Every finding on record at Ogl Holdings, LLC

The following statement of deficiencies represents the results of a Partial Extended Standard Recertification Survey of South Nassau Communities Hospital Home Care, 1000 South Oyster Bay Hicksville, New York 11801, conducted on 12/12/2022 through 12/16/2022. A Standard Recertification Survey was initiated on 12/12/22. Deficient practices were identified within Level 1 standards in 484.60 Care Planning, Coordination of Services, and Quality of Care resulting in a Partial Extended Survey. The survey consisted of a review of seventeen (17) Clinical Records, including five (5) Discharged Records, twelve (12) Personnel Records for Professional and Paraprofessional Personnel, two (2) Contracts, and seven (7) Observational Home Visits. The survey included a review of pertinent Policies and Procedures, Telehealth Program/Telehealth Monitoring, Health Commerce System, Criminal History Check, Complaints, Influenza, On Call, Clinical Supervision, Covid and Infection Control Practices, the agency's Admission Information Packet and Complaint Log for 2022. Pre-survey activities consisted of review on 12/9/22 of the agency's Health Commerce System Account, [Home Care Worker Registry, Criminal History Record Check], Certification and Survey Provider Enhanced Reports (CASPER), and the agency's compliance with report submissions for the 2019 Statistical Report and the Emergency Drill conducted on 06/11/19 through 06/13/19. The Director of Patient Services/Administrator, Assistant Director of Patient Services, Quality Improvement Coordinator, Telehealth Coordinator and various agency Professional Staff were interviewed. The findings were reviewed at the Exit Conference on 12/16/22. The following deficiencies were identified as a result of the survey: Standard Federal Deficiencies: G - 434 - Participant in Care; G- 574 - Plan of Care Must Include the Following; G- 578 - Conformance with Physician's Orders; G - 586 - Review and Revision of the Plan of Care; G - 590 - Promptly Alert Relevant Physician of Changes; State Deficiencies J - 1140, 1144, 1184, and 1260 - Governing Authority; J - 1424 and 1426 - Personnel; R- 1034- Responsibilities of Provider

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on record reviews, admission packet review and interview, the Governing Authority failed to inform Patients of the services the Patient is to receive and the frequency for the services. This was evident for seventeen (17) of seventeen (17) clinical records reviewed. (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, and #17) Failure to ensure that patients are informed in writing of rights has the potential for patients to be unaware of rights which may prevent them from making informed decisions. The findings are: A review of the Patient Admission Packet documents a form titled "Anticipated Services and Visit Frequency" is to be completed at the time of admission. A review of seventeen (17) clinical records (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, and #17) were conducted and lack documented evidence of this form being completed and placed in the file. During an interview with the Administrator on 12/14/22, the Administrator did not provide an explanation as to the reason the forms were not completed and placed in the records.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record reviews and interview, the agency failed to develop/revise complete and comprehensive Plans of Care. This was evident for three (3) of seventeen (17) clinical records reviewed. (Patients #4, #5, and #8) Failure to develop complete and comprehensive Plans of Care places patients at risk for negative patient outcomes. The findings are: 2. Patient #5 has a start of care date of 11/29/22 with diagnosis that include Diabetes Mellitus with Peripheral Vascular Disease, Pulmonary Hypertension, History of Deep Vein Thrombosis and Chronic Venous Stasis as documented on the “Home Health Certification and Plan of Care” for the Certification Period of 11/29/22 to 1/27/23. The “Home Health Certification and Plan of Care” for the Certification Period of 11/29/22 to 1/27/23 documents: "Orders for Discipline and Treatments: Skilled Nursing (SN) 1-3 x week x 3 weeks; Physical Therapy 1-2 weeks x 4 weeks; assess/instruct patient/caregiver on medication dosages, use, actions, side effects, and response to medications/side effects