Every finding on record at Overlook Visiting Nurse Association Inc

A Recertification survey was conducted at Overlook Visiting Nurse Association, Inc. on 4/19/23 through 4/21/23, and 4/25/23, for compliance with 42 CFR Part 484.102 Emergency Preparedness for Home Health Agencies and the Covid 19 Health Care Staff Vaccination requirements. As a result of this survey, it was determined the Agency was in compliance with these requirements. No deficiencies were cited.

A Recertification survey was conducted at Overlook Visiting Nurse Association, Inc. on 4/19/23 through 4/21/23, and 4/25/23, to determine compliance with the 42 CFR Part 488 requirements for Home Health Agencies and the Covid 19 Health Care Staff Vaccination requirements. As a result of this survey, it was determined the Agency was not in compliance with these requirements. Deficiencies were cited.

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 review and interview, the Agency failed to ensure its staff completed the initial admission assessment within 48 hours of the Physician's order for the start of care, for one Patient (#10), out of a total sample of 17 Patients. Findings include: Review of the Agency's policy, Client Admission Process, dated 10/1/11, indicated, but not limited to, the following: -Each client referral to home care shall be evaluated to determine the immediate care and support needs of the client; and for Medicare clients, by a Nurse or Therapist, to determine eligibility for the Medicare home benefits. The initial assessment will be completed within 48 hours of the referral, or within 48 hours of the client's return home, or on the Physician ordered start of care. Patient #10 was admitted to the Agency in November 2022 with diagnoses including Chronic Kidney Disease (CKD, a condition in which the kidneys are damaged and cannot filter waste and extra water properly) and Heart Failure. Review of a Physician's order, dated 10/26/23, indicated: Initial home care order-Skilled Nursing to evaluate. Review of the clinical record indicated the initial admission assessment was completed on 11/3/22 by a Skilled Nurse (SN). During an interview on 4/21/23 at 1:10 P.M., after reviewing the clinical record, the Agency Director said the initial admission assessment completed by the SN was not done within 48 hours of the Physician's order, as required.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record review and interview, the Agency failed to ensure its staff followed the Physician's orders for six Patients (#6, #9, #10, #11, #12, and #14), out of a total sample of 17 Patients. Specifically, -The Agency staff failed to ensure Skilled Nurse Visits (SNVs) were provided, as ordered for Patient's (#6, #11, #12 and #14). -The Agency staff failed to ensure a PTV was provided, as ordered for Patient's (#9 and #10). -The Agency staff failed to ensure OTVs were provided, as ordered for Patient (#12). Findings include: 1. Patient #6 was admitted to the Agency in April 2023 with a diagnosis of Cellulitis (a bacterial infection involving the inner layers of the skin) of the Abdominal Wall. Review of the Physician orders for certfication period 4/1/23 through 5/30/23 indicated the following: -SNV once a week for one week. -SNV three times a week for four weeks. -SNV twice a week for one week. -SNV once a week for two weeks. Review of the clinical record indicated for the week of 4/9/23 through4/1 5/23, a SNV was provided on 4/12/23 and 4/14/23 and not three, as ordered. Further review of the clinical indicated for the week of 4/16/23 through 4/22/23, a SNV was provided on 4/17/23 and 4/21/23 and not three, as ordered. During an interview on 4/25/23 at 2:42 P.M., after reviewing the clinical record, the Agency Director said that for the weeks of 4/9/23 through 4/15/23 and 4/16/23 through 4/22/23, only two of the three ordered SNVs were provided each week. 2. Patient #9 was admitted to the Agency in March 2023 with a diagnosis of Thrombophilia (an abnormality of blood clotting that increases the risk of blood clots in the blood vessels). Review of the Physician orders for the certification period 3/28/23 through 5/26/23 indicated the following: -PTV once a week for one week. -PTV twice a week for two weeks. -PTV once a week for two weeks. Review of the clinical record indicated for the week of 4/9/23 through 4/15/23, none of the ordered two PTVs were provided. During an interview on 4/25/23 at 2:57 P.M. after reviewing the clinical record, the Agency Director said for the week of 4/9/23 through 4/15/23, no PTVs were provided, as ordered. 