Every finding on record at Nyc Health and Hospital Corporation

The following Statement of Deficiencies represents the results of a partial extended re-certification survey of HHC Health and Home Care located at 50 Water St, 6th floor, New York, NY 10004 conducted on 07/09/2024 through 07/15/2024 and included complaint investigation # 96861. The allegations in Complaint # 96861 were determined to be substantiated. A Standard Initial Certification Survey was initiated on 07/09/2024. Deficient practices were identified within Level 1 standards in 484.55 Comprehensive Assessment of Patients, 484.60 Care planning, coordination of services, and quality of care, 484.75 Skilled professional services, and 484.80 Home Health Aide Services, resulting in a partial extended survey. The survey consisted of a review of seventeen (17) clinical records (identified as Patient #1, #2, #3, #4, #5, #6, #7, #8, #9 #10, #11, #12, #13, #14, #15, #16, and #17) including five (5) discharge records, eleven (11) personnel records (identified as Employee#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11) three (3) contracts, and seven (7) observational home visits. The survey included a review of pertinent policies and procedures, Quality Improvement Meeting Minutes for past 12 months, PIP (Performance Improvement Projects), Admission Packet, Emergency Preparedness Plan, Complaint Log, Three (3) contracts, and the agency's Infection Control and Flu policy and procedure. The active patient census is 513. Pre-survey activities consisted of review on 07/03/2024 of the agency’s Health Commerce System account, and the Internet Quality Improvement Evaluation System (iQIES) account. The Administrator, the Director of Nursing, the Director QAPI(Quality Assurance Performance Improvement and staff were interviewed. Findings were reviewed at the exit conference on 07/15/2024. The following deficiencies are identified as a result of the survey: G0374 – Accuracy of encoded OASIS data G0514 – RN performs assessment G0528 – Health, psychosocial, functional, cognition G0536 – A review of all current medications G0572 – Plan of care G0574 – Plan of care must include the following G0588 – Reviewed, revised by physician every 60 days G0608 – Coordinate care delivery G0710 – Provide services in the plan of care G0798 – Home health aide assignments and duties G0802 – Duties of Home health aide G0808 – Onsite supervisory visit every 14 days

Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient's status at the time of assessment. This STANDARD is not met as evidenced by: Based on clinical records review and staff interview the agency failed to ensure the encoded OASIS (The Outcome and Assessment Information Set) assessments accurately reflect each patient's status at the time of the assessment. This was evident for one (1) of seventeen (17) clinical records reviewed (Patient: #8). Failure to ensure the encoded OASIS (The Outcome and Assessment Information Set) accurately reflect the patient's status at the time of the assessment, has the potential for negative patient outcomes. The Findings Are: 1.Patient #8 has a Start of Care date of 3/14/2024 with the diagnosis “Type 2 Diabetes Mellitus without complications" documented on the Home Health Plan of Care for Certification Period 03/14/2024 to 05/12/2024. The Home Health Plan of Care dated 3/14/24 documents: “Skilled Nursing Visits: 1 visit every week for 1 week 3/14/2024 to 3/16/2024: 2 visits every week for 1 week 3/17/2024 to 3/23/2024: 1 Visit every week for 1 week 3/24/2024 to 3/30/2024 (discontinue as of 3/26/2024): 2 Visits every week for 1 week 3/28/2024 to 3/30/2024: 3 Visits every week for 1 week 3/31/2024 to 4/6/2024: 2 Visits every week for 1 week 4/7/2024 to 4/13/2024: 1 visit every week for 1 week 4/14/2024 to 4/20/2024”. The Home Care Visit in HH Home Care dated 3/19/2024SN (Skilled Nurse) documents: “Endocrine Diabetes Highest result from last 3 days (mg/dl) 236: highest result date: 3/19/24. The Home Care Visit in HH Home Care dated 3/21/2024 documents: “Endocrine /Diabetes" AM fasting result from last 3 days (mg/dl) 442." The Home Care – Facility Transfer of Care Encounter Notes dated 3/26/2024 documents: "Date of Service: 03/26/2024. Patient transferred to hospital on 3/26/24 due to hyperglycemia on 3/26/24. Physician notified of suspended home care on 3/26/24." The Home Care Visit in HH Home Care dated 3/26/2024 documents: "Emergent Care: M2301: Emergent Care- At the time of or at any time since the most recent SOC/ROC (Start of Care /Resumption of Care) assessment has the patient utilized a hospital emergency department? Yes: Used hospital emergency department with hospital admission. M2310- Reason for Emergent Care – For what reason (s) did the patient seek and/or receive emergent care (with or without hospitalization)? Hypo/ Hyperglycemia, diabetes out of control. Inpatient Facility Admission or Agency Discharge. M2410- Inpatient Facility- To which Inpatient Facility has the patient been admitted? Hospital. M0906- Discharge/ Transfer/ Death Date- Enter the date of the discharge, transfer, or death. 03/19/2024." The clinical record lacks documented evidence of accurate patient's transfer date. On 7/15/24 at 12:40PM the Director of Nursing was interviewed and stated "the transfer OASIS (Outcome and Assessment Information Set) date is incorrect, the patient did not have a high blood glucose on 3/19/24, the high blood glucose was on 3/21/24, and patient was transferred to the hospital on 3/21/24. The transfer OASIS (Outcome and Assessment Information Set) was completed on 3/26/24 instead of 3/21/24."

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record reviews and staff interview, the agency failed to ensure that initial assessments were conducted within the required time frames for all patients. This was evident for two (2) of seventeen (17) clinical records reviewed (Patient: #7, and #10). Failure to ensure that initial assessments are conducted within the required time frames for all patients, has the potential for negative patient outcomes. The Findings Are: 2. Patient #10 has a Start of Care date of 5/21/2024 with diagnosis “Hypertensive Chronic Kidney Disease with Stage 1 through Stage 4 Chronic Kidney Disease or Unspecified Chronic Disease” documented on the Home Health Plan of Care for the Certification Period 5/21/2024 to 7/19/2024. The Home Health Home Health Report Referral Instructions documents: “Please admit Name (Patient # 10) to Home Care: Referral Date: 5/15/2024: Requested Start of Care Date: 05/19/2024." The Referral Entry- Information Notes documents: “05/16/2024 2:49PM Pt (Patient requested SOC (Start of Care) on 5/19/2024, Provider in agreement with new SOC/ROC (Start of Care /Resumption of Care) date.” The Home Care Visit in HH Home Care Visit Information documents: “Visit Date 05/21/2024 SN (Skilled Nurse) - Initial Report." The Home Health Plan of Care documents: “Start of Care Date 5/21/2024: Certification Period 5/21/2024-7/19/2024.” The clinical record lacks documented evidence of the physician and the patient being notified regarding the change and the delay in the requested Start of Care date of 5/19/2024. On 07/12/24 at 1 PM the Director of Nursing was interviewed and did not provide an explanation for the finding. The agency’s Provision of Care, Treatment, and Service Admission Criteria and Process Policy N0.2-005.1 documents: "The initial visit must be performed either within 24 hours of the referral, within 24 hours of the patient’s return home, or on the start of the care date ordered by the physician (or other authorized licensed independent practitioner). If the patient refuses or delays the initial visit, physician (or other authorized licensed independent practitioner) must be notified and a new physician ordered Start of Care date be obtained and established. In the event that the time frame for assessment cannot be met, the patient’s physician and the referral source as well as the patient, will be notified for approval of the delay. Such notification and approval will be documented.” 1. Patient #7 has a Start of Care (SOC) date of 6/27/2024 with the following diagnoses: "Malignant neoplasm of middle lobe, bronchus or lung, Pulmonary mycobacterial infection, Aftercare following surgery for neoplasm " documented on Home Health Plan of Care for the Certification Period 06/27/2024 to 08/25/2024. The Home Health Report Referral Instructions documents: “Please admit Name (Patient # 7) to Home Care: Referral Date: 6/18/2024: Requested Start of Care Date: 06/25/2024: Primary reason for referring to Home Care: SN (Skilled Nursing) – To assess/instruct on disease process, oxygen use and safety precaution, symptoms/medication management and reconciliation." The Referral Entry Communication note dated 06/18/2024 documents Home Health SOC/ROC (Start of Care /Resumption of Care) Timeliness: “Patient requested SOC (Start of Care) on 6/25/2024. Provider in agreement with new SOC/ROC (Start of Care /Resumption of Care) date.” The Home Care -Start of Care Visit Encounter Notes documents: “Date 06/27/2024.” The Home Health Plan of Care documents: “Effective from 6/27/2024 to 8/25/2024”. The HH Admission Consent and the acknowledgement of receipt of Home Health Admission Booklet documents: “Patient #7 signature on 06/27/2024”. There is no documented evidence of the agency contacting the physician and the patient regarding the change in the Start of Care date from 6/25/2024 to 6/27/2024. On 07/15/2024 the Director of Nursing was interviewed and did not provide the explanation for the findings.