assessment is in the clinical record have the potential for negative patient outcomes. This is evident in three (3) of seventeen (17) clinical records reviewed. (Patients #15, #16 and #17). Findings are: 1) Patient # 15 has a start of care date of 01/10/2024 and discharge date of 01/23/2025 with diagnoses of "Pressure Ulcer of sacral region: stage 4, Dementia, Type II Diabetes, Non-Rheumatic Mitral valve insufficiency, Barrett’s Esophagus, Atrioventricular Block, Ventricular Block and Hyperlipidemia" as documented on the “Home Health Plan of Care” for certification period of 01/02/2025 to 03/02/2025. The “Home Health Plan of Care” for certification period of 01/02/2025 to 03/02/2025 documents orders for “skilled nursing: one visit every week for one week, one visit day for one day, 2 to 4 visits every week for three weeks, 1 to 2 visits as needed for wound care 2-4 visits every week for two weeks 2 to 4 every week for 7 weeks for cardiovascular and cardiopulmonary assessment, weekly wound measurements, nutritional requirements: diabetic diet, low cholesterol diet, low fat diet, and low sodium diet and under (Discharge Plans) documents: discharge plans not documented". The “skilled nursing visit” notes dated 01/06/2025, 01/08/2025, 01/13/2025, 01/15/2025, 01/17/2025, 01/20/205 and 01/22/2025 lacked documented evidence of diabetic diet and patient discharge plans. The "Skilled Nurse visit" notes dated 01/13/2025 and 01/15/2025 lacks documented evidence that the patient’s wound was measured the week of 01/13/2025. The Director of Patient Services, Assistant Vice President (AVP), Director of Clinical Education, and Director of Performance Improvement were interviewed on 4/14/2025 at 4:00PM and Assistant Vice President states that “the records should include patient plans for after discharge from the Agency”. The team acknowledged the survey findings, and no further explanation provided. 2) Patient #16 has a start of care date of 06/17/2024 and discharge date of 12/18/2024 with diagnoses of "Acute on Chronic Systolic Congestive Heart Failure, Permanent Atrial Fibrillation, Spondylosis, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease, Atherosclerotic Heart Disease of native Coronary Artery, Obstructive Sleep Apnea, long-term use of Anticoagulants, and long-term use of Aspirin" as documented on the “Home Health Plan of Care” for certification period of 11/15/2024 to 01/13/2025. The “Home Health Plan of Care” for certification period 11/15/2024 to 01/13/2025 documents orders for “Skilled Nursing 1 to 2 visits every week for 4 weeks and 1 to 3 visits as needed. Skilled Nurse to evaluate edema, location, and amount. Skilled Nurse to measure and document degree of edema”. The “Skilled Nurse home visit” notes dated 11/19/24, 11/21/24, 11/29/24, 12/03/24, and 12/11/24 lacks documentation that the nurse evaluated, measured, and documented the degree of edema. On 04/11/25 at 12:45 pm the Assistant Vice President was interviewed and stated, “You were accurate in your findings.” No additional information was provided. On 4/11/25 at 4:10 pm the survey findings were reviewed with the administrative team including the Director of Patient Services and Assistant Vice President. No explanation or additional information was provided. 3) Patient # 17 has a start of care date of 10/7/2023 and discharge date of 11/19/2024 with diagnoses of “Myelodysplastic Syndrome, Anemia, Atrial Fibrillation, Nonrheumatic Mitral Valve Insufficiency, Essential Hypertension, and Hypothyroidism” as documented on the “Home Health Plan of Care” for certification period of 09/21/2024 to 11/19/2024. The “Home Health Plan of Care” for certification period of 09/21/2024 to 11/19/2024 documents orders for “home health aide 1 to 2 visits every week for 9 weeks for 1 to 1.5 hours, Physical Therapy 1 to 2 visits every week for 9 weeks, and the most recent Skilled Nursing orders for 1 to 2 visits every week for 6 weeks”. The “Skilled Nurse Oasis Visit” assessment dated 09/16/2024 documents the Registered Nurse conducted the patient assessment on 09/16/2024 and submitted the document on 09/23/2024. The Governing Authority failed to ensure the Oasis reassessment documentation is submitted within forty-eight (48) hours of the nursing assessment as per agency protocol. Interview conducted on 04/14/2025 at 4:00PM with the Director of Patient Services (DPS) and states “the Oasis document must be submitted within forty-eight (48) hours of the Registered Nurse assessment”. The survey findings were reviewed on 04/14/2025 at 4:30 PM with the Director of Patient Services (DPS), Assistant Vice President, Director of Clinical Education, and Director of Performance Improvement. The team acknowledged findings with no further explanation given.