3. Patient #10 was admitted to the Agency in November 2022 with diagnoses including Chronic Kidney Disease (CKD, a condition in which the kidneys are damaged and cannot filter waste and extra water properly) and Heart Disease. Review of the Physician order for certification period 1/2/23 through 3/2/23, indicated the following: -Effective 2/12/23, Physical Therapy visit (PTV) once a week for one week. -PTV twice a week for two weeks. -Effective 2/26/23, PTV twice a week for one week. Review of the clinical record indicated a PTV was not provided on 2/22/23, and a second PTV was not provided during the week of 2/19/23 through 2/25/23, as ordered. Review of the clinical record indicated there were no PTVs provided during the week 2/26/23 through 3/2/23. 4. Patient #11 was admitted to the Agency in November 2022 with a diagnosis of Chronic Venous Insufficiency (improper functioning of the vein valves in the leg, causing swelling and skin changes). (a.) Review of the Physician orders for certification period 11/2/22 through 12/31/22, indicated the following: -Effective 12/4/22, SNV twice a week for one week. -SNV three times a week for one week. -SNV twice a week for one week. Review of the clinical record indicated two SNVs were provided, not three as ordered, during the week of 12/18/22 through 12/25/22. Review of the clinical record indicated three SNVs were provided, not two as ordered, during the week of 12/25/22 through 12/31/22. (b.) Review of the Physician orders for certification period 1/1/23 through 3/1/23, indicated the following: -Skilled Nursing (SN) to change the dressing to the right great toe on Monday, Wednesday, and Friday. -Effective 1/8/23, SNV twice a week for two weeks. -Effective 1/15/23, SNV twice a week for six weeks. -Effective 2/26/23, SNV once a week for one week. Review of the clinical record indicated SN provided the dressing change twice a week, not three times a week as ordered, for all the weeks of the certification period. (c.) Review of the Physician orders for certification period 3/2/23 through 4/20/23, indicated the following: -SN to change the dressing to the right great toe three times a week. -SNV once a week for one week -SNV twice a week for one week -SNV three times a week for one week. -SNV twice a week for six weeks. -Effective 4/16/23, SNV three times a week for one week. -SNV twice a week for one week. Review of the clinical record indicated the only weeks that Patient #11 received three SNVs with dressing changes, were the weeks of 3/12/23 through 3/18/23 and 4/17/23 through 4/22/23. 5. Patient #12 was admitted to the Agency in January 2023 with a diagnosis of Hemiplegia (paralysis of one side of the body) following a Cerebral Infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). Review of the Physician orders for certification period 1/7/23 through 3/7/23, indicated the following: -SNV once a week for one week. -SNV twice a week for two weeks. -SNV once a week for two weeks. -SNV once every two weeks for four weeks. -SNV once a week for one week. -Effective 3/5/23, SNV once a week for one week. -OTV twice a week for four weeks. -OTV once a week for three weeks. Review of the clinical record indicated an OTV was not provided, as ordered, during the week of 1/15/23 through 1/21/23. Further review, indicated that a second OTV was not provided, as ordered, during the weeks of 2/5/23 through 2/11/23, and 2/12/23 through 2/18/23. Review of the clinical record indicated a SNV was not provided, as ordered, during the week of 2/26/23 through 3/4/23. 6. Resident # 14 was admitted to the Agency in September 2022 with a diagnosis of Bilateral Osteoarthritis (degenerative joint disease) of the Knees. Review of the Physician orders for certification period 9/2/22 through 10/31/22, indicated the following: -SNV once a week for two weeks. -SNV twice a week for one week. -SNV once a week for two weeks. -Effective 9/25/22, SNV once a week for five weeks. Review of the clinical record indicated a SNV was not provided for the week of 10/2/22 through 10/8/22. During an interview on 4/21/23 at 1:15 P.M., after reviewing the clinical records for Patients #10, and #14, the Agency Director said: -For Patient #10, the PTVs were not provided, as ordered, during the last two weeks of the certification period (2/19/23 through 3/2/23). He also said that a second OTV was not provided, as ordered during the week of 2/26/23 