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on record reviews and staff interview, the agency failed to ensure that the nursing assessment is accurate. This was evident for two (2) of seventeen (17) clinical records reviewed (Patient: #3, and #5). Failure to ensure that the nursing assessment is accurate, has the potential for negative patient outcomes. The Findings Are: 1. Patient #3 has a Start of Care date of 09/21/2023, Discharge Date of 10/23/2023 with diagnoses Unspecified Intracapsular Fracture of Right Femur Subsequent Encounter for Closed Fracture with Routine Healing, Unspecified Fall Subsequent Encounter, Presence of Right Artificial Hip Joint, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Type 2 Diabetes Mellitus Without Complications, Vascular Dementia Moderate in the Home Health Plan of Care for Certification Period 09/21/2023 to 11/11/2023. The SN (Skilled Nurse) Revisit note dated 10/04/2023 documents the following regarding changes the patient’s Integumentary Status: “New Pressure Injury, New Wound” Right Heel, Measurement - Length 3cm, Width 3cm. Depth 0cm, Wound Bed – dry, color black; Dressing Status – Open to air as ordered;” ‘Noted with pressure injury to right heel with blanchable erythema and dark brownish at the center;” and “Wound picture taken and consent sent to WOCN (Wound Ostomy and Continence Nurse) for consult. Discussed with (Accountable Care Manager).” The Wound Care Conference note dared 10/04/2023 documents the following regarding the wound consult: “Right Heel DTI (Deep Tissue Injury); An intact area is persistent red/black/gray discoloration to the rth (right) heel;” The SN(Skilled Nurse) Revisit note dated 10/11/2023 documents: Integumentary Status: “DTI (Deep Tissue Injury) left heel;” and Encounter Notes: “Left heel is black and boggy.” The note lacks documentation of Right Heel DTI (Deep Tissue Injury) wound assessment. The SN (Skilled Nurse) Revisit note dated 10/16/2024 documents: Integumentary Status: “DTI (Deep Tissue) left heel;” and Encounter Notes: “Right heel ulcer is healing, and blister is subsiding.” The SN (Skilled Nurse) OASIS Discharge/comprehensive assessment dated 10/23/2023 documents: Active wound – Wound pressure injury right heel and wound assessment; Encounter Notes, “Wound to left heel is dry and no signs of infection;” and patient discharged with one unstageable pressure ulcer - Deep Tissue Injury. The comprehensive assessment documents right heel wound and left heel wound. There is no documented evidence of a consistent and accurate comprehensive assessment of the patient's wound status – one or two pressure ulcers (Left Heel DTI and/or Right DTI). On 07/12/2024 at 3:30pm, the Director of Nursing and the Director of Quality Assurance Performance Improvement were interviewed and did not provide an explanation for the survey finding. 2. Patient #5 has a Start of Care date of 06/03/2024 with diagnoses Encounter for Change or Removal of Surgical Wound Dressing, Encounter for Orthopedic Aftercare Following Surgical Amputation, Acquired Absence of left Great Toe, Type 2 Diabetes Mellitus with Diabetic Peripheral Angiopathy with Gangrene, Hypertensive Heart and Chronic Kidney Disease with Heart Failure and with Stage 5 Chronic Kidney Disease, or End Stage Renal Disease, Heart Failure Unspecified, Dependence on Renal Dialysis in the Plan of Care for Certification Period 06/03/2024 to 08/01/2024. The Registered Nurse Start of Care comprehensive assessment dated 06/03/2024 documents the following wound assessment of surgical left foot wound: Measurement -Length 8.6cm, width 5.6cm depth 3cm, Wound Bed Characteristics– Epithelialized Tissue, Surrounding Skin – Erythema, Drainage – Moderate Serosanguineous, Wound Odor – None; and Encounter Notes: S/P (Status Post) amputation Left Great Toes – “left foot wound photo taken downloaded” for wound consult;” “(Hospital) Discharge Instruction: Wound VAC to be changed 3xweekly, cleanse with normal saline pack with white foam over wound, covered with black foam @ 125mmhg daily – Wound VAC applied and well tolerated.t of Care.” The Accountable Care Manager Communication Notes dated 06/04/2024 1:54PM document the wound consult concern: “Based on the 6/3 assessment the wound bed is infected with slough tissue. Infection is contra indicated for VAC dressing as we may promote bacteria growth by placing the foam dressing over the wound for days.” The Registered Nurse Start of Care wound assessment lacks documented evidence of slough being included in the wound bed characteristics. There is no documented evidence of the Registered Nurse providing an accurate wound description/status in the Start of Care comprehensive assessment. On 07/12/2024 at 3:30pm, the Director of Nursing and the Director of Quality Assurance Performance Improvement were interviewed and did not provide an explanation for the survey finding.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, record reviews and staff interview, the agency failed to ensure that all patient's medications were reviewed and accurately reflected in the patient's plan of care. This was evident for one(1) of seventeen (17) clinical records reviewed (Patient: #13). Failure to ensure that all patient's medications are reviewed and accurately reflected in the patient's plan of care, has the potential for negative patient outcomes. The Findings Are: 1. Patient #13 has a Start of Care (SOC) date of 06/24/2024 with the following diagnoses "Cutaneous Abscess of Right Lower Limb, Cellulitis of Right Lower Limb, Type 2 Diabetes Mellitus" documented in the Home Health Plan of Care for Certification Period 06/24/2024 to 08/22/2024. The Home Health Plan of Care dated 06/24/2024 to 08/22/2024 documents: “Medications: Ibuprofen (Motrin) 400 mg (milligram) tablet – Removed: 7/1/2024); Lisinopril (Zestril) 20 mg (milligram) tablet; Insulin Glargine (Lantus Solostar) 100Unit/ml (milliliter) injection, Sig (let it be labeled): Inject 0.22 ml (22 units total) under the skin nightly.” The Patient Medication List dated 06/24/2024 documents: “Lantus 28U (units) SC (subcutaneous) daily.” There is no documented evidence of Lisinopril on the list. On 07/10/2024 at 10:30am a home visit was conducted; the Surveyor reviewed the patient’s medication and compared them with the Outpatient Medications of the Plan of Care (current medication list) printed on 07/10/2024. There is no documented evidence of Ibuprofen on the list and the patient is currently taking the medication, and Lisinopril is documented on list, but patient is not currently taking the medication. The nurse stated, “you are taking 28 units of Lantus insulin.” The Encounter Notes dated 06/26/2024 documents: “Patient takes 28 units of Lantus at night.” (the order is 22 units) The clinical record lacks documented evidence of all the medications the patient is currently taking being reviewed. There is no documented evidence of medication reconciliation. On 07/15/2024 at 11:43am, the Director of Nursing and the Director of Quality Assurance Performance Improvement were interviewed and did not provide an explanation for the findings.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on clinical records review, and staff interview the agency failed to ensure that all patients receive services as ordered in their individualized plan of care. This was evident for three (3) of seventeen (17) clinical records reviewed (Patient: #5, #9, and #14). Failure to ensure that all patients receive services as ordered in their individualized plan of care has the potential for negative patient outcomes. The Findings Are: 3. Patient #14 has a Start of Care (SOC) date of 03/14/2023 with the following diagnoses "Other Symptoms and Signs Involving Cognitive Functions Following Non-Traumatic Intracerebral Hemorrhage, Hypertensive Heart Disease" documented in the Home Health Plan of Care dated 03/14/2023 to 05/12/2023. The Home Health Order dated 03/20/2023 documents: Home Health Aide Services to be Provided: number of days per week: 5; Hha (home health aide) Start Date: 3/21/2023. The Duty Sheet documents aide providing services on: 03/21/2023, 03/22/2023, 03/23/2023, and 03/24/2023. The clinical record lacks documented evidence of the patient receiving aide services as ordered on the plan of care, missing one visit between 03/21/2023 to 03/25/2023. On 07/15/2024 at 11:51am, the Director of Nursing and the Director of Quality Assurance Performance Improvement were interviewed and did not provide an explanation for the findings. 2. Patient #9 has a Start of Care date of 2/2/2024 with the diagnosis “Type 2 Diabetes Mellitus with Foot Ulcer” documented on the Home Health Plan of Care for Certification Period 6/1/2024- 7/30/2024. The Home Health Plan of Care for Certification Period 6/1/2024 – 7/30/2024 documents: “Visit Sets: Skilled Nursing Visits: 3 visits every week for 8 weeks 6/2/2024-7/27/2024. Care Plan Skilled Nursing: Blood Glucose Management Starting 6/1/2024: Goal: Patient Demonstrates BG (Blood Glucose) Testing Proficiency: Pt/Cg will demonstrate proper use of Glucometer, importance of maintain log, when to notify provides and nurse of abnormal values. Evaluate Pt/Cg ability to perform and document blood glucose testing by return demonstration. Verbalize importance of Blood glucose testing frequency 1-2x/d (one to two times a day) Blood glucose testing to be performed by Caregiver.” Parameters: Fasting Blood Glucose above (ml/dl):280 Fasting Blood Glucose below (mg/dl):70 Random Blood Glucose above (ml/dl):280 Random Blood Glucose below (ml/dl):70 The clinical record lacks documented evidence of the Registered nurse documenting the patient/caregiver proficiency, understanding, use of and maintenance of log for blood sugar recording and return demonstration for the Registered Nurse visit dates on 6/3, 6/6, week 6/9- 6/15, 6/19, 6/21, 6/24, 6/29, week 6/30-7/6 as ordered in the plan of care. The Home Health Plan of Care for Certification Period 6/1/2024 – 7/30/2024 documents: “Problem: Open Wounds: Starting: 6/1/2024: Goal: Promote Wound Healing and Prevent infection and other complications: Intervention: Take wound photo: Take photo at SOC (Start of Care) and at least every 2 weeks or with any signs of wound deterioration as needed and send to Wound Care Specialist. The clinical record lacks documented evidence of wound photos being taken for the dates 6/1/24-7/6/24 as ordered in the plan of care. On 7/15/24 at 12:30PM the Director of Nursing was interviewed and did not provide an explanation for the findings. The clinical record documents: “06/28/2024 Home Care Visit: Endocrine/Diabetes: AM fasting result from last 3 days (mg/dl) 117. AM fasting result date :6/28/2024: Blood glucose testing needs cuing.” 