to report, Medications: Acetaminophen by mouth (PO) tablet (Tab) 325 mg two tab every 6 hours as needed (PRN) pain, Potassium Chloride ER PO extended release 20 MEQ (milliequivalent) one tablet daily in the morning, Warfarin Sodium PO tab 2.5 mg one tab at bedtime, Metoprolol Tartrate PO 25 mg one tab daily in the morning, Atorvastatin calcium PO 10 mg tab at bedtime, Furosemide PO 40 mg one tab daily in the morning, and Colace 50 mg capsule one capsule at bedtime". On 12/13/22 at 1:00PM, during an observational home visit, the surveyor reviewed the medications with the Physical Therapist. The surveyor observed the following during the review: a bottle labeled Acetaminophen 500 mg, a bottle without a label with white pills with insignia number 10, a bottle labeled Senna 8.6 mg without a label for method of administration, Warfarin 5 mg one tab PO QD 2 tabs on the other day with a filled date of 10/1/22, and Furosemide 40 mg one tab twice a day with a filled date of 9/2/22. The surveyor interviewed the Patient, and the Patient stated: “I take the Acetaminophen 500 mg now, the white pill in the bottle is Potassium, I do not take the Colace any longer, I am taking Senna, and I take Warfarin 5mg, 2.5 mg”. The Patient did not clarify the amount of the Warfarin that is taken. The “Chart/Clinical Notes” document the skilled nursing visits were made on 11/29/22, 12/1/22, and 12/7/22. The “Charts/ Clinical Notes” document the Physical Therapist visits were made on 11/30/22, 12/6/22, and 12/8/22. There is no documented evidence of a prescription labeled for the Potassium, and no instructions for the time and dosage for administration of the medication. There is no documented evidence the Plan of was updated to include all medications. During the home visit, the surveyor observed the Physical Therapist assessing the patient’s lower extremities. The surveyor observed the patient’s thighs were severely swollen. The “Charts/ Clinical Note” dated 11/29/22 documents: “Skilled Nurse instructed Patient to keep a daily log of weight and to call MD if Patient has a weight of 2 or more pounds in one day or 5 pounds in 5 days”. The surveyor reviewed the patient weight log from 12/5/222 to 12/13/22. The weights are in pounds and are:12/5/22- 142.8, 12/6/22- 143.4, 12/7/22- 144.8, 12/8/22 -142, 12/9/22-142, 12/11/22 - 142.4, 12/12/22 - 143.8, and 12/13/22 - 144.4. The “Charts/ Clinical Notes” document the Skilled Nursing visits were made on 11/29/22, 12/1/22, and 12/7/22. There is no documented evidence of weight monitoring, and weight parameters for physician notification included in the Plan of Care. On 12/16/22, at 1:30PM, the Clinical Manager was interviewed, and did not provide an explanation for the above. 3. Patient #8 has a start of care date of 5/17/22 with diagnosis that include Diabetes Mellitus with Ulcer of Foot, Non-Pressure Chronic Ulcer of Right Heel, Decubitus Ulcer of Left Heel as documented on the “Home Health Certification and Plan of Care” for the Certification Period of 11/29/22 to 1/27/23. The “Home Health Certification and Plan of Care” for the Certification Period of 11/29/22 to 1/27/23 documents:” Orders for Discipline and Treatments: Skilled Nursing (SN) 1-3 x week x 9 weeks; Medications: Acetaminophen by mouth (PO) tablet (Tab) 325 mg 2 tabs every 6 hours as needed pain, Allopurinol PO 100 mg one tab PO daily, Cardizem CD Extended Release 24 hour 120 mg capsule PO daily, Clopidogrel Bisulfate 75 mg one tab PO daily, FeroSol 325 mg one tab PO daily, Lantus SoloStar Subcutaneous Pen Injector 100 unit/ml 10 units at bedtime, Metoprolol Succinate ER 24 hour 25 mg 50 mg daily, Novolog Flex Pen Subcutaneous Solution Pen Injector 100 unit/ml, check blood sugar (BS) before meals, coverage as follows: BS 150-199 =1 unit, BS 200-249 = 3units, BS 250-299 = 5units, BS 300- 350 = 7 units, BS 350 -400 = 8 unit, Protonix Delayed Release 40 mg PO daily, and Vit D ( Ergocalciferol) 1.25 mg (50,000UT) one tablet weekly every Sunday". On 12/14/22, at 11:30 AM, during an observational home visit, the surveyor reviewed the medications with the nurse present. The following bottles were found in the home among the patient’s medications: Valsarta 80/12.5 mg with a filled date of 12/6/22, Tricor (Finofibrate) 145mg PO at bedtime with a filled date of 11/22/22, and Humalog Kwik Pen 3 ml 100 units/ ml, 10 units 3 times a day. The Patient stated” I no longer