through 3/2/23. He said staff did not document why the visits were not provided. -For Patient #14, a SNV was not provided, as ordered during the week of 10/2//22 thrrough 10/8/22, and there was no documentation why it was not provided. During an interview on 4/25/23 at 3:15 P.M., after reviewing the clinical records for Patients #11, and #13, the Agency Director said: -For Patient #11, (a) a SNV was missed for the week of 12/18/22 through 12/24/22, and an extra SNV was provided the week of 12/25/22 through 12/31/22. He said the Physician orders were not followed, as ordered, for SNVs. (b) He also said the Agency staff were not providing dressing changes three times a week ,as ordered. He said staff should have updated the wound dressing orders for certification periods 1/1/23 through 3/1/23, and 3/2/23 through 4/30/23 to reflect what the Agency was providing. -For Patient #12, the OTVs were not provided, as ordered, during the weeks of 1/15/23 though 1/21/23, 2/5/23 though 2/11/23 and 2/12/23 through 2/18/23. He also said a SNV should have been provided during the week of 2/26/23 through 3/4/23, and the plan of care was not followed.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure its staff completed clinical notes within 24 hours after home visits for eight Patients (#2, #4, #10, #11, #12, #8, #9 and #15), out of a total sample of 17 Patients. Findings include: Review of the Agency's policy, Clinical Documentation, dated October 2011, included, but not limited to, the following: -Documentation of services ordered on the plan of care will be completed the day service is rendered and incorporated into the clinical record. 1. Patient #2 was admitted to the Agency in February 2023 with a diagnosis of Pain Due to An Internal Orthopedic Device. Review of the Physician orders for certification period 4/11/23 through 6/9/23, indicated the following: -Physical Therapy (PT) twice a week for four weeks. Review of a Late Visit Documentation PT note, dated 4/9/23, indicated a visit was provided on 4/7/23. 2. Patient #4 was admitted to the Agency in February 2023 with a diagnosis of Fitting and Adjustment of a Urinary Device. (a.) Review of the Physician orders for certification period 2/7/23 through 4/7/23, indicated the following: -SNV twice a week for two weeks. -SNV once a week for three weeks. -SNV once every four weeks for four weeks. Review of a Late Visit Documentation note, dated 2/16/23, indicated a SNV was provided on 2/13/23. (b.) Review of the Physician orders for certification period 4/8/23 through 6/6/23, indicated the following: -Effective 4/9/23, SNV once a week for two weeks. -SNV once every two weeks for four weeks. -SNV twice every two weeks for two weeks. Review of a Late Visit Documentation note, dated 4/16/23, indicated a SNV was provided on 4/14/23. Review of a Late Visit Documentation note, dated 4/19/23, indicated a SNV was provide on 4/17/23. 3. Patient #10 was admitted to the Agency in November 2022 with diagnoses including Chronic Kidney Disease (CKD, damaged kidneys can no longer properly filter excess water and waste from the blood) and Heart Failure. (a.) Review of the Physician orders for certification period 11/3/22 through 1/1/23, indicated the following: -SNV once a week for one week. -SNV twice a week for two weeks. -SNV once every other week for two weeks. -Effective 12/18/22, SNV three times a week for one week. -Effective 12/25/22, SNV twice a week for one week. Review of the following Late Visit Documentation notes indicated: -11/5/22, a SNV was provided on 11/3/22. -11/15/22, a SNV was provided on 11/10/22. -11/18/22, a SNV was provided on 11/15/22. -11/22/22, a SNV was provided on 11/18/22. -12/10/22, a SNV was provided on 12/5/22. -12/18/22, a SNV was provided on 12/15/22. -12/22/22, a SNV was provided on 12/19/22. -12/26/22, a SNV was provided on 12/23/22. -12/31/22, a SNV was provided on 12/28/22. (b.) Review of the Physician orders for certification period 1/2/23 through 3/2/23, indicated the following: -Effective 2/12/23, SNV twice a week for two weeks. -SNV once a week for one week. Review of the following Late Visit Documentation notes: -2/19/23, a SNV was provided on 2/17/23. -2/28/23, a SNV was provided on 2/23/23. 