Every finding on record at Prospect Acquisition III, LLC

This Statement of Deficiencies is the result of an on-site complaint investigation of complaint IQIES #2634157 on 12/29/2025, conducted at Cassena Care at Home, located at 1000 Gates Avenue, 4th Floor, Brooklyn, NY 11221 as authorized by CMS (Centers of Medicare and Medicaid Services) to evaluate the Certified Home Health Agency's compliance with Federal Conditions of Participation (CoP): 0406 Patient Rights and (CoP) 0510: Comprehensive Assessment of Patients. The active census at the time of the survey was 2,006. The investigation consisted of a review of three (3) clinical records and three (3) personnel records. Additionally, the Certified Home Health Agency's complaint logs from July 2025 to December 2025 and Admission Packet were reviewed. Pre-survey activities consisted of a review on 12/26/2025 of the agency's Health Commerce System account and compliance history. The Director of Patient Services/Administrator, Chief Executive Officer, and Director of Rehabilitation were interviewed. Findings were reviewed at the exit conference on 12/29/2025. The Provider is considered to be in substantial compliance with the following Conditions of Participation: (CoP): 0406 Patient Rights (CoP) 0510: Comprehensive Assessment of Patients The complaint is unsubstantiated. The following Standard deficiencies unrelated to the allegations were identified as a result of the on-site complaint investigation: G0428 - Property and Person Treated with Respect G0434 - Participate in Care G0436 - Receive All Services in Plan of Care

Property and person treated with respect CFR(s): 484.50(c)(1) Have his or her property and person treated with respect; This ELEMENT is not met as evidenced by: Based on clinical record reviews and staff interviews, the agency failed to treat patients' personhood with respect by not keeping patients informed of their visit schedule, and timely and promptly notifying patients when scheduled services are changed. This was evident in two (2) of three (3) clinical records reviewed (Patients #1 and #3). Failure to treat patients' personhood with respect has the potential for negative patient outcomes. The Findings Are: 1. Patient #1 has a Start of Care date of 09/05/2025, a discharge date of 10/09/2025, with diagnoses of Hemiplegia following Cerebral Infarction Affecting Right Dominant Side, Aphasia following Cerebral Infarction, and Apraxia following Cerebral Infarction documented on the Home Health Certification and Plan of Care for the Certification Period 09/05/2025 to 11/03/2025. The Home Health Certification and Plan of Care for the Certification Period 09/05/2025 to 11/03/2025 documents: OT effective 09/07/2025 2 wk 6 (Occupational Therapy, effective 09/07/2025, 2 times a week, for 6 weeks). The patient schedule calendar documents there was a missed Occupational Therapy visit on 10/02/2025. There is no documented evidence of the patient being promptly notified of a change in scheduled services, (missed visit). On 12/29/2025 at 4:25 PM, the Director of Rehabilitation was interviewed and did not provide an explanation for the findings. 2. Patient #3 has a Start of Care date of 09/24/2025 with the following diagnoses of Essential Hypertension, Type 2 Diabetes Mellitus, Other Chronic Pain documented on the Home Health Certification and Plan of Care for the Certification Period 09/24/2025 to 11/22/2025. The Home Health Certification and Plan of Care for the Certification Period 09/24/2025 to 11/22/2025 documents: PT (Physical Therapy) 1WK1 (once a week for one week), 2WK7 (twice a week for seven weeks); HHA (home health aide) effective 09/28/2025 3WK2 (three times a week for two weeks). The Client Calendar Report printed on 12/29/2025 documents: Physical therapy visits on 09/25/2025 and 10/03/2025; Aide visits on 10/01/2025 and 10/03/2025. There is no documented evidence of the patient being informed of the visit schedule, and timely and promptly notifying the patient when scheduled services are missed. There was one missed Physical Therapy visit and one missed aide services for the week of 09/28/2025 to 10/04/2025. On 12/29/2025 at 02:04 PM, the Chief Executive Officer, Director of Patient Services/Administrator and Director of Rehabilitation were interviewed and did not provide an explanation for the findings.