1. Patient #5 has a Start of Care date of 06/03/2024 with diagnoses Encounter for Change or Removal of Surgical Wound Dressing, Encounter for Orthopedic Aftercare Following Surgical Amputation, Acquired Absence of left Great Toe, Type 2 Diabetes Mellitus with Diabetic Peripheral Angiopathy with Gangrene, Hypertensive Heart and Chronic Kidney Disease with Heart Failure and with Stage 5 Chronic Kidney Disease, or End Stage Renal Disease, Heart Failure Unspecified, Dependence on Renal Dialysis in the Home Health Plan of Care dated 06/03/2024 to 08/01/2024. The Home Health Plan of Care for certification period 06/03/2024 to 08/01/2024 documents Skilled Nursing visits, three visits every week to provide wound care and treatment, to “assess surgical site/skin integrity,” and to “assess wound status including, improvement, no improvement, deterioration and current status.” The SN (Skilled Nurse) Revisit dated 06/14/2024, 06/26/2024, 07/01/2024, 07/06/2024, and 07/10/2024 lack documented evidence of a wound assessment. There is no documented evidence of the Skilled Nurse assessing the surgical wound site and status as specified in the plan of care. On 07/12/2024 at 3:30pm, the Director of Nursing and the Director of Quality Assurance/Performance Improvement were interviewed and did not provide an explanation for the survey findings.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical records review and staff interview the agency failed to ensure each individualized plan of care includes all the required information. This was evident for five (5) of seventeen (17) clinical records reviewed (Patient: #1, #2, #5,12,and #13). Failure to ensure each individualized plan of care includes all the required information, has the potential for negative patient outcomes. The Findings Are: 4. Patient #12 has a Start of Care (SOC) date of 06/28/2024 with the following diagnoses "Encounter for Change or Removal of Surgical Wound Dressing, Carbuncle of Back" documented in the Home Health Plan of Care dated 06/28/2024 to 08/26/2024. The Physician Discharge Summary/Hospital Course with date of discharge on 06/26/2024 documents: “Wound vac placed right back 6/21/24 Wound vac changes instructions (please change on a Monday, Wednesday, Friday schedule).” The Home Health Plan of Care dated 06/28/2024 to 08/26/2024 documents: “To back right wound, Cleanse with NS (normal saline), apply black foam, set the wound vac continuously at 125mmHg (millimeter of mercury), not to exceed 72 hours between dressing change. RN (registered nurse) to perform wound care.” “Vital Parameters - No Vital Parameters note has been created for the current plan.” The Intervention dated 07/05/2024 documents: Frequency / Dates: Each Visit; Intervention Description: To back right wound, Cleanse with NS (normal saline), apply black foam, set the wound vac continuously at 125 mmHg (millimeter of mercury), not to exceed 72 hours, RN (registered nurse) to perform wound care.” The plan of care and medical order lacks documented evidence of the frequency of the wound vac dressing change and the vital signs parameters. On 07/15/2024 at 11:51am, the Director of Nursing and the Director of Quality Assurance Performance Improvement were interviewed and did not provide an explanation for the findings. 5. Patient #13 has a Start of Care (SOC) date of 06/24/2024 with the following diagnoses "Cutaneous Abscess of Right Lower Limb, Cellulitis of Right Lower Limb, Type 2 Diabetes Mellitus" documented in the Home Health Plan of Care dated 06/24/2024 to 08/22/2024. The Home Health Plan of Care dated 06/24/2024 to 08/22/2024 documents: “Insulin Aspart (Novolog) 100 Unit/ml (milliliters) injection; Sig (let it be labeled): Inject 0.06 ml (6 units total) under the skin 3 (three) times a day with meals.” “Verbalize importance Blood glucose testing frequency daily.” “Vital Parameters: No Vital Parameters note has been created for the current plan.” On 07/10/2024 at 10:30am during the home visit, the patient stated, “I check my sugar before eating, three times a day. I check it before injecting the Novolog insulin.” The plan of care and medical order lacks documented evidence of the accurate frequency of the blood glucose monitoring and the vital signs parameters. On 07/15/2024 at 11:51am, the Director of Nursing and the Director of Quality Assurance Performance Improvement were interviewed and did not provide an explanation for the findings. The agency’s “Care Planning Process (Revised October 2023)” Policy documents: “A written plan of care will be initiated within five (5) days of start of care;” “the plan of care will be developed or revised within five (5) working days of initiation of each service or of the reassessment of the patient.” 1. Patient #1 has a Start of Care date of 06/16/2024 with diagnoses Displaced Intertrochanteric Fracture of Right Femur Subsequent Encounter for Closed Fracture with Routine Healing, Chronic Kidney Disease Stage 4 (Severe), Thrombocytopenia Unspecified, Presence of Cardiac Pacemaker, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease in the Home Health Plan of Care dated 06/16/2024 to 08/14/2024. The Registered Nurse Start of Care comprehensive assessment dated 06/16/2024 documents, an attestation o the following Patient-Specific Vital & Pain Parameters to inform/report to the “Provider (Physician):” Temperature (above 100.4 F, Below 96.8 F), Heart Rate (Above 100, Below 60), Respiratory Rate (Above 24, Below 12), Systolic Blood Pressure (Above 140, Below 95), Diastolic Blood Pressure (Above 89), Fasting Blood Glucose (Above 120, Below 70), Random Blood Glucose (Above 180, Below 70), and Pain level greater than 7. The Draft Home Health Plan of Care effective from 06/16/20224 to 08/14/2024, last updated 7/10/2024, documents: “Goal: Patient Will Remain Safe in the Community”- Starting 06/16/2024 “Assess vital signs and inform Provider (Physician) of vitals outside the patient specific ranges;” Vital Parameters: “No Vital Parameters note has been created for the current plan.” The Home Health Plan of Care and orders for skilled professional services – Skilled Nursing, 06/16/2024 to 07/06/2024; Physical Therapy, 06/16/2024 to 07/13/2024; Occupational Therapy, 06/16/2024 to 07/06/2024; and Medical Social Services, 06/16/2024 to 07/15/2024. There is no documented evidence of patient-specific vital parameters, established at the start of care, are included in the individualized plan of care and available to all clinical staff, if needed. The plan of care lacks documented evidence of being initiated/developed as specified the agency agency’s “Care Planning Process.” On 07/12/2024 at 3:30pm, the Director of Nursing and the Director of Quality Assurance/Performance Improvement were interviewed. The Director of Nursing confirmed the plan of care did not include the parameters, and stated the parameters can be viewed “in the start of care” assessment. 2. Patient #2 has a Start of Care date of 06/25/2024 with diagnoses Displaced Bicondylar Fracture of Right Tibia Subsequent Encounter for Closed Fracture with Routine Healing, Other Motorcycle Driver Injured in Noncollision Transport Accident in Traffic Accident Subsequent Encounter, Unspecified Asthma Uncomplicated, Nicotine Dependence, Cigarettes Uncomplicated in the Home Health Plan of Care dated 06/25/2024 to 08/23/2024. The Registered Nurse Start of Care comprehensive assessment dated 06/25/2024 documents, an attestation of the following Patient-Specific Vital & Pain Parameters to inform/report to the “Provider (Physician):” Temperature (above 100.4 F, Below 96.8 F), Heart Rate (Above 100, Below 60), Respiratory Rate (Above 24, Below 12), Systolic Blood Pressure (Above 140, Below 95), Diastolic Blood Pressure (Above 89), and Pain level greater than 7. The Draft" Home Health Plan of Care effective from 06/25/2024 to 08/23/2024, last updated 7/10/2024, documents: “Goal: Patient Will Remain Safe in the Community”- Starting 06/25/2024 “Assess vital signs and inform Provider (Physician) of vitals outside the patient specific ranges;” Vital Parameters: “No Vital Parameters note has been created for the current plan” and orders for skilled professional services – Skilled Nursing, 06/25/2024 to 07/13/2024; Physical Therapy, 06/25/2024 to 07/13/2024; Occupational Therapy, 06/27/2024 to 07/06/2024; and Medical Social Services, 06/25/2024 to 07/24/2024. There is no documented evidence of patient-specific vital parameters, established at the start of care, are included in the individualized plan of care and available to all clinical staff, if needed. The plan of care lacks documented evidence of being initiated/developed as specified the agency agency’s “Care Planning Process.” On 07/12/2024 at 3:30pm, the Director of Nursing and the Director of Quality Assurance/Performance Improvement were interviewed. The Director of Nursing confirmed the plan of care did not include the parameters, and stated the parameters can be viewed “in the start of care” assessment. 3. Patient #5 has a Start of Care date of 06/03/2024 with diagnoses Encounter for Change or Removal of Surgical Wound Dressing, Encounter for Orthopedic Aftercare Following Surgical Amputation, Acquired Absence of left Great Toe, Type 2 Diabetes Mellitus with Diabetic Peripheral Angiopathy with Gangrene, Hypertensive Heart and Chronic Kidney Disease with Heart Failure and with Stage 5 Chronic Kidney Disease, or End Stage Renal Disease, Heart Failure Unspecified, Dependence on Renal Dialysis in the Home Health Plan of Care dated 06/03/2024 to 08/01/2024. The Home Health Plan of Care for certification period 06/03/2024 to 08/01/2024, last updated 07/01/2024 documents the following: “Goal: Patient Will Remain Safe in the Community”- Starting 06/03/2024 “Assess vital signs and inform Provider (Physician) of vitals outside the patient specific ranges;” Vital Parameters with the Registered Nurse electronic signature dated 07/01/2024: Temperature (above 100.4 F, Below 96.8 F), Heart Rate (Above 100, Below 60), Respiratory Rate (Above 24, Below 12), Systolic Blood Pressure (Above 150, Below 95), Diastolic Blood Pressure (Above 95), and Pain level greater than 7. The Registered Nurse Start of Care comprehensive assessment dated 06/03/2024 documents, an attestation of the Patient-Specific Vital & Pain Parameters to inform/report to the “Provider (Physician)” were established at the start of care. There is no documented evidence of patient-specific vital parameters, established at the start of care, were included in the individualized plan of care and available to all clinical staff, if needed, prior to 07/01/2024. The plan of care lacks documented evidence of being initiated/developed as specified the agency agency’s “Care Planning Process.” On 07/12/2024 at 3:30pm, the Director of Nursing and the Director of Quality Assurance/Performance Improvement were interviewed. The Director of Nursing stated the parameters were “not pulled in from” the start of care assessment until 07/01/2024.