4. Patient #11 was admitted to the Agency in November 2022 with a diagnosis of Chronic Venous Insufficiency (improper functioning of the vein valves in the leg, causing swelling and skin changes). (a.) Review of the Physician orders for certification period 11/2/22 through 12/31/22, indicated the following: -SNV twice a week for one week. -SNV three times a week for one week. -SNV twice a week for one week. -SNV three times a week for one week -SNV twice a week for one week. Effective 12/4/22, SNV twice a week for two weeks. -SNV three times a week for one week. -SNV twice a week for one week. Review of a Late Visit Documentation note, dated 12/5/22, indicated a SNV was provided on 12/3/23. (b.) Review of the Physician orders for certification period 1/1/23 through 3/1/23, indicated the following: -Effective 1/8/23, SNV twice a week for two weeks. -Effective 1/15/23, SNV twice a week for six weeks. -SNV once a week for one week. Review of the following Late Visit Documentation notes indicated: -1/15/23, a SNV was provided on 1/13/23 -2/19/23, a SNV was provided on 2/17/23. -2/26/23, a SNV was provided on 2/24/23. (c.) Review of the Physician orders for certification period 3/2/23 through 4/30/23, indicated the following: -SNV once a week for one week. -SNV twice a week for one week. -SNV three times a week for one week. -SNV twice a week for six weeks. Review of the following Late Visit Documentation notes indicated: -3/27/23, a SNV was provided on 3/24/23. -4/12/23, a SNV was provided on 4/7/23. 5. Resident # 12 was admitted to the Agency in January 2023 with a diagnosis of Hemiplegia (paralysis of one side of the body) following a Cerebral Infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). (a.) Review of the Physician orders for certification period 1/7/23 through 3/7/23, indicated the following: -SNV once a week for one week. -SNV twice a week for two weeks. -SNV once a week for two weeks. -SNV once every two weeks for four weeks. -SNV once a week for one week. -Effective 3/5/23, SNV once a week for one week. -Effective 1/8/23, OTV once a week for two weeks. -OTV twice a week for four weeks. -OTV once a week for three weeks. -Effective 1/15/23, Speech Therapy visit (STV) twice a week for two weeks. -STV twice a week for three weeks. -STV once a week for two weeks. -Effective 2/26/23, STV once a week for two weeks. Review of the following Late Visit Document notes and Missed Visit notes indicated: -1/15/23, an OTV was provided on 1/13/23. -1/30/23, an OTV was missed on 1/27/23. -2/10/23, an OTV was missed on 2/2/23. -2/11/23, a STV was provided on 2/0/23. -2/18/23, a SNV was provided on 2/15/23. -2/20//23, a STV was provided on 2/16/23. -2/20/23, a STV was missed a visit on 2/18/23. -2/27/23, a STV was provided on 2/25/23. (b.) Review of the Physician orders for certification period 3/8/23 through 5/6/23, indicated: -Effective 3/12/23, STV once a week for 8 weeks. Review of Late Visit Documentation notes and a Missed Visit note indicated: -3/20/23, a STV was provided 3/18/23. -3/28/23, a STV was provided 3/24/23. -4/24/23, a STV was missed on 4/19/23. During an interview on 4/21/23 at 1:15 P.M., and again on 4/25/23 at 3:30 P.M., the Agency Director said the staff are required to document and upload their notes to a Patient's electronic medical record with 24 hours if the note is not documented during a visit. After reviewing the clinical records of Patients #2, #4, #10, #11, and #12, that the documented notes were late, and not done within the 24 hours of the visits, as required. 6.Patient #8 was admitted to the Agency in December 2022 with a diagnosis of Unspecified Perichondritis (an infection of the skin and tissue surrounding the cartilage of the outer ear) of the Left External Ear. a. Review of the Physician orders for certification period 12/11/22 through 2/8/23 indicated the following: -SNV four times a week for one week. -SNV once a week for three weeks. -SNV once every two weeks four times. -SNV once a week for one week Review of a Late Visit Documentation note, dated 12/19/22, indicated a visit was provided on 12/16/22. b. Review of the Physician orders for the certificion period 2/9/23 through 4/9/23 indicated the following: -SNV once a week for three weeks. -SNV once every two weeks for twice. -SNV once a week for two weeks. Review of a Late Visit Documentation note, dated 2/27/23, indicated a visit was provided on 2/22/23. 7. Patient #9 was admitted to the Agency in March 2023 with a diagnosis of Thrombophilia (an abnormality of blood clotting that increases the risk of blood clots in the blood vessels). Review of the Physician orders for certification period 3/28/23 through 5/26/23 indicated the following: -SNV twice a week for two weeks. -SNV once a week for two weeks. Review of a Late Visit Docuentation note, dated 4/10/23, indicated a visit was provided on 4/7/23. 