take the Novolog”. The “Charts/Clinical Notes” document the following Skilled Nursing Visits: 11/23/22, 11/28/22, 11/30/22, 12/2/22, 12/5/22, 12/7/22, and 12/12/22. The record lacks documented evidence of medication reconciliation by the nurse. There is no documentation the medications were included in the Plan of Care. The “Physical Therapy OASIS” dated 12/1/22 documents: “Physical Therapy with Treatment Initial visit, reason for referral: Evaluate and treat” The “Physical Therapy notes document the following visit dates: 12/5/22, 12/7/22, and 12/12/22. There is no documented evidence of a physician order for Physical Therapy Evaluation and Treatment in the Plan of Care. There is no documented evidence the Plan of Care is complete. On 12/15/22 at 11:30 AM, the Administrator was interviewed and did not provide an explanation for the findings. 1. Patient #4 has a start of care date of 11/16/22 and a discharge date of 12/9/22 with diagnoses of Congestive Heart Failure, Diabetes Mellitus Type Two, and Chronic Kidney Disease as documented on the Home Health Certification and Plan of Care with a certification period of 11/16/22 through 1/14/23. The Home Health Certification and Plan of Care with a certification date of 11/16/22 through 1/14/23 documents: "Skilled Nursing visits 1 to 2 times a week for assessment". The initial nursing assessment dated 11/16/22 documents the "Patient is not testing the blood glucose because there are no lancets". The Skilled Nursing (SN) visits document the blood glucose readings are: 11/30/22 - "175", 12/6/22 - "105", and 12/9/22 - "105". The Plan of Care lacks documented evidence of a frequency for blood glucose monitoring and ranges for physician notification. During an interview with the Administrator on 12/14/22 at 12:30 PM, the Administrator did not provide an explanation..

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 observations, record reviews and interviews, the agency failed to ensure that services are provided in accordance with the Physicians orders. This was evident for three (3) of seventeen (17) clinical records reviewed. (Patients #2, #9, and #10) Failure to ensure that patient care is provided in accordance with the physician's orders has the potential for negative patient outcomes. The findings are: 5) Patient # 9 has a start of care date of 11/4/2022 with diagnoses of Cutaneous Abscess of Groin, Klebsiella Infection, Enterococcus Faecalis Infection and Acute Deep Vein Thrombosis as documented on the "Home Health Certification and Plan of Care" for certification period of 11/04/2022 to 01/02/2023. The "Home Health Certification and Plan of Care" for certification period of 11/04/2022 to 01/02/2023 documents orders for "SN (Skilled Nurse) 1-2 x week x 1 week, 1 -3 x week for 4 weeks (one to two visit a week for one week, one to three visits a week for four weeks). SN to “assess/instruct patient/caregiver on medication dosage, uses, actions, side effects, and response to medications. Medications include “Tumeric one tablet daily p.o (per oral) with breakfast, Bumetanide tablet 2 mg (milligram) one tablet daily p.o with breakfast, Cholesterol relief by mouth 2 capsules at bedtime p.o, and Vitamin D3tablet 50 mcg (microgram) one (1) tablet twice a day p.o”. SN to "assess/instruct patient/caregiver on medications dosages, use, actions, side effects and response". SN to “assess/instruct patient/caregiver on cardiovascular disease management/complications and appropriate intervention”. The “Routine Visit” reports dated 11/07/22, and 11/08/22, the SN documents the patient has “Lower Extremities edema”. The SN “Routine Visit” report dated 11/07/2022 and 11/08/2022 lack documented evidence that the SN performed measurement of the LE edema, to instruct on cardiovascular management and appropriate interventions to address the patient’s LE edema. The clinical record lacks documented evidence of SN visits conducted 1- 3 (one to three) visits a week. The SN visit dated 12/05/22, 12/08/22 and 12/09/22 documents: "medications reconcile without issue". There is no documented evidence that the SN assess/instruct the patient/caregiver on the discontinued medications Tumeric, Bumetanide, Cholesterol relief and Vitamin D3. A Home Visit (HV) was conducted on 12/13/2022 with the Agency’s SN. During the HV, the SN reviewed the patient’s medications with the Surveyor. Medication discrepancies were