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 Clinical Record review and staff interview, the agency failed to ensure that agency staff are reviewing and revising the Plan of Care (POC). This was evident in one (1) out of seventeen (17) clinical records reviewed (Patient # 3). Failure to review and revise the Plan of Care (POC), has potential for negative patient outcomes. The Findings Are: 1. Patient #3 has a Start of Care date of 09/21/2023, Discharge Date of 10/23/2023, with diagnoses Unspecified Intracapsular Fracture of Right Femur Subsequent Encounter for Closed Fracture with Routine Healing, Unspecified Fall Subsequent Encounter, Presence of Right Artificial Hip Joint, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Type 2 Diabetes Mellitus Without Complications, Vascular Dementia Moderate in the Home Health Plan of Care for Certification Period 09/21/2023 to 11/11/2023. The Home Health Plan of Care dated 09/21/2023 to 11/11/2023 documents the following for Skilled Nursing services: Visits 1 visit every week for 1 week 9/21/2023 to 09/23/2023 and 2 visits every week for 2 weeks 9/24/2023 to 10/07/2023; Care Plan: Problem: Prevention of Skin Breakdown – Pressure Ulcer. Patient is at high risk of skin breakdown.” The Registered Nurse Start of Care comprehensive assessment dated 09/21/2023 documents the patient has “no” unhealed pressure ulcer/injury stage 2 or higher, has difficulty in turning and mobility, and caregiver was instructed on pressure ulcer prevention and to position every two hours. The SN(Skilled Nurse) Revisit note dated 09/29/2023 documents: “noted redness to right heel ,(home attendant/aide) instructed to offload both feet to prevent pressure ulcer and to turn and position every2 hours.” The SN (Skilled Nurse) Revisit note dated 10/02/2023 documents: “Right heel is red and reinforced to apply heel pads at all times and apply zinc oxide to promote healing.” The SN (Skilled Nurse Revisit note dated 10/04/2023 documents the following regarding changes the patient’s Integumentary Status: “New Pressure Injury, New Wound” Right Heel, Measurement - Length 3cm, Width 3cm. Depth 0cm, Wound Bed – dry, color black; Dressing Status – Open to air as ordered; and ‘Noted with pressure injury to right heel with blanchable erythema and dark brownish at the center. HA (Home Attendant) is instructed to offload heal and to wear a heel pad, agreed to instruction. Wound picture taken and consent sent to WOCN (Wound Ostomy and Continence Nurse) for consult. Discussed with (Accountable Care Manager).” The Wound Care Conference note dated 10/04/2023 documents the following regarding the wound consult: “Encounter Notes – Right Heel DTI (Deep Tissue Injury); An intact area is persistent red/black/gray discoloration to the rth (right) heel;” “Currently ordered treatment/frequency: Dry Dressing;” and To physician - “Pt (Patient) now noted with DTI (Deep Tissue Injury) to the R (Right) Heel. We would like to suggest the following topical tx (treatment) to pt’s (patient’s) R (Right) Heel DTI (Deep Tissue Injury). Wound Care Specialist treatment recommendation: R (Right) Heel Clean with NS (Normal Saline), pat dry, apply Benzoin tincture, and let dry, then cover with Heel foam dressing 3x week, off load heels; Please let us know if you approve of this suggestion.” There is no documented evidence of the physician’s response to the recommended treatment for the Right Heel pressure ulcer and revising the plan of care. The insurance Authorization Request dated 10/04/2023 documents, “Authorization request for the following disciplines and reasons: Skilled Nursing - Clinical Deficits:” “Requesting 3 additional SN visits, new skin issues.” The “Change in Visit Order for Skilled Nursing” dated 10/04/2023 and included in the plan of care documents: “Added Visit Sets, 1 visit every week for 3 weeks (3 additional visits) from 10/08/2023 to 10/28/2023.” There is no documented evidence of the plan of care being revised on 10/04/2023 to include the patient-specific interventions and education for the new wound. The subsequent SN Revisit notes 10/11/2023, 10/16/2023, and 10/23/2023 document the three additional visits, and dressing status as “Dry, Open to air as ordered.” The SN(Skilled Nurse) Revisit note dated 10/16/2023 documents, the “right heel ulcer is healing, and blister is subsiding, patient is compliant with using the heel pads and offloading of heel from mattress to promote wound healing.” The SN(Skilled Nurse) OASIS Discharge visit note dated 10/23/2023 documents the patient was discharged with one unstageable pressure ulcer - Deep Tissue Injury. There is no documented evidence of the plan of care being revised to include goals, interventions, and treatment for the Right Heel pressure ulcer, prior to discharge. On 07/12/2024 at 3:30pm, the Director of Nursing and the Director of Quality Assurance Performance Improvement were interviewed and did not provide an explanation for the survey 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 coordinate care delivery to meet patients needs. This was evident for two (2) of seventeen (17) clinical records reviewed. (Patients #14, and #15). Failure to ensure to coordinate care delivery to meet patient’s needs, has the potential for negative patient outcomes. The findings are 1. Patient #14 has a Start of Care (SOC) date of 03/14/2023 with the following diagnoses "Other Symptoms and Signs Involving Cognitive Functions Following Non-Traumatic Intracerebral Hemorrhage, Hypertensive Heart Disease" documented in the Home Health Plan of Care for Certification Period 03/14/2023 to 05/12/2023. The Home. Health Plan of Care dated 03/14/2023 to 05/12/2023 documents: "Referral Date: 3/9/2023." The Referral Information dated 03/09/2023 documents: “Referral Received 3/9/2023” “Referral Date: 3/13/23; Requested Start of Care Date: 3/14/23.” “Primary reason for referring to Home Care: evaluate for HHA (home health aide) svcs (services). PT (physical therapy) due to limited mobility.” The Home Health Report dated 03/14/2023 documents: Home Care Visit – Start of Care “Inpatient Facilities – From which of the following Inpatient Facilities was the patient discharged within the past 14 days/ Short-stay acute hospital; Inpatient Discharge Date: 3/10/2023.” “M2200 - Therapy Need: 6 (Identifies the total number of planned therapy visits).” Encounter Notes “Recommendation: Physical Therapy.” All Conversations “03/16/2023 PT (physical therapy) and MSW (medical social worker) to consult. HHA (home health aide) services is being requested for assistance with ADL/IADL’s (activities of daily living / instrumental activities of daily living).” The Communication Notes dated 03/17/2023 documents: “PT (physical therapy) visits for Mon-Fri 9-3pm (Monday to Friday from nine am to three pm).” “HHA (home health aide) services are pending and (name) request 12-4 pm.” The clinical record lacks documented evidence of the patient being notified of the late start of care 03/14/2023, and late referral to physical therapy – 3/17/2023 and aide services – 3/17/2023 request for authorization. There is no documented evidence of the coordination of care activities to meet the patient’s needs. On 07/12/2024 at 12:50pm, the Director of Nursing and the Director of Quality Assurance Performance Improvement were interviewed and did not provide an explanation for the findings. 