8. Patient #15 was admitted to the Agency in November 2022 with a diagnosis of Subarachnoid Hemorrhage (bleeding in the space between the brain and the tissue covering the brain). Review of the Physican orders for certification period 11/25/22 through 1/23/23 indicated the following: -PTV once a week for one week. -PTV two visits every two weeks times two. -PTV twice a week for one week. -PTV once a week for four weeks. Review of a Late Visit Docuentation note, dated 12/5/22, indicated a visit was provided on 12/2/22. Review of a Late Visit Docuentation note, dated 12/12/22, indicated a visit was provided on 12/6/22. Review of a Late Visit Docuentation note, dated 12/24/22, indicated a visit was provided on 12/21/22. During an interview on 4/25/23 at 3:00 P.M., after reviewing the clinical records, the Agency Director said the following: -For Patient #8, the SNV clinical notes completed on12/16/22, 12/20/22 and 2/22/23 were late. -For Patient #9, the SNV clinical note on 4/7/23 was completed late. -For Patient #15, the PTV clinical notes on 12/2/22, 12/6/22 and 12/21/22 were completed late.

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 record review and interview, the Agency failed to ensure its staff communicated with the Physician when there was a change in the plan of care for 11 Patients (#2, #10, #11, #12, #13, #14, #6, #9, #15, #16 and #17). Specifically, The Physician was not notified when Skilled Nursing Visits (SNVs) were not provided, as ordered for Patient's #2, #12, #11, #14 and #6 The Physician was not notified when Physical Therapy Visits (PTVs) were not provided, as ordered for Patient's #10, #9, #15 The Physician was not notified when Occupational Therapy Visits (OTVs) were not provided, as ordered for Patient's #12, #13 and #16 The Physician was not notified when wound dressing changes were not provided, as ordered for Patient #11, The Physician was not notified when the following Patients were discharged from SN (Skilled Nursing) services: Patient's #2 and #12 The Physician was not notified when the following Patients were discharged from OT (Occupational Therapy) services: Patient's #2, #10, #12 The Physician was not notified when the following Patients were discharged from PT (Physical Therapy) services: Patient's #13, #15 The Physician was not notified when Patient #17 was transferred to the hospital and discharged from the Agency. Findings include: 1.Patient #2 was admitted to the agency in February 2023 with a diagnosis of Pain Due to An Internal Orthopedic Prosthetic Device. Review of the Physician orders for certification period 2/10/23 through 4/9/23, indicated the following: -Effective 3/12/23, Skilled Nursing visit (SNV) once a week for three weeks. -Effective 3/26/23, Occupational Therapy visit (OTV) once a week for two weeks. Review of an OTV note, dated 4/4/23, indicated Patient #2 was being discharged from Occupational Therapy (OT) services. The note, nor the clinical record, indicated any documented evidence that the Physician was notified of the discharge from OT services. Review of the clinical record indicated a SNV was provided during the week of 4/2/23 through 4/6/23 and not the week of 3/26/23 through 4/1/23, as Patient #4 refused the SNV that week. Review of a SNV note, dated 4/6/23, indicated Patient #2 was being discharged from Skilled Nursing (SN) services. The note, nor the clinical record, indicated any documented evidence that the Physician was notified of the discharge from SN services. 2. Patient #10 was admitted to the Agency in November 2022 with diagnoses including Chronic Kidney Disease (CKD, a condition in which kidney are damaged and cannot filter excess waste and water properly). (a.) Review of the Physician orders for certification period 1/2/23 through 3/2/23, indicated the following: -Effective 2/12/23, Physical Therapy visit (PTV) once a week for one week. -PTV twice a week for two weeks. -Effective 2/26/23, PTV twice a week for one week. Review of the clinical record indicated only one PTV was provided for the weeks of 2/19/23 through 2/25/23, and 2/26/23 through 3/2/23. Further review of the clinical record indicated no evidence that the Physician was notified that the Physical Therapy had not provided services, as ordered. (b.) Review of the Physician orders for certification period 3/3/23 through 5/1/23, indicated the following: -Effective 3/5/23, OTV once a week for four weeks. Review of an OTV note, 3/27/23, indicated Patient #10 was being discharged from Occupational Therapy (OT) services that day. The note, nor the clinical record, indicated any evidence that the Physician had been notified of the discharge from OT services. 