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 clinical record reviews and staff interviews, the agency failed to inform patients of the frequency of services. This was evident for three (3) of three (3) clinical records reviewed (Patients #1, #2 and #3). Failure to ensure that patients are informed of the frequency of visits for the disciplines that will provide care, has the potential for negative patient outcomes. The Findings Are: 1. Patient #1 has a Start of Care date of 09/05/2025, a discharge date of 10/09/2025, with diagnoses of Hemiplegia following Cerebral Infarction Affecting Right Dominant Side, Aphasia following Cerebral Infarction, and Apraxia following Cerebral Infarction documented on the Home Health Certification and Plan of Care for the Certification Period 09/05/2025 to 11/03/2025. The Patient Consent form signed on 09/05/2025 documents, " I understand that the health care services rendered will be coordinated by a Registered Nurse and that care includes but is not limited to Skilled Nursing care, and may include other services, such as Physical Therapy, Respiratory Therapy, Occupational Therapy, Speech Therapy, Social Work, Home Health Aide and Nutritionist Services as required." The Patient Consent form lacks documented evidence of informing the patient of the frequency of visits of the disciplines to be provided. On 12/29/2025 at 2:04 PM, the Chief Executive Officer, Director of Patient Services/Administrator, and Director of Rehabilitation were interviewed and did not provide an explanation for the findings. 2. Patient #2 has a Start of Care Date of 07/08/2025 to 09/05/2025, a discharge date of 09/03/2025, with diagnoses of Displaced Bicondylar Fracture of Right Tiba, Subsequent for Closed Fracture with Routine Healing and Long Term (current) Use of Aspirin documented on the Home Health Certification and Plan of Care for the Certification Period 07/08/2025 to 09/05/2025. The Patient Consent form signed on 07/08/2025 documents, " I understand that the health care services rendered will be coordinated by a Registered Nurse and that care includes but is not limited to Skilled Nursing care, and may include other services, such as Physical Therapy, Respiratory Therapy, Occupational Therapy, Speech Therapy, Social Work, Home Health Aide and Nutritionist Services as required." The Patient Consent form lacks documented evidence of informing the patient of the frequency of visits of the disciplines to be provided. On 12/29/2025 at 2:04 PM, the Chief Executive Officer, Director of Patient Services/Administrator, and Director of Rehabilitation were interviewed and did not provide an explanation for the findings. 3. Patient #3 has a Start of Care date of 09/24/2025 with the following diagnoses of Essential Hypertension, Type 2 Diabetes Mellitus, Other Chronic Pain documented on the Home Health Certification and Plan of Care for the Certification Period 09/24/2025 to 11/22/2025. The Patient Consent form signed on 09/24/2025 documents, " I understand that the health care services rendered will be coordinated by a Registered Nurse and that care includes but is not limited to Skilled Nursing care, and may include other services, such as Physical Therapy, Respiratory Therapy, Occupational Therapy, Speech Therapy, Social Work, Home Health Aide and Nutritionist Services as required." The Patient Consent form lacks documented evidence of informing the patient of the frequency of visits of the disciplines to be provided. On 12/29/2025 at 02:04 PM, the Chief Executive Officer, the Director of Patient Services/Administrator and the Director of Rehabilitation were interviewed and did not provide an explanation for the findings.

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on clinical record reviews, and staff interviews, the agency failed to ensure that patients receive all services as outlined in their individualized plan of care. This was evident for two (2) of three (3) clinical records reviewed (Patients #1 and #3). Failure to ensure that patients receive all services outlined in their individualized plan of care, has the potential for negative patient outcomes. The Findings Are: 1. Patient #1 has a Start of Care date of 09/05/2025, a discharge date of 10/09/2025, with diagnoses of Hemiplegia following Cerebral Infarction Affecting Right Dominant Side, Aphasia following Cerebral Infarction, and Apraxia following Cerebral Infarction documented on the Home Health Certification and Plan of Care for the Certification Period 09/05/2025 to 11/03/2025. The Home Health Certification and Plan of Care for the Certification Period 09/05/2025 to 11/03/2025 documents OT effective 09/07/2025 2 wk 6 (Occupational Therapy, effective 09/07/2025, 2 times a week, for 6 weeks). The week of 09/28/2025, the patient scheduling calendar documents one missed OT visit on 10/02/2025. There is no documented evidence of the patient receiving OT services as outlined in the Plan of Care. On 12/29/2025 at 4:25 PM, the Director of Rehabilitation was interviewed and did not provide an explanation for the findings. 2. Patient #3 has a Start of Care date of 09/24/2025 with the following diagnoses of Essential Hypertension, Type 2 Diabetes Mellitus, Other Chronic Pain documented on the Home Health Certification and Plan of Care for the Certification Period 09/24/2025 to 11/22/2025. The Home Health Certification and Plan of Care for the Certification Period 09/24/2025 to 11/22/2025 documents: PT (Physical Therapy) 1WK1 (once a week for one week), 2WK7 (twice a week for seven weeks); HHA (home health aide) effective 09/28/2025 3WK2 (three times a week for two weeks). The Client Calendar Report printed on 12/29/2025 documents: Physical Therapy visits on 09/25/2025 and 10/03/2025; Aide visits on 10/01/2025 and 10/03/2025. The clinical record lacks documented evidence that the patient received all services as outlined in the plan of care. There was one missed Physical Therapy visit and one missed aide services for the week of 09/28/2025 to 10/04/2025. On 12/29/2025 at 02:04 PM, the Chief Executive Officer, Director of Patient Services/Administrator and Director of Rehabilitation were interviewed and did not provide an explanation for the findings.