An onsite complaint (71446) survey was conducted on 08/29/22 at Catholic Home Care located at 110 Bi-County Boulevard, Farmingdale, NY 11735. Three (3) patient records, one (1) personnel record , On-Call Log for 07/31/22, and Patient Complaint Log for 07/07/22 – 08/08/22 were reviewed. Interview was conducted with the Agency's Registered Nurse on 08/29/22. Complaint 71446 is substantiated. The following deficiencies are identified as a result of the survey: G0718 - Communication with the Physician '

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, the Agency failed to ensure that the Registered Nurse maintain ongoing communication with the Physician related to the current Plan of Care. This was evident in one (1) of three (3) patient records reviewed. (Patient #1). Failure to ensure communication with the Physician has the potential for negative patient outcome. The findings include: The patient has a start of care date of 08/01/2022 with diagnoses of “Cutaneous Abscess of Left Hand” as documented on the “Home Health Certification and Plan of Care” dated 08/01/22 – 09/29/22. The “Home Health Certification and Plan of Care” for certification period from 08/01/22 to 09/29/22, documents an order for “SN (Skilled Nurse) 1 x day for 3 days to perform “wound care : cleanse wound to Left index finger w/NS (with Normal saline) pat dry repack with 1/4 inch Iodoform cover cdd (clean dry dressing)/ Kling". The Initial RN Comprehensive Assessment is dated 08/01/22. The RN documents wound care performed 08/01/22 as ordered in the Plan of Care. The clinical note dated 08/02/22, the RN documents “unable to pack (wound) with Iodoform” MD was notified on 08/02/22 and patient is scheduled to see MD. The clinical note dated 08/04/22, the RN documents, TCT (Telephone Call To) patient , no answer left message trc (to return call)”. The clinical record lacks documented evidence of further RN visit made after 08/02/22 to assess the patient’s wound status. The clinical note dated 08/09/22, the RN documents that “patient report: surgeon advise that no further RN is needed, case DC at this time. The patient has a discharge date of 08/09/22 from the agency. The Registered Nurse (RN) clinical note dated 07/30/22, the RN documents “call to patient to scheduled visit by kept (patient) hanging up the phone , unable to make the visit”. The clinical note dated 07/31/22, the RN documents “patient request Monday” (8/1/22) for visit. The clinical record lacks documented evidence that the Physician was notified that the patient was not seen 07/30/22 and 07/31/22 for RN services. The Agency failed to ensure communication with the Physician for no RN visit after 08/02/22 and the patient s discharged from the agency. A telephone interview was conducted with the Registered Nurse (RN) on 08/29/22 at 01:30 PM, the RN stated that the Physician was not notified on 08/04/22 and 08/09/22 of patient status and discharge. The survey findings were reviewed on 08/29/22 at 02:2:45 PM with the Agency's Assistant Vice President (AVP) of Home Care and the Director of Patient Services (DPS). No explanation was provided.