3. Patient #11 was admitted to the Agency in November 2022 with a diagnosis of Chronic Venous Insufficiency (improper functioning of the vein valves in the leg, causing swelling and skin changes). (a.) Review of the Physician orders for certification period 11/2/22 through 12/31/22, indicated the following: -Effective 12/4/22, SNV twice a week for one week. -SNV three times a week for one week. -SNV twice a week for one week. Review of the clinical record indicated two SNVs were provided, not three as ordered, during the week of 12/18/22 through 12/25/2, and three SNVs were provided, not two as ordered, during the week of 12/25/22 through 12/31/22. Further review of the record indicated no documentation that the Physician was notified that the plan of care was not followed for those two weeks, as ordered. (b.) Review of the Physician orders for certification period 1/1/23 through 3/1/23, indicated the following: -Skilled Nursing (SN) to change the dressing to the right great toe on Monday, Wednesday, and Friday. -Effective 1/8/23, SNV twice a week for two weeks. -Effective 1/15/23, SNV twice a week for six weeks. -Effective 2/26/23, SNV once a week for one week. Review of the clinical record indicated SN provided the dressing change twice a week, not three times a week as ordered, for all weeks of the certification period. Further review of the record indicated no documentation that the Physician was notified that the plan of care relative to wound dressing changes was not being followed, as ordered. (c.) Review of the Physician orders for certification period 3/2/23 through 4/20/23, indicated the following: -SN to change the dressing to the right great toe three times a week. -SNV once a week for one week. -SNV twice a week for one week. -SNV three times a week for one week. -SNV twice a week for six weeks. -Effective 4/16/23, SNV three times a week for one week. -SNV twice a week for one week. Review of the clinical record indicated the only weeks that Patient #11 received three SNV with dressing changes, were the weeks of 3/12/23 through 3/18/23 and 4/17/23 through 4/22/23. Further review of the clinical record indicated there was no documentation that the Physician was notified that the plan of care relative to wound dressing changes was not followed for six of the eight during the certification period, as ordered. 4. Patient #12 was admitted to the Agency in January 2023 with a diagnosis of Hemiplegia (paralysis of one side of the body) following a Cerebral Infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). Review of the Physician orders for certification period 1/7/23 through 3/7/23, indicated the following: -SNV once a week for one week. -SNV twice a week for two weeks. -SNV once a week for two weeks. -SNV once every two weeks for four weeks. -SNV once a week for one week. -Effective 3/5/23, SNV once a week for one week. -Effective 1/8/23, OTV once a week for two weeks. -OTV twice a week for four weeks. -OTV once a week for three weeks. Review of the clinical record indicated an OTV was not provided, as ordered, during the week of 1/15/23 through 1/21/23. Further review, indicated that a second OTV was not provided, as ordered, during the weeks of 2/5/23 through 2/11/23, and 2/12/23 through 2/18/23. The record did not indicate any documentation that the Physician had been notified of that the plan of care was not followed those weeks, as ordered. Review of the clinical record indicated a SNV was not provided, as ordered, during the week of 2/26/23 through 3/4/23, and there was no documentation that the Physician had been notified of the SNV not being provided, as ordered. Additionally, the record indicated the Patient was discharged from Occupational Therapy (OT) services on 3/2/23 and discharged from SN services on 3/7/23. Neither Discharge Summary indicated the Physician had been notified of the discharged from services. 