identified for Tumeric, Bumetanide, Cholesterol relief and Vitamin D3 were discontinued and not available in the home. The medication list in the home includes “Furosemide 20 mg one tablet daily p.o”. The Agency failed to ensure that the SN conform to the Physician’s order to assess /instruct patient/caregiver on medication regimen, cardiovascular complications and conform to the ordered visit frequency of SN 1- 3 (one to three) visits a week. Survey findings were reviewed with the Agency’s Director of Patient Services (DPS) and Performance Improvement Supervisor (PIS) on 12/14/2022 at 12:00 PM. The DPS and PIS were interviewed on 12/15/22 at 04:00 PM and acknowledged the findings. 6. Patient # 10 has a start of care date of 09/08/2022 with diagnoses of Decubitus Ulcer of Right Buttock Stage 2, Decubitus Ulcer of Sacral Region, Benign Essential Hypertension, and Adenocarcinoma of Prostate as documented on the “Home Health Certification and Plan of Care” for certification period 09/08/2022 to 11/06/2022. The “Home Health Certification and Plan of Care” for certification period 09/08/2022 to 11/06/2022 documents an order for “SN (Skilled Nurse) 1 - 2 x week for 3 weeks. SN to “assess wound location, size, stage, drainage, wound-bed, and peri-wound”. The “Start of Care assessment” dated 09/08/2022, the SN documents a wound to the Right Buttock: wound measurement is “2.5 cm X 2.0 X 0.2” centimeters. The SN visit reports dated 09/14/22, 09/20/22, and 09/22/22 lack documented evidence of wound measurements. The “SN Routine Visit” report dated 10/12/22 lacks documentation of wound care measurement for wounds #2 and #4. The “Routine Visit” reports dated 10/14/22, 10/17/22, 10/19/22, 10/20/22, 10/21/22, and 10/24/22 lack documentation of wound care measurements for wounds #1, #2 and #4. Survey findings were reviewed with the Agency’s Director of Patient Services (DPS) and Performance Improvement Supervisor (PIS) on 12/14/2022 at 12:10 PM. The PIS was interviewed on 12/16/22 at 12:00 PM and acknowledged the findings. 1. Patient #1 has a start of care date of 10/8/22 with diagnoses of Stage Three Pressure Ulcer to the Back, Cardiac Disease and Kidney Disease as documented on the Home Health Certification and Plan of Care with the certification period of 10/8/22 through 12/6/22 The Home Health Certification and Plan of Care with a certification date of 10/8/22 through 12/6/22 documents: "SN visits one times one week then 1 to 3 times a week for nine weeks for assessment and instruct in signs and symptoms of infection, assess cardiovascular disease and instruct in methods to decrease edema, perform wound care, and notify physician if blood pressure is out of parameters"; assess/instruct patient/caregiver on medication, dosages, use, actions, side effects, and response to medications; Bumetanide (Diuretic and antihypertensive) 1 mg two times a day". The SN note dated 11/2/22 documents the Patient has "edema to the lower extremities". The note lacks documented evidence of complete assessment of the edema to include whether the edema is pitting and measurements of the edema and whether the Patient is compliant with Bumetanide and its effectiveness. 2. Patient #2 has a start of care date of 9/4/22 and a discharge date of 10/5/22 with diagnoses of Ulcer to the Toe and Cardiac Disease as documented on the Home Health Certification and Plan of Care with the certification period of 9/4/22 through 11/2/22. The Home Health Certification and Plan of Care with a certification date of 9/4/22 through 11/2/22 documents: "SN visits 2 to 4 times a week for 6 weeks; SN is to perform assessment and instruction, assess/instruct patient/caregiver on medication, dosages, use, actions, side effects, and response to medications; assess and perform wound care; assess response to and effectiveness of medications; Physical Therapy visits 1 to 2 times a week for two weeks; Patient will verbalize two ways to alleviate pain such as position change and use of analgesics; Acetaminophen 500 mg every 8 hours as needed; Lasix 40 mg daily; Lasix 40 mg two times a day". The SN visit dated 9/6/22 documents: "Caregiver needs education regarding pain management". There is no documentation as to whether the caregiver received education regarding pain management and whether the Patient is using the Acetaminophen. The PT visit dated 9/8/22 documents the Patient has "pain to the lower extremities and pain of a 5 to the right shoulder". The Physical Therapy note lacks documentation as to whether the Patient is using the Acetaminophen, and if so, the amount, frequency, and effectiveness of the medication. The SN note dated 9/23/22 documents the Patient has edema to the lower extremities. The note lacks documented evidence of complete assessment of the edema to include whether the edema is pitting and measurements of the edema and if the Lasix is being taken as ordered and the effectiveness. The SN notes between 9/23/22 through 9/30/22 lack documented evidence the Patient's wound was assessed/measured. 