This Statement of Deficiencies is a result of an on-site investigation of complaint 113690 conducted at Cassena Care at Home, located at 1000 Gates Ave 4th floor, Brooklyn, NY 11221 on 04/03/2025 to evaluate the agency's compliance with Federal regulations. The active patient census is 1940. The investigation consisted of a review of three (3) clinical records (identified as Patient #1, #2, and #3), the agency's complaint log, and interviews with the Chief Executive Officer, the Administrator/Director of Patient Services, and the Assistant /Director of Patient Services. Pre-survey activities consisted of a review on 04/02/2025 of the agency's Health Commerce System account and compliance history. Findings were reviewed at the exit conference. The allegations in complaint #113690 were determined substantiated. The following deficiencies are being cited as result of the survey: G0514 – RN performs assessment G0572 – Plan of Care G0574 – Plan of Care must include the following G0606 – Integrate all services G0608 – Coordinate care delivery

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 interviews, the agency failed to ensure that initial assessments were conducted within the required time frames for all patients. This was evident for one (1) of three (3) clinical records reviewed (Patient: #1). 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: 1. Patient #1 has a Start of Care date of 02/12/2025 with diagnoses Other Sequelae of Cerebral Infarction, Hyperlipidemia, Myocardial Infarction, Other Abnormalities of Gait and Mobility documented in the Home Health Certification and Plan of Care for the Certification Period 02/12/2025 to 04/12/2025. The clinical record documents patient discharged from a Rehabilitation Facility(Against Medical Advice) on 01/31/2025. The Admission Report documents referral date 02/07/2025. The Client Coordination Note Report dated 02/11/25 documents: “I called patient got voicemail and set up blind SOC (Start of Care) 02/12/25 when there was no answer.” The clinical record lacks documented evidence of any attempts to contact the patient from 02/07/25 to 02/11/25. There is no documented evidence of initial assessment being conducted within 48 hours of referral. On 04/03/2025 at 04:30PM, the Administrator/Director of Patient Services, the Assistant Director of Patient Services, and the Chief Executive Officer were interviewed and did not have 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 record reviews and staff interview the agency failed to ensure that all patients receive services as documented in their individualized plan of care. This was evident for one (1) of three (3) clinical records reviewed (Patient: #1). Failure to ensure that all patients receive services as documented in their individualized plan of care has the potential for negative patient outcomes. The Findings Are: 1. Patient #1 has a Start of Care date of 02/12/2025 with diagnoses Other Sequelae of Cerebral Infarction, Hyperlipidemia, Myocardial Infarction, Other Abnormalities of Gait and Mobility documented in the Home Health Certification and Plan of Care for the Certification Period 02/12/2025 to 04/12/2025. The Home Health Certification and Plan of Care for the Certification Period 02/12/2025 to 04/12/2025 documents an order for "SN (Skilled Nursing) 2WK5 (two visits a week for five weeks).” 1WK3 (one visit a week for three weeks); PT (Physical Therapy) 1WK1 (One time a week for one week), 2WK8 (two times a week for eight weeks); OT (Occupational Therapy) effective 02/16/20251WK1 (one time a week for one week); HHA (Home Health Aide) effective 2/16/2025 1wk1( one time a week for one week), 3wk3(three times a week for three weeks)” The clinical record lacks documented evidence of the patient receiving Occupational Therapy, and Home Health Aide services as documented in their individualized Plan of Care. On 04/03/2025 at 03:30PM, the Administrator/Director of Patient Services was interviewed stated: “Occupational Therapy services was ordered by mistake, and Home Health Aide Services is not covered by patient’s insurance.”