5. Patient #13 was admitted to the Agency in December 2022 with a diagnosis of Gastrointestinal Hemorrhage (bleeding within the gastrointestinal tract). Review the Physician orders for certfication period 12/31/22 through 2/28/23, indicated the following: -Effective 1/15/23, OTV twice a week for four weeks. -Effective 1/29/23, PTV once a week for two weeks. Review of the clinical record indicated a Missed Visit Notification, dated 2/6/23, that indicated an OTV was not provided. The note did not indicate that the Physician was notified that the OTV was not provided that day. Review of the clinical record indicated the Patient was discharged from Physical Therapy (PT) services on 2/7/23. The Discharge Summary did not indicate the Physician was notified that the Patient was discharged from PT services before the end of the certification period. 6. Resident # 14 was admitted to the Agency in September 2022 with a diagnosis of Bilateral Osteoarthritis (degenerative joint disease) of the Knees. Review of the Physician orders for certification period 9/2/22 through 10/31/22, indicated the following: -SNV once a week for two weeks. -SNV twice a week for one week. -SNV once a week for two weeks. -Effective 9/25/22, SNV once a week for five weeks. Review of the clinical record indicated a SNV was not provided for the week of 10/2/22 through 10/8/22. During an interview on 4/21/23 at 1:15 P.M., after reviewing the clinical records for Patients #10, and #14, the Agency Director said: -For Patient #10, the PTVs were not provided, as ordered, during the last two weeks of the certification period (2/19/23 through 3/2/23). He also said that a second OTV was not provided, as ordered, during the week of 2/26/23 through 3/2/23. He said staff did not document why the visits were not provided. -For Patient #14, a SNV was not provided, as ordered, during the week of 10/2//22 through 10/8/22, and there was no documentation why it was not provided. During an interview on 4/25/23 at 3:15 P.M., after reviewing the clinical records for Patients #11, and #13, the Agency Director said: -For Patient #11, (a) a SNV was missed for the week of 12/18/22 through 12/24/22, and an extra SNV was provided the week of 12/25/22 through 12/31/22. He said the Physician orders were not followed, as ordered, for SNVs. (b) He also said the Agency staff were not providing dressing changes three times a week, as ordered. He said staff should have updated the wound dressing orders for certification periods 1/1/23 through 3/1/23, and 3/2/23 through 4/30/23 to reflect what the Agency was providing. -For Patient #12, the OTVs were not provided, as ordered, during the weeks of 1/15/23 through 1/21/23, 2/5/23 through 2/11/23 and 2/12/23 through 2/18/23. He also said a SNV should have been provided during the week of 2/26/23 through 3/4/23, and the plan of care was not followed. During an interview on 4/21/23 at 1:15 P.M. and again on 4/25/23 at 3:30 P.M., the Agency Director said that staff are required to notify a Patient's Physician if there is a change in the plan of care for that Patient. After reviewing clinical records for Patients #2, #10, #11, #12, #13 and #14, he said that the Physicians were not notified of any of the care plan changes, as required. 7. Patient #6 was admitted to the Agency in April 2023 with a diagnosis of Cellulitis (a bacterial infection involving the inner layers of the skin) of the Abdominal Wall. Review of the Physician orders for certfication period 4/1/23 through 5/30/23 indicated the following: -SNV once a week for one week. -SNV three times a week for four weeks. -SNV twice a week for one week. -SNV once a week for two weeks. Review of the clinical record indicated for the week of 4/9/23 through 4/15/23, only two of the three ordered SNVs were provided. Review of the clinical record Indicated for the week of 4/16/23 through 4/22/23, only two of the three ordered SNVs were provided. Further review of the clinical record contained no documentation that the Physician had been notified of the one missed weekly SNV for the weeks of 4/9/23 through 4/15/23 and 4/16/23 through 4/22/22. During an interview on 2/25/23 at 2:42 P.M., after reviewing the clinical record, the Agency Director said the Physician was not notified of the one missed weekly SNV for the weeks of 4/9/23- through 4/15/23 and 4/16/23 through 4/22/23, as required. 8. Patient #9 was admitted to the Agency in March 2023 with a diagnosis of Thrombophilia (an abnormality of blood clotting that increases the risk of blood clots in the blood vessels). Review of the Physician orders for the certification period 3/28/23 through 5/26/23 indicated the following: -PTV once a week for one week. -PTV twice a week for two weeks. -PTV once a week for two weeks. Review of the clinical record indicated for the week of 4/9/23 through 4/15/23, none of the two ordered PTVs were provided. Further review of the clinical record contained no documentation that the Physician had been notified of the two missed PTVs for the week of 4/9/23 through 4/15/23. During an interview on 4/25/23 at 2:57 P.M. after reviewing the clinical record, the Agency Director said for the week of 4/9/23 through 4/15/23, no PTVs were provided, as ordered. 