3. Patient #3 has a start of care date of 7/25/22 and a discharge date of 8/19/22 with diagnoses of Congestive Heart Failure and Cardiac Disease as documented on the Home Health Certification and Plan of Care with the certification period of 7/25/22 through 9/22/22. The Home Health Certification and Plan of Care with a certification date of 7/25/22 through 9/22/22 documents: "SN visits one to three times per week for one week then one to two times a week for three weeks for assessment and instruction; assess/instruct patient/caregiver on medication, dosages, use, actions, side effects, and response to medications; Lasix 40 mg two times a day". The SN notes dated 7/27/22, 8/8/22, and 8/12/22 lack documented evidence of complete assessment to include measurements of the edema, whether it is pitting, and is the Patient is compliant with the Lasix and effectiveness of the Lasix. 4. Patient #4 has a start of care date of 11/16/22 and a discharge date of 12/9/22 with diagnoses of Congestive Heart Failure, Diabetes Mellitus Type Two, and Chronic Kidney Disease as documented on the Home Health Certification and Plan of Care with a certification period of 11/16/22 through 1/14/23. The Home Health Certification and Plan of Care with a certification date of 11/16/22 through 1/14/23 documents "SN visits one to two times a week for four weeks for assessment and instruct; assess/instruct patient/caregiver on medication, dosages, use, actions, side effects, and response to medications; Furosemide (Lasix) 40 mg daily". The initial nursing assessment dated 11/16/22 documents the Patient has "edema to the lower extremities". The note lacks documented evidence of complete assessment to include measurements of the edema, whether it is pitting, and is the Patient is compliant with the Lasix and effectiveness of the Lasix. During an interview with the Administrator on 12/14/22 at 12:30 PM, the Administrator did not provide an explanation for the above.

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 clinical record review and staff interview, the agency failed to ensure the review and revision of Plan of Care. This was evident in one (1) of seventeen (17) clinical records reviewed. (Patient #16). Failure to ensure the review and revision of the Plan of Care places patients at risk for negative outcomes. The findings are: Patient #16 had a start of care date of 12/1/22 with diagnoses of Other Sequelae of Cerebral Infarction, Unsteady Gait, Abnormal Coordination, Hypertension, Diabetes, and Hyperlipidemia documented on the Home Health Certification and Plan of Care for Certification Period from 12/1/22 to 1/29/23. The Home Health Certification and Plan of Care for Certification Period from 12/1/22 to 1/29/23 documents, “Skilled Nursing 1 time per week times 1 week; 1 to 2 times per week x 3 weeks; 2 PRN (As Needed visits) Telehealth Management; Medications: Aspirin delayed release 81 mg daily, Clopidogrel 75 mg daily, Metformin1000 mg twice daily, Losartan100 mg daily, Metoprolol100 mg daily, and Toujeo Solostar subcutaneous (Insulin) 300 Unit/ml 20 units daily” During a home visit on 12/14/22 at 11:36 AM the surveyor observed Atorvastatin 40 mg with a filled date of 11/26/22 and Metoprolol take one half tablet filled 12/1/22 in the home. The clinical record documents the following visit dates: “Skilled Nursing 12/1/22, 12/6/22, and 12/13/22; Physical Therapy- 12/2/22, 12/7/22, and 12/12/22”. The Plan of Care lacks documented evidence of Atorvastatin 40 mg and Metoprolol 50mg. There is no documented the Plan of Care was reviewed/revised and/or updated to reflect the patient’s current medication regimen. On 12/15/22, at 11:30 AM, the Administrator/ Director of Patient Services was interviewed and did not provide an explanation for the findings.