2. Patient #15 has a Start of Care (SOC) date of 05/17/2024 with the following diagnoses "Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Hypertension" documented in the Home Health Plan of Care for Certification Period 05/17/2024 to 07/15/2024. The Home Health Report documents: 05/13/2024 “Notes copied from referral order (name of Medical Doctor 5/13/24); Requested Start of Care Date: 5/13/24; Which disciplines should be scheduled? Physical Therapy, Occupational Therapy, Home Health Aide.” “Referral Date: 5/14/24; Requested Start of Care Date: 5/17/24.” 05/17/2024 “Inpatient Facilities – From which of the following Inpatient Facilities was the patient discharged within the past 14 days/ Short-stay acute hospital; Inpatient Discharge Date: 5/13/2024.” The clinical record lacks documented evidence of the patient being notified of the change of start of care from 05/13/2024 to 05/17/2024. There is no documented evidence of the coordination of care activities to meet the patient’s needs. On 07/12/2024 at 12:50pm, the Director of Nursing and the Director of Quality Assurance Performance Improvement were interviewed and did not provide an explanation for the findings.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on clinical record review, and staff interviews, the agency failed to provide services that are ordered by the physician as indicated in the plan of care. This was evident for one (1) of seventeen (17) clinical records reviewed (Patient: #15). Failure to provide services that are ordered by the physician as indicated in the plan of care, has the potential for negative patient outcomes. The Findings Are: 1. Patient #15 has a Start of Care (SOC) date of 05/17/2024 with the following diagnoses "Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Hypertension," documented in the Home Health Plan of Care for Certification Period 05/17/2024 to 07/15/2024. The Home Health Plan of Care dated 05/17/2024 to 07/15/2024 documents: "Skilled Nursing Visits 2 visits every week for 2 weeks 5/19/2024 to 6/1/2024." The clinical record documents skilled nurse visits on 05/22/2024 and 05/29/2024. There is no documented evidence of the services being provided for SN for the week: 5/19/2024 - missed 1 visit, and 05/26/2024 - missed 1visit. There is no documented evidence of the patient receiving SN services as ordered by the physician as documented in the plan of care. On 07/12/2024 at 12:50pm, the Director of Nursing and the Director of Quality Assurance Performance Improvement were interviewed and did not provide an explanation for the findings.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on clinical record reviews, and staff interviews, the agency failed to ensure all paraprofessionals receive a complete hha (home health aide) plan of care when providing patient care. This was evident for one (1) of seventeen (17) clinical records reviewed (Patient: #14). Failure to ensure all paraprofessionals receive a complete hha plan of care has potential for negative patient outcomes. The Findings Are: 1. Patient #14 has a Start of Care (SOC) date of 03/14/2023 with the following diagnoses "Other Symptoms and Signs Involving Cognitive Functions Following Non-Traumatic Intracerebral Hemorrhage, Hypertensive Heart Disease" documented in the Home Health Plan of Care for Certification Period 03/14/2023 to 05/12/2023. The Home Health Plan of Care dated 03/14/2023 to 05/12/2023 documents: “Nutritional Requirements: Diabetic diet, Low sodium diet.” The Home Health Order dated 03/20/2023 documents: "Home Health Aide Services to be Provided: number of days per week: 5; Hha (home health aide) Start Date: 3/21/2023." The Aide Assignment Sheet dated 03/17/2023 documents: “Diet: low salt.” Duty Sheet documents aide providing services on: 03/21/2023 to 03/24/2023, 03/27/2023 to 03/31/2023, 04/03/2023, 04/05/2023, and 04/06/2023. The Aide Assignment Sheet (written patient care instruction) lacks documented evidence of the frequency of the task to be provided for 03/17/2023 and 03/30/2023, and incomplete diet for 03/17/2023 and missing diet for 03/30/2023. The clinical record lacks documented evidence of a complete aide plan of care addressing the patient’s needs. On 07/15/2024 at 11:51am, the Director of Nursing and the Director of Quality Assurance Performance Improvement were interviewed and did not provide an explanation for the findings.

Duties of a HH aide CFR(s): 484.80(g)(3) The duties of a home health aide include: (i) The provision of hands-on personal care; (ii) The performance of simple procedures as an extension of therapy or nursing services; (iii) Assistance in ambulation or exercises; and (iv) Assistance in administering medications ordinarily self-administered. This ELEMENT is not met as evidenced by: Based on clinical record review, and staff interviews, the agency failed to ensure that Home Health Aides performed tasks documented in the aide plan of care. This was evident for one (1) of seventeen (17) clinical records reviewed (Patient: #14). Failure to ensure that Home Health Aides performed tasks documented in the aide plan of care has the potential for negative patient outcomes. The Findings Are: 1. Patient #14 has a Start of Care (SOC) date of 03/14/2023 with the following diagnoses "Other Symptoms and Signs Involving Cognitive Functions Following Non-Traumatic Intracerebral Hemorrhage, Hypertensive Heart Disease" documented in the Home Health Plan of Care for Certification Period 03/14/2023 to 05/12/2023. The Home Health Order dated 03/20/2023 documents: "Home Health Aide Services to be Provided: number of days per week: 5; Hha (home health aide) Start Date: 3/21/2023." The Aide Assignment Sheet dated 03/17/2023 documents: “Assignment: Bath – Tub/Shower, Oral Care, Elimination Assist, and Ambulation Assist.” The Duty Sheets lacks documented evidence of the following task being provided: Bath, Oral Care, and Ambulation Assist on 03/21/2023 to 03/23/2023, 03/29/2023, 03/30/2023; and Elimination Assist on 03/24/2023, 03/27/2023, and 03/28/2023. On 07/15/2024 at 11:51am, the Director of Nursing and the Director of Quality Assurance Performance Improvement were interviewed and did not provide an explanation for the findings.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on clinical record review, and staff interviews, the agency failed to ensure that all home health aides receive onsite supervision every 14 days. This was evident for one(1) of seventeen (17) clinical records reviewed (Patient: #14). Failure to ensure that all home health aides receive onsite supervision every 14 days, has the potential for negative patient outcomes. The Findings Are: 1. Patient #14 has a Start of Care (SOC) date of 03/14/2023 with the following diagnoses "Other Symptoms and Signs Involving Cognitive Functions Following Non-Traumatic Intracerebral Hemorrhage, Hypertensive Heart Disease" documented in the Home Health Plan of Care for Certification Period 03/14/2023 to 05/12/2023. The Home Health Order dated 03/20/2023 documents: "Home Health Aide Services to be Provided: number of days per week: 5; hha (home health aide) Start Date: 3/21/2023." The Duty Sheet documents aide services being provided on: 03/21/2023 to 03/24/2023, 03/27/2023 to 03/31/2023, 04/03/2023, 04/05/2023, and 04/06/2023. The clinical record documents aide supervision on 03/21/2023 by the skilled nurse. The clinical record lacks documented evidence of the aide supervision every 14 days. On 07/15/2024 at 11:50 am, the Director of Nursing and the Director of Quality Assurance Performance Improvement were interviewed and did not provide an explanation for the findings.