9. Patient #15 was admitted to the Agency in November 2022 with a diagnosis of Subarachnoid Hemorrhage (bleeding in the space between the brain and the tissue covering the brain). Review of the Physican orders for certification period 11/25/22 through 1/23/23 indicated the following: -PTV once a week for one week. -PTV two visits every two weeks times two. -PTV twice a week for one week. -PTV once a week for four weeks. Review of the clinical record indicated a scheduled PTV for 12/23/22 did not occur as the Patient declined the PTV. Further review of the clinical record did not contain documentation that the Physician had been notified of the missed PTV. During an interview on 4/25/23 at 3:04 P.M., after reviewing the clinical record, the Agency Director said the Physician had not been notified of the missed 12/23/22 PTV, as required. 10. Patient #16 was admitted to the Agency in February 2023 with a diagnosis of Spinal Stenosis (a narrowing of the spinal column), Lumbar Region (lower back) with Neurogenic Claudication (compression of the spinal nerves in the lower spine). Review of the Physician orders for the certification period 2/9/23 through 4/9/23 indicated the following: -OTV, effective 2/12/23, once a week for one week. -OTV twice a week for three weeks. -OTV once a week for four weeeks. Review of the clinical record indicated documentation that the Patient declined an OTV on 2/21/23. Further review of the clinical record did not contain any documentation that the Physician had been notified of the missed OTV. During an interview on 4/25/23 at 4:10 P.M., after reviewing the clinical record, the Agency Director said the Physician was not notified of the missed OTV, as required. 11. Patient #17 was admitted to the Agency in February 2023 with a diagnosis of Neurogenic Dsorder (inability to exchange information with others because of problems caused by impairment of the brain or nerves) with Lewy Bodies (abnormal protein deposits in the brain which affect thinking, memory and involvement). Review of a Physician order, effective 2/26/23, indicated the following: -PTV once a week for one week. Review of the clinical record indicated a PTV note, dated 3/1/23, that the Patient would be discharged from the Agency. Further review of the medical record did not indicate the Physician was notified of the Patient's discharge. During an interview on 4/25/23 at 3:13 P.M., after reviewing the clinical record, the Agency Director said the Physician was not notified of the Patient's discharge from services, as required.

Rehab services supervised by PT, OT CFR(s): 484.75(c)(2) Rehabilitative therapy services are provided under the supervision of an occupational therapist or physical therapist that meets the requirements of §484.115(f) or (h), respectively. This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency staff failed to ensure an order for a Physical Therapy (PT) Reassessment was performed by a Physical Therapist for one Patient (#9), out of a total sample of 17 Patients. Findings include: Review of the policy titled, Physical Therapy Assistant (PTA) Supervision, dated 10/2011, included, but not limited to: -Home care shall provide PTA services under the direction and supervision of a Registered Physical Therapist when services are indicated and ordered by the Physician. Patient #9 was admitted to the Agency in March 2023 with a diagnosis of Thrombophilia (an abnormality of blood clotting that increases the risk of blood clots in the blood vessels). Review of the clinical record for the certification period 3/28/23 through 5/26/23 indicated a Physician order, dated 4/18/23, that the Patient would benefit from a PT Reassessment due to a recent functional decline. Further review of the clinical record indicated a PT Assessment was performed on 4/18/23 by a PTA. During an interview on 4/25/23 at 3:00 P.M., after reviewing the clinical record, the Agency Director said the PT Reassessment which was ordered due to a functional decline should have been performed by a Physical Therapist and not a PTA, as required.