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 observation, clinical record reviews and interview, the agency failed to promptly notify the physician of changes in patients' status which may require alteration in Plans of Care. This was evident for seven (7) of seventeen (17) clinical records reviewed. (Patients #1, #2, #3, #4, #5, #8, and #9) Failure to notify the physician of the patient's status which may require an alteration in the plan of treatment has the potential for negative patient outcomes. The findings are: 7. Patient # 9 has a start of care date of 11/-4/2022 with diagnoses of Cutaneous Abscess of Groin, Klebsiella Infection, Enterococcus Faecalis Infection and Acute Deep Vein Thrombosis as documented on the "Home Health Certification and Plan of Care" for certification period of 11/04/2022 to 01/02/2023. The "Home Health Certification and Plan of Care" for certification period of 11/04/2022 to 01/02/2023 documents orders for "SN (Skilled Nurse) 1-2 x week x 1 week, 1 -3 x week for 4 weeks (one to two visit a week for one week, one to three visits a week for four weeks). SN to “assess/instruct patient/caregiver on medication dosage, uses, actions, side effects, and response to medications. Medications include “Tumeric one tablet daily p.o (per oral) with breakfast, Bumetanide tablet 2 mg (milligram) one tablet daily p.o with breakfast, Cholesterol relief by mouth 2 capsules at bedtime p.o, and Vitamin D3tablet 50 mcg (microgram) one (1) tablet twice a day p.o”. SN to “assess/instruct patient/caregiver on cardiovascular disease management/complications and appropriate intervention”. The “Routine Visit” reports dated 11/07/22, and 11/08/22, the SN documents the patient has “Lower Extremities edema”. The SN “Routine Visit” reports dated 11/07/2022 and 11/08/2022 lack documented evidence that the Physician was notified of the patients’ Lower Extremity (LE) edema. The survey findings were reviewed with the Agency’s Director of Patient Services (DPS) and Performance Improvement Supervisor (PIS) on 12/14/2022 at 12:00 PM. The DPS and PIS were interviewed on 12/15/22 at 04:00 PM and acknowledged the findings. 5. Patient #5 has a start of care date of 11/29/22 with diagnosis that include Diabetes Mellitus with Peripheral Vascular Disease, Pulmonary Hypertension, History of Deep Vein Thrombosis, Chronic Venous Stasis as documented on the “Home Health Certification and Plan of Care” for the Certification Period of 11/29/22 to 1/27/23. The “Home Health Certification and Plan of Care” for the Certification Period of 11/29/22 to 1/27/23 documents:” Orders for Discipline and Treatments: Skilled Nursing (SN) 1-3 x week x 3 weeks. Physical Therapy 1-2 weeks x 4 weeks". The "Chart/Clinical Note" dated 12/6/22 documents: "Patient reports she does not monitor Blood Sugar (BS) daily; Patient encouraged constant monitoring; Patient with swelling of both lower extremities and instructed on both lower extremity's elevation. The Patient reported Dr. evaluated Patient and the edema and encouraged Patient to allow a second doctor to evaluate. The Patient has appointment on 12/19/22". The " Chart/Clinical Note" dated 12/8/22 documents: "Patient did not monitor BS today; Patient stated she just ate and was told she should wait to check BS by Physician; Patient stated she would monitor it later; Patient encouraged to be constant with BS and foot checks; Patient verbalized understanding". There is no documented evidence the Physician was notified about the Patient's noncompliance with blood sugar checking. On 12/16/22 at 1:45 PM, the Administrator was interviewed and did not provide an explanation for the findings. 6. Patient #8 has a start of care date of 5/17/22 with diagnosis that include Diabetes Mellitus with Ulcer of Foot, Non-Pressure Chronic Ulcer of Right Heel, Decubitus Ulcer of Left Heel as documented on the “Home Health Certification and Plan of Care” for the Certification Period of 11/29/22 to1/27/23. The “Home Health Certification and Plan of Care” for the Certification Period of 11/29/22 to 1/27/23 documents:” Orders for Discipline and Treatments: Skilled Nursing (SN) 1-3 x week x 9 weeks”. The “Physical Therapy OASIS” dated 12/1/22 document: “Physical with Treatment Initial visit, reason for referral: Evaluate and treat” The “Physical Therapy OASIS with Treatment document the following visit dates: 12/5/22, 12/7/22, and 12/12/22. There is no documented evidence the Physician was notified about the Physical Therapist evaluation and treatment. On 12/16/22, at 11:30 AM, the Administrator was interviewed and did not provide an explanation for the findings. 