A standard re-certification survey, focused COVID-19 Infection Control and complaints 59745 (NY00266336) and 59746 (NY00274614) survey of Catholic Home Care located at 110 Bi-County Boulevard, Farmingdale, NY 11735 was initiated on 04/18/2022 and exited 04/22/2022. Deficient practices were identified within Level 1 standards in 484.60 condition and 484.75 condition resulting in a Partial Extended survey. The agency's active patient census as of 04/18/2022 is 2,652. Seventeen (17) clinical records were reviewed and are identified as Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, and #17. Seven (7) Home Visit observations were conducted with patients #1, #2, #3, #4, #5, #6 and #7. Fifteen (15) personnel records were reviewed and are identified as Employees #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14 and #15. Policies and procedures for Emergency Preparedness Plan, Health Commerce System, Home Care Registry, Criminal History Record Check, Home Care Covid 19 Infection Control, and Influenza Vaccination policy were reviewed. The agency's Patient Admission Packet and Patient Complaint log for the years 01/10/2020 through 03/18/2022 were reviewed. The agency's Quality Improvement meeting minutes were reviewed for 2021 and 2022. Pre-survey activities consisted of review on 04/14/2022 of the agency’s Health Commerce System account, Home Care Worker Registry, Criminal History Record Check. The Agency's OBQI Adverse Event Outcome Reports were reviewed for the period of 02/2021 through 01/2022. Complaint 59745 (NY00266336) is substantiated. Complaint 59746 (NY00274614) is unsubstantiated. The agency’s Associate Vice President and Clinical Manager were interviewed. The following Federal deficiencies are cited: G0574 - Plan of Care must include the following G0578 - Conformance with Physician Orders G0586 -Review and Revise the Plan of Care G0718 - Communication with Physician G0726 - Nursing Services supervised by RN The following State deficiencies are cited: J1156 - Governing Authority J1260- Governing Authority J1426 - Personnel

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record reviews and staff interview, the Agency failed to develop individualized patient Plans of Care. This was evident in one (1) of seventeen (17) clinical records reviewed. (Patient #14) Failure to develop individualized Plans of Care, has the potential for negative patient outcome. The findings are: 1) Patient #14 has a start of care date 12/21/21 with diagnoses of Fracture of Left Pubis, Open wound of Left Upper Arm, Essential Hypertension (HTN), Hypothyroidism, Chronic Obstructive Pulmonary Disease (COPD) as documented in the "Home Health Certification and Plan of Care" dated 12/21/21 to 02/19/22. The “Home Health Certification and Plan of Care" dated 12/21/21 to 02/19/22 documents an order for "SN (Skilled Nursing) visits 1 - 3 times a week for 1 week, 1 - 3 times a week for 3 weeks"; SN to instruct in use/maintenance of O2 (Oxygen); Oxygen at 3.0 Liters per minute continuous via nasal cannula". The Plan of Care (POC) lacks documentation of an order for the SN to assess the patient's Oxygen saturation and Blood Pressure parameters to ensure patient safety and protect against injury. Survey findings were reviewed on 04/20/22 at 04:15 PM with the agency's Assistant Vice President (AVP). On 04/22/22 at 11:20AM, the AVP acknowledged the findings.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on Home Visit (HV) observations, clinical record reviews and staff interviews, the Agency failed to ensure that Telehealth monitor, medications, patient care treatments, and home health aide (hha) services are provided in conformance to Physician's Orders. This was evident in five (5) of seventeen (17) clinical records reviewed. Patients #2, #3, #7, #8 and #10. Failure to ensure that Telehealth, medications, treatments and hha services are provided, has the potential for negative patient outcome. The findings include: 4) Patient #2 has a start of care date of 3/29/22 with diagnoses of Breakdown (mechanical) of other Gastrointestinal Prosthetic devices, Implants and Grafts, initial encounter, Essential (Primary) Hypertension, Type II Diabetes Mellitus without complications documented on the Home health Certification and Plan of Care for Certification Period 3/29/22 to 5/27/22. The Home Health Certification and Plan of Care for Certification Period 3/29/22 to 5/27/22 documents, “SN (Skilled Nursing) 1-2 visit/ week x 1 week, 1-2 visit/week x 3 weeks; contact MD for O2 (oxygen) sat 2) Patient #7 has a start of care date of 4/2/22 with diagnoses of Influenza, Chronic Obstructive Pulmonary Disease, Atrial Fibrillation, Osteoarthritis, and Hypertension as documented on the Home Health Certification and Care Plan dated 4/2/22 through 5/31/22. The Home Health Certification and Care Plan dated 4/2/22 through 5/31/22 documents: SN visits 1 time a week for one week then 1 – 2 times a week for 4 weeks; parameters for physician notification include Oxygen saturation less than 90%; Oxygen 3 liters continuous via nasal cannula. The SN made visits on 4/2/22, 4/5/22, 4/7/22, and 4/16/22. The notes lack documented evidence of Oxygen saturation readings. During an interview with the Administrator on 4/20/22 at 11:30 AM, the Administrator stated “Oxygen saturations are done only with Telehealth”. 