The following statement of deficiencies represents the results of partial extended re-certification survey of HHC Health and Home Care Certified Home Health Agency conducted on 08/09/2021 through 08/13/2021 and included complaint investigation NY00257219 and NY00269360. The allegation in Complaint NY 00257219 was determined unsubstantiated. Allegations #1 and #2 in Complaint NY00269360 were determined unsubstantiated. Allegation #3 in Complaint NY00269360 was determined unsubstantiated. A standard re-certification survey was initiated on 08/09/2021. Deficient practices were identified within Level 1 Standards in 484.55 Condition: Comprehensive Assessment of Patients, 484.600 Condition: Care Planning, Coordination, Quality of Care, and 484.75 Condition: Skilled professional services resulting in a partial extended survey. The survey consisted of a review of seventeen (17) clinical records, including five (5) discharge records with three (3) Potentially Avoidable Event (PAE) records, seven (7) observational home visits and ten (10) record review for professional and paraprofessional. The survey included a review of pertinent policies and procedures, Quality Improvement meeting minutes for past 12 months, PIP (Performance Improvement Projects), Infection Control and COVID policies, Admission packet, Emergency Preparedness Plan, Complaint Log, and three (3) contracts. Pre-survey activities consisted of Internet Quality Improvement and Evaluation System (iQIES) for the period 06/2020 to 04/2021, a review on 07/29/21 of the agency's Health Commerce System account, and the agency compliance with report submissions for the latest statistical report and participation in the 2019 Emergency Drill. The Associate Executive Director was interviewed throughout the survey. Findings were reviewed at the exit conference on 08/13/2021. The following deficiencies are identified as a result of the survey: G0374 - Accuracy of encoded OASIS data: G0440 - Payment from federally funded programs G0514 - RN performs assessment: G0528 - Health, psychosocial, functional, cognition G0536 - A review of all current medications G0544 - Update of the comprehensive assessment G0548 - Within 48 hours of the patient's return G0578 - Conformance with physician orders G0580 - Only as Ordered by a physician G0718 - Communication with physicians J1304- Contracts

Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient's status at the time of assessment. This STANDARD is not met as evidenced by: Based on clinical record review and staff interview the agency failed to ensure all encoded OASIS assessments accurately reflect each patient's status at the time of the assessment. This was evident for one (1) of five (5) clinical discharged records reviewed (Patient: #11). Failure to ensure all encoded OASIS Assessments accurately reflect the patient's status at the time of the assessment, has the potential for negative patient outcomes. The Finding is 1.Patient #11 (PAE) has a Start of Care (SOC) date of 2/22/2020, a Discharge Date of 3/15/2020, with the following diagnoses: "Type 2 Diabetes Mellitus with Foot Ulcer, Non-Pressure Chronic Ulcer of Left Heel and Midfoot with Muscle Involvement, Hypertensive Heart Disease with Heart Failure" documented on Home Health Certification and Plan of Care for the Certification Period 2/22/2020 to 4/21/2020. The SN (Skilled Nurse) - OASIS (Outcome and Assessment Information Set) Transfer with Discharge dated 3/15/2020 documents: M0090 - Date Assessment Completed: 3/15/2020 M0100 - This Assessment is Currently being completed for the Following Reason: Transferred to an inpatient facility-patient discharged from agency M2310 - Reason for Emergent Care - Hypo/Hyperglycemia, diabetes out of control. The Report Viewer documents: ED (emergency department) Discharged, Note Initiated 3/16/2020, History of Present Illness: Patient was here in emergency room 3 days for depression/suicidal ideation the patient was cleared by psychiatrist today. There is no documented evidence that the OASIS - Discharge from agency on 3/15/2020 accurately reflects the patient's status at the time of assessment. On 08/13/2021 at 10:00am, the Associate Executive Director was interviewed and stated "Patient #11 was hospitalized for depression, no further explanation for the survey 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 clinical record review and staff interview, the agency failed to ensure all patients are informed in writing of services, frequency of services and potential financial liability for each service provided before care is initiated. This was evident for six (6) of seventeen (17) clinical records reviewed. (Patients #3, #5, #7,#11, #14 and #5). Failure to ensure all patients are informed in writing of services, frequency of services and potential financial liability for services before care is initiated has the potential for negative patient outcomes. The findings are: 1.Patient #3 has a Start of Care date of 09/12/2019 with the following diagnoses "Rheumatoid Arthritis of Multiple Sites with Involvement of other Organs and Systems, Essential (primary) Hypertension, Adjustment Disorder with Anxiety" documented on the Home Health Certification and Plan of Care dated 07/03/2021 to 08/31/2021. The Admission Consent signed by the patient on 09/12/2019 documents: "Skilled Nursing: Insurance pays column is blank, You pay column is blank." There is no documented evidence of the patient being informed orally and in writing of the financial responsibility for services. On 08/12/2021 at 4:30 pm, the Associate Executive Director was interviewed and did not provide an explanation for the findings. 2.Patient #5 has a Start of Care date of 05/21/2021 with the following diagnoses "Type 2 Diabetes Mellitus with Foot Ulcer, Essential(primary) Hypertension, Parkinson's Disease, Gastro-Esophageal Reflux Disease without Esophagitis" documented on the Home Health Certification and Plan of Care dated 05/21/2021 to 07/19/2021. The Admission Consent signed by patient on 05/21/2021 documents: "Skilled Nursing: Insurance pays column is blank, You pay column is blank; Medical Social Services: Insurance pays column is blank, You pay column is blank; Physical Therapy: Insurance pay column is blank, You pay column is blank; Nutrition: Insurance pays column is blank, You pay column is blank; Home Health Aide: Cost column is blank, Insurance pays column is blank, You pay column is blank." There is no documented evidence of the patient being informed orally and in writing of the financial responsibility for services. On 08/12/2021 at 4:30 pm, the Associate Executive Director was interviewed and did not provide an explanation for the findings. 3.Patient #7 (HV) has a Start of Care (SOC) date of 8/6/2021 with the following diagnosis: "Aftercare Joint Replacement Surgery status post Total Knee Arthroplasty" documented on Home Health Certification and Plan of Care for the Certification Period 8/6/2021 to 10/4/2021. The Admission Consents are signed and dated 8/6/2021 by the patient or the patient's representative. Under the Initial Services and Frequency: Insurance Pays, You Pay (Patient's Financial Liability) are not completed (Blank). There is no documented evidence of the patient being informed orally and in writing of the complete Financial Agreement / Assignment of Benefits for each service to be provided. On 08/13/2021 at 10:00am, the Associate Executive Director was interviewed and did not provide an explanation for the survey findings. 4.Patient #11 (PAE) has a Start of Care (SOC) date of 2/22/2020, a Discharge Date of 3/15/2020, with the following diagnoses: "Type 2 Diabetes Mellitus with Foot Ulcer, Non-Pressure Chronic Ulcer of Left Heel and Midfoot with Muscle Involvement, Hypertensive Heart Disease with Heart Failure" documented on Home Health Certification and Plan of Care for the Certification Period 2/22/2020 to 4/21/2020. The Admission Consents are signed and dated 2/22/2020 by the patient or the patient's representative. Under the Initial Services and Frequency: Insurance Pays, You Pay (Patient's Financial Liability) are not completed (Blank). There is no documented evidence of the patient being informed orally and in writing of the complete Financial Agreement / Assignment of Benefits for each service to be provided. On 08/13/2021 at 10:00am, the Associate Executive Director was interviewed and did not provide an explanation for the survey findings. 5.Patient #14 has start of care date 07/292021 with following diagnosis "Aftercare following joint replacement surgery" for Certification Period from 07/29/2021 to 09/26/2021. The admission consent signed by patient on 07/29/2021 documents: "Skilled Nursing: Insurance pays (blank), You pay (blank); Physical Therapy: Insurance pay (blank), You pay (blank)." There is no documented evidence of the patient being informed in writing of financial responsibility for services that may not be covered. On 08/12/2021 at 3:30 pm, the Associate Executive Director was interviewed and did not provide an explanation for the findings. 6.Patient #15 has start of care date 07/06/2021 with following diagnosis "Type 2 Diabetes Mellitus Without Complications" for Certification Period from 07/06/2021 to 09/03/2021. The admission consent signed by patient on 07/06/2021 documents: "Skilled Nursing: Insurance pays (blank), You pay (blank); Physical Therapy: Insurance pay (blank), You pay (blank)." There is no documented evidence of the patient being informed in writing of financial responsibility for services that may not be covered. On 08/12/2021 at 3:30 pm, the Associate Executive Director was interviewed and did not provide an explanation for the findings.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on clinical record reviews, and staff interview, the agency failed to ensure that initial assessments were conducted within the required time frames for all patients. This was evident for two (2) of seventeen (17) clinical records reviewed (Patient: #9, and #16). Failure to ensure that initial assessments are conducted within the required time frames for all patients, has the potential for negative outcome. The Findings Are: 1.Patient #9 has a Start of Care (SOC) date of 06/24/2021 with the following diagnoses: "Monoplegia of Lower Limb following Cerebral Infarction affecting Left Non-Dominant Side, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Hypertensive Chronic Kidney Disease with Stage 5 Chronic Kidney Disease or End Stage Renal Disease" documented on Home Health Certification and Plan of Care for the Certification Period 06/24/2021 to 08/22/2021. The SN (Skilled Nurse) - OASIS (Outcome and Assessment Information Set) Start of Care with Visit Information date of 6/24/2021 documents: Start of Care Date: 6/24/2021, Inpatient Discharge Date: 6/15/2021, SOC is 9 days after the discharge in hospital. There is no documented evidence of a Registered Nurse completing the initial assessment visit within 48 hours of referral date 7/20/21, to determine the immediate care and support needs of the patient. On 08/13/2021 at 10:00am, the Associate Executive Director was interviewed and did not provide an explanation for the survey findings. 