1. Patient #1 has a start of care date of 10/8/22 with diagnoses of Stage Three Pressure Ulcer to the Back and Cardiac Disease as documented on the Home Health Certification and Plan of Care with the certification period of 10/8/22 through 12/6/22. The Home Health Certification and Plan of Care with a certification date of 10/8/22 through 12/6/22 documents: "Skilled Nurse (SN) visits one time a week for one week than one to three times a week for nine weeks for assessment and wound care; Physical Therapy (PT) one to two times a week for three weeks". The PT notes document: 11/11/22- "pain to the joints, left knee pain is rated an 8" on a scale of 0 to 10; 11/18/22 - "pain to the knees, left thigh and right hip is rated 6 to 7"; 11/22/22 - "right hip pain is rated 4 to 9"; 12/2/22 - "hips and knees pain is rated 4 to 8"; 12/8/22 - "hips pain is a 6". The record lacks documented evidence of communication between the PT, SN, and the physician regarding the Patient's pain. 2. Patient #2 has a start of care date of 9/4/22 with a discharge date of 10/5/22 with diagnoses of Osteomyelitis of the Ankle and Cardiac Disease as documented on the Home Health Certification and Plan of Care with the certification period of 10/5/22 through 12/2/22. The Home Health Certification and Plan of Care with a certification date of 10/5/22 through 12/2/22 documents: "SN visits two to four times a week for six weeks for assessment and wound care; PT one to two times a week for two weeks; Acetaminophen 500 mg every 8 hours as needed for pain for pain". The PT notes document: 9/8/22 - pain to the lower extremities and right shoulder and is rated a 5; 9/13/22- pain to shoulders and is rated a 7. The PT note does not document whether the Patient is using the Acetaminophen, and if so, the amount and frequency of use. There is no documented evidence of communication between the PT, SN and physician regarding the Patient's pain. 3. Patient #3 has a start of care date of 7/25/22 and a discharge date of 8/19/22 with diagnoses of Congestive Heart Failure as documented on the Home Health Certification and Plan of Care with the certification period of 7/25/22 through 9/22/22. The Home Health Certification and Plan of Care with a certification date of 7/25/22 through 9/22/22 documents: "SN visits one to three times a week for one week than one to two times a week for three weeks for assessment and instruction; assess/instruct patient/caregiver on medications, dosages, use, actions, side effects, and response to medications/side effects to report; assess location, intensity, duration, precipitating factors, and character of pain; assess effectiveness of interventions to mitigate pain; Oxygen 2 liters continuous via nasal cannula; notify physician of blood pressure less than 90/50 or greater than 160/100" Lasix 40 mg daily. The SN note dated 7/25/22 documents the Patient has "plus three edema to the lower extremities, pain to the legs (not rated), and Patient cannot elevate legs due to back pain". The back pain is not assessed or rated. The SN note dated 7/27/22 documents the Patient's blood pressure is "86/50 times two than 90/50". The SN notes dated between 7/25/22 through 8/12/22 document the Patient is not using Oxygen continuously and only uses it at night. The record lacks documented evidence of communication between the SN and physician regarding the Patient's edema, low blood pressure readings, back pain and is not using the Oxygen continuously. 4. Patient #4 has a start of care date of 11/16/22 and a discharge date of 12/9/22 with diagnoses of Congestive Heart Failure, Diabetes Meletus Type Two and Chronic Kidney Disease as documented on the Home Health Certification and Plan of Care with the certification period of 11/16/22 through of 1/14/23. The Home Health Certification and Plan of Care with a certification date of 11/16/22 through 1/14/23 documents: "SN visits one to two times a week for four weeks for assessment and instruction". The initial nursing visit dated 11/16/22 documents the Patient is a Diabetic but blood sugars are not being monitored and the Patient's caregiver stated, "there are no lancets in the home and she has been too busy to reorder them"; four medications were found in the home and are expired. A call was placed to the physician and a message was left with the secretary". The record lacks documented evidence of nurse communicated with the physician regarding the above. During an interview with the Administrator on 12/14/22 at 12:30 PM, the Administrator did not provide an explanation for the above.