3) Patient #8 has a start of care date of 10/8/20 and a discharge date of 10/30/20 with diagnoses of Cardiac Disease, Diabetes Mellitus Type Two, and Epilepsy as documented on the Home Health Certification and Care Plan dated 10/8/20 through 12/6/20. The Home Health Certification and Care Plan dated 10/8/20 through 12/6/20 documents: SN visits 1 to 2 times a week for 6 weeks; parameters for physician notification include Oxygen saturation lower than 90 % and blood glucose less than 70 or greater than 240; assess and instruct on pain management; assess blood sugar (frequency is before meals and hs (bedtime); Telehealth monitoring daily after instillation; Oxycodone 5 mg every 8 hours as needed; Percocet 5-325 mg one tablet daily for severe pain; Lidocaine External Patch to knees and lower back for 12 hours a day; hha 2 to 3 times a week for 3 to 4 hours each day to assist with personal care and ADL’s (Activities of Daily Living); hha 2 to 3 days a week for 4 weeks for 3 to 4 hours a day. The SN notes dated between 10/8/20 through 10/22/20 lack documented evidence of the following: Oxygen saturation on each visit; blood glucose readings; complete pain assessments to include the location and rating of the pain and the amount/frequency and effectiveness of the pain medication. The record lacks documented evidence of the Telemonitoring equipment was installed, and monitoring was performed. The record documents the hha went the following days/times: 10/14/20 – 1.75 hours; 10/16/20 – 1.5 hours; 10/22/20 – 1 hour; 10/27/20 – 2 hours. There is no documentation as to the reason the Patient did not receive the full number of hours and the physician was informed. During an interview with the Administrator on 4/20/22 at 11:30 AM, the Administrator stated “Oxygen saturations are done only with Telehealth”. 1) Patient # 10 has a start of care date of 04/01/2022 with diagnoses of Pneumonia, Acute Respiratory Failure with Hypoxia, Hypertensive Heart Failure and Rheumatic Heart Failure as documented on the "Home Health Certification and Plan of Care" for certification period 04/01//22 to 05/30/22. The "Home Health Certification and Plan of Care" for certification period 04/01//22 to 05/30/22 documents an order for: “SN (Skilled Nursing) 1-2 visit/ week x 1 week, 1-2 visit/week x 3 weeks, SN Telehealth monitoring daily after installation, SN to contact MD for weight gain of 2 lbs (pounds) per day and greater than 5 lbs in 5 days, contact MD for O2 (Oxygen) saturation less than 90% (percentage)". The SN visit notes dated 04/05/22, 04/12/22, and 04/19/22 lack documented evidence of Telehealth monitoring, patient's Oxygen saturation levels and weight status. The clinical record lacks documented evidence that Telehealth monitor was installed in conformance to Physician's orders. Survey findings were reviewed with the Associate Vice President (AVP) on 4/21/22 at 04:10 PM. On 04/22/22 at 11:30 AM, the AVP acknowledged the findings.

Review and revision of the plan of care CFR(s): 484.60(c) Standard: Review and revision of the plan of care. This STANDARD is not met as evidenced by: Based on Home Visit observations, clinical records review and staff interviews, the Agency failed to ensure that the Plan of Care was updated and revised to reflect the patient's current medications and treatments. This was evident in four (4) of seven (7) Home Visit (HV) observations and clinical records reviewed (Patients #1HV, #4HV, #6HV, and #7HV). Failure to ensure that the Plan of Care is updated and revised has the potential to result in unmet patient needs and negative patient outcomes. The findings are: 4) Patient #6HV has a start of care date of 3/24/22 with diagnoses of Pleural Effusion, not elsewhere classified, Encounter for Attention of other artificial openings, Acute Respiratory Failure with Hypoxia and Unspecified B-Cell Lymphoma, Spleen documented on the Home Health Certification and Plan of Care for Certification Period 3/24/22 to 5/22/22. The Home Health Certification and Plan of Care for Certification Period 3/24/22 to 5/22/22 documents, “SN (Skilled Nursing) 1-2 visit/ week x 1 week, 1-2 visit/week x 6 weeks, 3 PRN: complications of Pleurix, 2-3 visits/week x 3 weeks; Instruct patient/caregiver in use/maintenance of O2 (Oxygen); drain Chest Catheter Left Flank every 3rd day, maximum amount of 1000cc Chest drainage at one time; PT 1-2 visit/week x 7 week” On 4/19/22 at 11:00 AM a home visit was conducted. The patient states that he is not on oxygen and that there is no oxygen in the home. There is no documented evidence the Plan of Care is reviewed/revised as often as necessary to meet the patient care needs. On 4/21/22 at 2:00 PM the Associate Vice President was interviewed. The Associate Vice President did not provide an explanation. 1) Patient #1HV has a start of care date of 4/7/22 with diagnoses of Polio, Ulcerative Colitis, and Congestive Heart Failure as documented on the Home Health Certification and Care Plan dated 4/7/22 through 6/5/22. The Home Health Certification and Care Plan dated 4/7/22 through 6/5/22 documents: SN (Skilled Nursing) visits 1 time a week for 1 week than 1 to 2 times a week for 4 weeks; medications include- Acetaminophen 500 mg two tablets every 8 hours as needed for pain, Docusate Sodium 100 mg two times a day as needed for Constipation, Feosol 325 mg three times a day, Melatonin 3 mg before meals, Senna 8.6 mg two tablets daily as needed for Constipation. During a home visit on 4/18/22, the Patient’s Significant Other stated that he is in charge of the Patient’s medications and provided a list of the medications he is administering. The list documents the following: The Melatonin was discontinued on 4/11/22, Mirtazapine 15 mg at bedtime, Iron (65 mg) is taken two times a day, Acetaminophen (the bottle reads 325 mg), Docusate Sodium 100 mg is taken two times a day (not as needed) and Senna 8.6 mg two tablets daily (not as needed). The Nurse made visits on 4/11/22 and 4/13/22. The notes do not document the medication changes. 