2.Patient #16 has start of care date 12/14/2020 with following diagnosis "Bilateral Primary Osteoarthritis of Knee" for Certification Period from 12/14/2020 to 02/11/2021. The referral dated 12 /08/2020 documents: "Requested Start of Care Date: 12/11/20." The Home Health Certification and Plan of Care dated 12/14/2020 to 02/11/2021 documents: "Start of Care Date 12/14/2020." There is no documented evidence initial assessment was performed within 48 hours from physician ordered start of care. On 08/13/2021 at 4:00 pm, the Associate Executive Director was interviewed and did not provide an explanation for the findings.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to ensure that all patients have an accurate assessment. This was evident for one (1) of seventeen (17) clinical records reviewed (Patient: #11). Failure to ensure all patients have an accurate comprehensive assessment is accurate, has the potential for negative patient outcomes. The Findings is: 1.Patient #11 (PAE) has a Start of Care (SOC) date of 2/22/2020, a Discharge Date of 3/15/2020, with the following diagnoses: "Type 2 Diabetes Mellitus with Foot Ulcer, Non-Pressure Chronic Ulcer of Left Heel and Midfoot with Muscle Involvement, Hypertensive Heart Disease with Heart Failure" documented on Home Health Certification and Plan of Care for the Certification Period 2/22/2020 to 4/21/2020. The SN (Skilled Nurse) - OASIS (Outcome and Assessment Information Set) Start of Care dated 3/15/2020 documents: M1340 - Surgical Wound - Does this patient have a Surgical Wound? Yes, patient has at least one (observable) surgical wound. Action/Narrative: he was hospitalized and treated for an infected left lower extremity wound. He had wound debridement. On 08/12/2021 at 3:00am, the Associate Executive Director/Director of Patient Services was interviewed to clarify if wound is surgical - no diagnosis of surgical wound and stated "it's not a surgical wound. There is no documented evidence of an accurate reflection of the patient's wound status in the comprehensive assessment to assist in developing the patient's plan of care. On 08/13/2021 at 10:00am, the Associate Executive Director was interviewed and did not provide an explanation for the survey findings.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview the agency failed to ensure an accurate and comprehensive review of each patient's medications. This was evident for one (1) of seventeen (17) clinical records reviewed (Patient: #6). Failure to ensure review of all patients' current medications are complete, accurate and are reflected in the patient's plan of care has the potential for negative patient outcomes. The findings are: 1.Patient #6 (PAE) has a Start of Care date of 04/23/2020 with the following diagnoses "Type 2 Diabetes mellitus without Complications, Essential(primary) Hypertension, Pressure Ulcer of Sacral Region, unstageable" documented on the Home Health Certification and Plan of Care dated 04/23/2020 to 06/21/2020. The Home Health Certification and Plan of Care dated 04/23/2020 to 06/21/2020 documents:"SN: Assess/Instruct in safe insulin preparation and Administration[Start: 4/23/2020] [Caregiver will administer insulin as ordered] SN Goals Patient demonstrates insulin management[Patient/caregiver will demonstrate the ability to prepare and administer insulin using correct technique and site rotation, including disposal of sharps, within 2 week(s)." The SN (Skilled Nurse) - OASIS Start of Care with Visit Information date of 04/23/2020 documents:" Active Diagnoses-Comorbidities and Co-existing Conditions M1028(continued). 2 - Diabetes Mellitus (DM) 1 - Yes Diabetes: Type: type 2 diabetes Insulin dependent? Yes Signs and Symptoms Present: asymptomatic Current Management Approach: diabetic diet, insulin The SN (Skilled Nurse) Revisit dated 04/30/2020 documents: Diabetes: Type: type 2 diabetes Insulin dependent? No The SN (Skilled Nurse) Revisit dated 05/02/2020 documents: Diabetes: Type: type 2 diabetes Signs and Symptoms Present: asymptomatic Current Management Approach: diabetic diet, oral hypoglycemic agent The SN (Skilled Nurse) - Resumption date of 05/14/2020 documents:" Active Diagnoses-Comorbidities and Co-existing Conditions M1028(continued). 2 - Diabetes Mellitus (DM) 1 - Yes Diabetes: Type: type 2 diabetes Insulin dependent? No Signs and Symptoms Present: asymptomatic Current Management Approach: diabetic diet, insulin The Nurse Actions/Narrative dated 05/26/2020 documents:" ...She(patient) has PMHx of COVID-19 virus infection, type 2 diabetes mellitus without complication, with long-term current use of insulin, pneumonia of both lungs due to infectious organism, high blood pressure ... ." The Home Health Certification and Plan of Care for the Certification Period 04/23/2020 to 06/21/2020 lacks documented evidence of the insulin and oral hypoglycemic agent. There is no documented evidence of all the medications being reviewed and reconciled. On 08/12/2021 at 4:30 pm, the Associate Executive Director was interviewed and did not provide an explanation for the survey findings.

Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than- This STANDARD is not met as evidenced by: Based on clinical record review and staff interview the agency failed to ensure all comprehensive assessments are updated as frequently as the patient's condition warrants to reflect changes in the patient's health status. This was evident for one (1) of seventeen (17) clinical records reviewed. (Patient #11). Failure to ensure that all comprehensive assessments are updated and revised as the patient's condition warrants has the potential for negative patient outcomes. The findings are: 1.Patient #11 (PAE) has a Start of Care (SOC) date of 2/22/2020, a Discharge Date of 3/15/2020, with the following diagnoses: "Type 2 Diabetes Mellitus with Foot Ulcer, Non-Pressure Chronic Ulcer of Left Heel and Midfoot with Muscle Involvement, Hypertensive Heart Disease with Heart Failure" documented on Home Health Certification and Plan of Care for the Certification Period 2/22/2020 to 4/21/2020. The Home Health Certification and Plan of Care for the Certification Period 2/22/2020 to 4/21/2020 documents: Provide wound care and treatment, Frequency of wound care: 3 x (three times) weekly; wound site: left Foot Ulcer; Incision care: left foot wound: lightly clean with NS (normal saline), apply Ca (calcium) Alginate with Silver, cover with dry dressing and secure with Kling 3 times a week. Place gauze between toes to manage moisture. RN (Registered Nurse) to perform dressing change. There is no documented evidence that the wound was assessed on the following visit dates: 2/27/2020, 3/6/2020, and 3/15/2020. The clinical record lacks documented evidence of the skilled nurse updating the comprehensive assessment for the wound. On 08/13/2021 at 10:00am, the Associate Executive Director was interviewed and did not provide an explanation for the survey findings.

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview the agency failed to ensure comprehensive assessments are updated and revised within forty-eight (48) hours of the patient's return to the home from a hospital admission of twenty-four (24) hours or more. This was evident for one (1) of seventeen (17 ) clinical records reviewed (Patient #9). Failure to ensure Comphrensive assessments are updated within 48 hours of a patient's return from a hospital admission, has the potential for negative patient outcomes. The Finding are: 1.Patient #9 has a Start of Care (SOC) date of 06/24/2021 with the following diagnoses: "Monoplegia of Lower Limb following Cerebral Infarction affecting Left Non-Dominant Side, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Hypertensive Chronic Kidney Disease with Stage 5 Chronic Kidney Disease or End Stage Renal Disease" documented on Home Health Certification and Plan of Care for the Certification Period 06/24/2021 to 08/22/2021. The Intake for Home Health documents: Referral Instructions Please admit Patient #9 to Home Care. Referral Date: 7/20/2021. The SN (Skilled Nurse) - OASIS (Outcome and Assessment Information Set) dated 7/23/2021 documents: Date of Assessment Completed: 7/23/2021 and Inpatient Discharge Date: 7/19/2021, 3 days after the referral 7/20/2021. There is no documented evidence of a Registered Nurse completing the resumption assessment visit within 48 hours of the patient's return to the home from a hospital admission. On 08/13/2021 at 10:00am, the Associate Executive Director was interviewed and did not provide an explanation for the survey 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 clinical review records and staff interview the agency failed to provide services in accordance with physician orders. This was evident for one (1) of seventeen clinical records reviewed. (Patient#11). Failure to ensure patient care is provided in accordance with the Physician Orders has the potential for negative patient outcome. The finding is. 1.Patient #11 (PAE) has a Start of Care (SOC) date of 2/22/2020, a Discharge Date of 3/15/2020, with the following diagnoses: "Type 2 Diabetes Mellitus with Foot Ulcer, Non-Pressure Chronic Ulcer of Left Heel and Midfoot with Muscle Involvement, Hypertensive Heart Disease with Heart Failure" documented on Home Health Certification and Plan of Care for the Certification Period 2/22/2020 to 4/21/2020. The Home Health Certification and Plan of Care for the Certification Period 2/22/2020 to 4/21/2020 documents: SN (Skilled Nurse) 2/22/2020 to 2/29/2020: 3 visits every week for 2 weeks 3/1/2020 to 3/14/2020: 2 visits every week for 2 weeks 3/6/2020 to 3/7/2020: 1 visit every week for 1 week 3/8/2020 to 3/14/2020: 1 visit every week for 1 week 3/15/2020 to 4/21/2020: 2 visits every week for 6 weeks. Provide wound care and treatment, Frequency of wound care: 3 x (three times) weekly; wound site: left Foot Ulcer; Incision care: left foot wound: lightly clean with NS (normal saline), apply Ca (calcium) Alginate with Silver, cover with dry dressing and secure with Kling 3x week. Place gauze between toes to manage moisture. RN (Registered Nurse) to perform dressing change. There is no documented evidence that the wound was cleaned, and dressed on the following visit dates: 2/22/2020, 2/27/2020, 3/6/2020, and 3/15/2020. The clinical record lacks documented evidence of the skilled nurse visit of three times a week, missing 1 visit on the week of 2/23/2020 to 2/29/2020. There is no documented evidence that the Skilled Nurse conformed with Physician's order of wound care three times a week. On 08/13/2021 at 10:00am, the Associate Executive Director was interviewed and did not provide an explanation for the survey findings.