2) Patient #4HV has a start of care date of 1/27/21 with diagnoses of Traumatic Brain Injury, Hypertension, and Seizure Disorder as documented on the Home Health Certification and Care Plan dated 3/23/22 through 5/21/22. The Home Health Certification and Care Plan dated 3/23/22 through 5/21/22 documents: SN visits one time a week for 9 weeks; Ketoconazole Shampoo 2% two times a week, Nystatin Powder two times a day, and Ketoconazole cream 2% daily to the face, chest, and groin daily. During a home visit on 4/20/22, the Patient’s caregiver states the Ketoconazole Shampoo every other day, the Nystatin Powder is applied once a day, and the Ketoconazole cream is not being used. 3) Patient #7HV has a start of care date of 4/2/22 with diagnoses of Influenza, Atrial Fibrillation, Osteoarthritis, Chronic Obstructive Pulmonary Disease, and Hypertension as documented on the Home Health Certification and Care Plan dated 4/2/22 through 5/31/22. The Home Health Certification and Care Plan dated 4/2/22 through 5/31/22 documents: SN visits 1 time a week for 1 week, 1 to 2 times a week for 4 weeks; parameters for physician notification include Oxygen saturation less than 90 %; PT visits 1 to 2 times a week for 4 weeks; hha (Home Health Aide) 1 to 3 weeks per week for 4 weeks; Baclofen 10 mg two times a day; Oxygen 3 liters continuous via nasal cannula. The record documents the Patient was admitted to the hospital on 4/15/22 and a Resumption of Care assessment was performed on 4/16/22. During a home visit on 4/20/22, the Patient’s medication bottles were reviewed. The bottle labeled Baclofen was empty and the Patient stated she was informed on discharge from the hospital not to take it. A review of the hospital discharge directions was provided and does not document Baclofen. The Resumption of Care assessment does not document the Baclofen was discontinued. During an interview with the Administrator on 4/20/22 at 11:30 AM, the Administrator did not provide an explanation for the above.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interviews, the Agency failed to communicate with the Physician related to patient care services and treatments in the Plan of Care. This was evident in two (2) of seventeen (17) clinical records reviewed. Patients #9 and #10. Failure to communicate with the Physician related to patient care services and treatments, has the potential for negative patient outcome. The findings include: 1) Patient #9, has a start of care date of 10/30/20 and a discharge date of 12/4/20 with diagnoses of Myocardial Infarction involving other Coronary Artery Wall, Neuromuscular Dysfunction of Bladder, Retention of Urine, Dysphagia unspecified, Gastro-Esophageal Reflux Disease without Esophagitis, Anxiety Disorder, Age-related Osteoporosis without current pathological fracture, and Coronary Angioplasty Status documented on the Home health Certification and Plan of Care for Certification Period 10/30/20 to 12/28/20. The Home health Certification and Plan of Care for Certification Period 10/30/20 to 12/28/20 documents, “SN (Skilled Nursing) 1visit/ week x 1 week, 1-2 visit/week x 1 week, 3 PRN visits, 1-2 visit/week x 4 week; MSS (Medical Social Service) 1-2 visit/month x 2 months assessment of social and emotional factors, instruct in community resources, instruct in financial entitlements counseling for long range planning and decision making, brief therapeutic counseling to promote effective coping strategies to enhance compliance with treatment plan”. The Medical Social Work (MSW) visit note dated 11/11/20 documents “patient feels she is not going to recover; MSW discussed palliative care briefly and made referral". There is no documented evidence the MSW discuss/coordinate care with the patient physician and other members on the treatment team prior to sending a referral for palliative care. The record lacks communication with the patient physician involved in the Plan of Care regarding palliative care. On 4/20/22 at 2:00 PM the Associate Vice President was interviewed. The Associate Vice President did not provide an explanation. 2) Patient # 10 has a start of care date of 04/01/2022 with diagnoses of Pneumonia, Acute Respiratory Failure with Hypoxia, Hypertensive Heart Failure and Rheumatic Heart Failure as documented on the "Home Health Certification and Plan of Care” for certification period 04/01//22 to 05/30/22. The "Home Health Certification and Plan of Care” for certification period 04/01//22 to 05/30/22 documents an order for: “SN (Skilled Nursing) 1-2 visit/ week x 1 week, 1-2 visit/week x 3 weeks, SN Telehealth monitoring daily after installation. The clinical record lacks documented evidence that Telehealth monitor was installed from 04/01/22 to date of survey 04/22/22. The clinical record lacks documented evidence that the Physician was notified that the patient is not receiving daily Telehealth monitoring as per the current Plan of Care. Survey findings were reviewed with the Associate Vice President (AVP) on 4/21/22 at 04:10 PM. On 04/22/22 at 11:30 AM, the AVP acknowledged the findings.