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to ensure that treatments are administered only as ordered by the physician for each patient. This was evident for one (1) of seventeen (17) clinical records reviewed. (Patient #9). Failure to ensure that treatments are administered only as ordered by the physician has the potential for negative patient outcomes. The Findings are: 1.Patient #9 has a Start of Care (SOC) date of 06/24/2021 with the following diagnoses: "Monoplegia of Lower Limb following Cerebral Infarction affecting Left Non-Dominant Side, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Hypertensive Chronic Kidney Disease with Stage 5 Chronic Kidney Disease or End Stage Renal Disease" documented on Home Health Certification and Plan of Care for the Certification Period 06/24/2021 to 08/22/2021. The Home Health Certification and Plan of Care for the Certification Period 06/24/2021 to 08/22/2021 documents: Insulin Lispro (Humalog) Inject 8 units under the skin 3 times a day with meals, Insulin Glargine (Basaglar Kwikpen) Inject 42 units total under the skin nightly. The Encounter Notes dated 7/1/2021 documents: Patient states she takes Lispro 8 units before meals and Lantus 10 units before bed. The SN (Skilled Nurse) - OASIS (Outcome and Assessment Information Set) dated 7/23/2021 documents: Outpatient Medication on the Plan of Care as of 7/23/2021: Insulin Lispro (Humalog) Inject 0.05 ml (5 units total) under the skin 3 times a day with meals. The Encounter Date 7/23/2021 documents: Patient does not have Levemir (not covered by insurance) and has only been taking short acting insulin Lispro. RN (Registered nurse) instructed patient's son for patient to take 25 units Lantus instead, as well as Insulin Lispro 5mg qAC (five mg before every meal). This is what is typed on the discharge summary, even though the orders differ. Updated prescriptions sent to pharmacy on file. Informed RN that it is ok for patient to adjust insulin Lispro based on her FSG (finger stick glucose) and actually take her insulin. The SN Revisit dated 7/28/2021 documents: Continue Lispro 8 Units with meals and 25 units Lantus at bedtime. There is no documented evidence that drugs - Lantus 25 Units, Insulin Lispro 5 units are administered as ordered by the Physician. On 08/13/2021 at 10:00am, the Associate Executive Director was interviewed and did not provide an explanation for the survey findings.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview the agency failed to ensure ongoing communication with all physicians is maintained. This was evident for six (6) of seventeen (17) clinical records reviewed. (Patients#5,#6,#9,#10,#11, and #16). Failure to ensure ongoing communication with all physicians is maintained has the potential for negative patient outcome. The Findings are: 1.Patient #5 has a Start of Care date of 05/21/2021 with the following diagnoses "Type 2 Diabetes Mellitus with Foot Ulcer, Essential(primary) Hypertension, Parkinson's Disease, Gastro-Esophageal Reflux Disease without Esophagitis" documented on the Home Health Certification and Plan of Care dated 05/21/2021 to 07/19/2021. The Home Health Certification and Plan of Care dated 05/21/2021 to 07/19/2021 documents:"SN (Skilled Nurse): 05/21/2021 to 05/22/2021:2 (two) visits every week for 1(one) week; 05/23/2021 to 07/03/2021:7 (seven) visits every week for 6 (six) weeks." There is no documented evidence of the SN visits on 06/05/2021 and 06/06/2021. There is no documented evidence of the SN services being provided as documented on the Plan of Care, and no documented evidence of the physician is being notified of the missed SN visits on 06/05/2021 and 06/06/2021. On 08/11/2021 at 3:30 pm, the Associate Executive Director was interviewed and did not provide an explanation for the findings. 2.Patient #6 has a Start of Care date of 04/23/2020 with diagnosis of "Type 2 Diabetes Mellitus, Essential (primary) Hypertension, Pressure Ulcer of Sacral Region, unstageable"documented on the Home Health Certification and Plan of Care dated 04/23/2020 to 06/21/2020. The Home Health Certification and Plan of Care dated 04/23/2020 to 06/21/2020 documents:"Inform MD of vital signs outside of Parameters[Start:4/23/2020...SaO%(Oxygen) below 92%] The SN(Skilled Nurse) - Oasis Start of Care dated 04/23/2020 documents at 01:40 PM: " Vitals: SpO2 (!) 90 %" There is no documented evidence of the physician being notified of the patient having an SpO2 reading lower than 92% as documented on the Plan of Care. On 08/12/2021 at 4:40 pm, the Associate Executive Director was interviewed and did not provide an explanation for the findings. 3.Patient #9 has a Start of Care (SOC) date of 06/24/2021 with the following diagnoses: "Monoplegia of Lower Limb following Cerebral Infarction affecting Left Non-Dominant Side, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Hypertensive Chronic Kidney Disease with Stage 5 Chronic Kidney Disease or End Stage Renal Disease" documented on Home Health Certification and Plan of Care for the Certification Period 06/24/2021 to 08/22/2021. The Home Health Certification and Plan of Care dated period 06/24/2021 to 08/22/2021 documents: Inform the MD (Medical Doctor) if blood glucose is above 300mg/dl or below 70 mg/dl (milligram per deciliter). The Case Communication dated 6/29/2021 documents: Patient non-compliant with blood glucose monitoring and medication administration. Elevated blood glucose levels > (greater than) 400mg/dl. Patient declined going to hospital and self-administered Insulin during visit. The SN (Skilled Nurse) Revisit dated 7/1/2021 documents: Patient continues to have consistently elevated blood glucose levels > (greater than) 400mg/dl due to inadequate blood glucose testing frequency and insulin administration. AM (morning) fasting result from last 3 days: 478, AM fasting result date: 7/1/2021. Patient was hospitalized on 7/15/2021 secondary to high glucose level of 448mg/dl and returned home on 7/19/2021 SN revisit dated 7/24/2021 but no FS monitoring done. The clinical record lacks documented evidence of the SN communicating with the physician about the glucose level above 300mg/dl as per plan of care and non-compliance. On 08/12/2021 at 03:00PM, the the Associate Executive Director was interviewed, and did not provide an explanation for the survey findings. 4.Patient #10 has a Start of Care date of 7/9/2021, a Discharge Date of 8/5/2021, with the following diagnoses: "Type 2 Diabetes Mellitus, Malignant Neoplasm of Prostate, Secondary Malignant Neoplasm of Bone, Essential Hypertension" documented on Home Health Certification and Plan of Care for the certification period 7/9/2021 to 9/6/2021. The Home Health Certification and Plan of Care for the Certification Period 7/9/2021 to 9/6/2021 documents: PT (Physical Therapy: 7/9/2021 to 7/17/2021: 1 visit every week for 2 weeks. The Changed Visit Order for Physical Therapy dated 7/21/2021 documents: Added Visits Sets 1 visit every week for 2 weeks from 7/21/2021 to 7/31/2021. Unchanged Visits Sets 1 visit every week for 2 weeks from 7/9/2021 to 7/17/2021. The clinical record lacks documented evidence of PT visits from 7/9/2021 to 7/17/2021, missed 1 visit. The clinical record lacks documented evidence of the PT communicating with the physician about the missed visit. On 08/12/2021 at 03:00PM, the Associate Executive Director was interviewed, and did not provide an explanation for the survey findings. 5.Patient #11 (PAE) has a Start of Care (SOC) date of 2/22/2020, a Discharge Date of 3/15/2020, with the following diagnoses: "Type 2 Diabetes Mellitus with Foot Ulcer, Non-Pressure Chronic Ulcer of Left Heel and Midfoot with Muscle Involvement, Hypertensive Heart Disease with Heart Failure" documented on Home Health Certification and Plan of Care for the Certification Period 2/22/2020 to 4/21/2020. The Home Health Certification and Plan of Care for the Certification Period 2/22/2020 to 4/21/2020 documents: SN (Skilled Nurse) 2/22/2020 to 2/29/2020: 3 visits every week for 2 weeks; Provide wound care and treatment, Frequency of wound care: 3 x (three times) weekly; wound site: left Foot Ulcer; Incision care: left foot wound: lightly clean with NS (normal saline), apply Ca (calcium) Alginate with Silver, cover with dry dressing and secure with Kling 3xweek. Place gauze between toes to manage moisture. RN (Registered Nurse) to perform dressing change. The clinical record lacks documented evidence of the skilled nurse visit of three times a week for 2/23/2020 to 2/29/2020 - missed 1 visit. The clinical record lacks documented evidence of the SN communicating with the physician about the missed visits. On 08/12/2021 at 03:00PM, the Associate Executive Director was interviewed, and did not provide an explanation for the survey findings. 6.Patient #16 has start of care date 12/14/2020 with following diagnosis "Bilateral Primary Osteoarthritis of Knee" for Certification Period from 12/14/2020 to 02/11/2021. The Home Health Certification and Plan of Care dated 12/14/2020 to 02/11/2021 documents: "1.Number of personal care hours per day:4 2. Total number of home health hours per day: 4 3. Number of days per week: 5 4. Number of weeks: 3 5. Preferred HHA Language: English HHA (Home Health Aide) Start 12/17/20 HHA End Date: 12/31/20." There is no documented evidence of Home Health Aide services from 12/17/20 to 12/31/20. There is no documented evidence of notification to physician that patient did not receive HHA service. On 08/12/2021 at 3:30 pm, the Associate Executive Director was interviewed and did not provide an explanation for the findings.