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 clinical record reviews and staff interviews , the agency failed to ensure that only Registered Nurses perform assessments, and that nursing services are provided under the supervision of a Registered Nurse (RN). This was evident for four (4) of four (4) patients receiving LPN services. (Patients #7, #8, #11, and #17). Failure to ensure that only Registered Nurses perform assessments and that nursing services are provided under the supervision of a Registered Nurse has the potential for negative patient outcomes. The findings are: 1. Patient #7 has a start of care date of 4/2/22 with diagnoses of Influenza, Atrial Fibrillation and Chronic Obstructive Pulmonary Disease as documented on the Home Health Certification and Plan of Care for certification period 4/2/22 through 5/31/22. The Home Health Certification and Plan of Care for certification period 4/2/22 through 5/31/22 documents the Patient is to receive SN (Skilled Nursing) visits one to two times a week for four weeks for observation, assessment, and instruction. The record documents a Licensed Practical Nurse (LPN) went to the home on 4/7/22. The Skilled Nursing note titled: "Visit Note Report" has sections titled "Assessment". The Patient assessment is out of the scope of practice for LPN services. 2. Patient #8 has a start of care date of 10/8/20 and a discharge date of 10/30/21 with diagnoses of Cardiac Disease, Diabetes Mellitus Type Two and Epilepsy as documented on the Home Health Certification and Plan of Care for certification period 10/8/20 through 12/6/20. The Home Health Certification and Plan of Care for certification period 10/8/20 through 12/6/20 documents the Patient is to receive SN visits one to two times a week for six weeks for observation, assessment, and instruction. The record documents an LPN went to the home 10/25/20 and 10/22/20. The Skilled Nursing notes titled: "Visit Note Report" has sections titled "Assessment". Patient assessment is out of the scope of practice for LPN services. 3. Patient #11 has a start of care date of 2/15/22 with diagnoses of Chronic Right Ankle Ulcer, Peripheral Vascular Disease, and Hypertension as documented on the Home Health Certification and Plan of Care for certification period 2/15/22 through 4/15/22. The Home Health Certification and Plan of Care for certification period 2/15/22 through 4/15/22 documents the Patient is to receive SN visits three to four visits a week for eight weeks for observation, assessment, and instruction. The record documents an LPN went to the home 3/20/22, 3/24/22, 3/27/22, and 4/16/22. The Skilled Nursing notes titled: "Visit Note Report" has sections titled "Assessment". Patient assessment is out of the scope of practice for LPN services. 4. Patient #17 has a start of care date of 3/2/22 with diagnoses of Chronic Obstructive Pulmonary Disease and Pseudomonas as documented on the Home Health Certification and Plan of Care for certification period 3/8/22 through 5/6/22. The Home Health Certification and Plan of Care for certification period 3/8/22 through 5/6/22 documents the Patient is to receive SN visits one to two times a week for eight weeks for observation, assessment, and instruction. The record documents an LPN went to the home 3/10/22, 3/17/22, and 3/25/22. The Skilled Nursing notes titled: "Visit Note Report" has sections titled "Assessment". There is no documented evidence LPN’s are 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 4/20/22 at 2:00PM the Administrator was interviewed and did not provide an explanation for the above.