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record reviews, and staff interviews, the agency failed to ensure each patient's individualized plan of care includes all the required information. This was evident for one (1) of three (3) clinical records reviewed (Patient: #1). Failure to ensure each individualized plan of care includes all the required information, has the potential risk for negative patient outcomes. The Findings Are: 1. Patient #1 has a Start of Care date of 02/12/2025 with diagnoses Other Sequelae of Cerebral Infarction, Hyperlipidemia, Myocardial Infarction, Other Abnormalities of Gait and Mobility documented in the Home Health Certification and Plan of Care for the Certification Period 02/12/2025 to 04/12/2025. The Home Health Certification and Plan of Care for the Certification Period 02/12/2025 to 04/12/2025 documents an order for "SN (Skilled Nursing) 2WK5 (two visits a week for five weeks).” 1WK3 (one visit a week for three weeks)” The RN (Registered Nurse) OASIS Admission visit note dated 02/12/2025 documents: “PT (Patient) has a left AV(Arteriovenous) Fistula that is not in use.” The Home Health Certification and Plan of Care for the Certification Period 02/12/2025 to 04/12/2025 lacks documented evidence that the patient has AV(Arteriovenous) Fistula, and the safety measures: not to use left arm for blood pressure readings. There is no documented evidence of individualized plan of care including all the required information. On 04/03/2025 at 2:30PM, the Administrator/Director of Patient Services, the Assistant Director of Patient Services, and the Chief Executive Officer were interviewed and did not have an explanation for the findings.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on clinical record reviews and staff interview the Agency failed to ensure the coordination of care is being provided to identify patient needs. This was evident for one (1) of three (3) clinical records reviewed. (Patients #3). Failure to ensure the coordination of care is being provided to identify patient needs, has the potential for negative patient outcomes. The Findings Are: 1. Patient #3 has a Start of Care date of 02/26/2025 with diagnoses Peripheral Vascular Disease Unspecified, Spondylopathy in Diseases Classified Elsewhere Lumbar Region, Primary Generalized Osteoarthritis documented in the Home Health Certification and Plan of Care for the Certification Period 02/26/2025 to 04/26/2025. The Home Health Certification and Plan of Care for the Certification Period 02/26/2025 to 04/26/2025 documents an order for "PT (Physical Therapy) Effective (week of) 03/02/2025 1WK1 (one visit a week for one week), 2WK6 (two visits a week for six weeks).” The “Physical Therapy Evaluation” visit note dated 03/08/2025 documents the first Physical Therapist visit during the week of 03/02/2025. The clinical record lacks documented evidence of the patient receiving Physical Therapy visits during the following week of 03/09/2025. The Physician Order - MD Notification dated 03/14/2025 documents: “PT (Physical Therapist) revisits were not done for the week of 3-10-25 due to patient has a dog and primary PT (Physical Therapist) is allergic. Revisits reassigned to another therapist starting the week of 03-16-25.” The “RN (Registered Nurse) OASIS Admission” visit note dated 02/26/2025 documents: the patient has “2 dogs.” The clinical record lacks evidence of the primary Physical Therapist notifying the agency of being allergic to dogs on 03/08/2025, or at the time of the assignment, to ensure revisits are timely reassigned to another therapist. The agency failed to ensure the coordination of care and the timely management of the scheduling of the patient’s physician therapy visits at the start of care. On 04/03/2025 at 3:00 PM, the Chief Executive Officer was interviewed and stated, “the first time the therapist notified the agency of allergy to dogs was on 3/14.”

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 three (3) clinical records reviewed. (Patients: #1, and #3). Failure to ensure to coordinate care delivery to meet patient’s needs, has the potential for negative patient outcomes. The Findings Are: 1. Patient #3 has a start of care date of 02/26/2025 with diagnoses Peripheral Vascular Disease Unspecified, Spondylopathy in Diseases Classified Elsewhere Lumbar Region, Primary Generalized Osteoarthritis documented in the Home Health Certification and Plan of Care for the Certification Period 02/26/2025 to 04/26/2025. The Home Health Certification and Plan of Care for the Certification Period 02/26/2025 to 04/26/2025 documents an order for "PT (Physical Therapy) Effective (week of) 03/02/2025 1WK1 (one visit a week for one week), 2WK6 (two visits a week for six weeks).” The Physician Order - MD Notification dated 03/14/2025 documents: “PT (Physical Therapist) revisits were not done for the week of 3-10-25 due to patient has a dog and primary PT (Physical Therapist) is allergic. Revisits reassigned to another therapist starting the week of 03-16-25.” The clinical record lacks documented evidence of the agency communicating with the patient/family about the missed physical therapy visits. On 04/03/2025 at 2:25 PM, the Agency's Administrator/Director of Patient Services, the Assistant Director of Patient Services, and the Chief Executive Officer were interviewed. On 04/03/2025 at 4:25 PM, the Chief Executive Officer stated, “we don’t have a note that we informed the family" about the missed physical therapy visits. 1. Patient #1 has a start of care date of 02/12/2025 with diagnoses Other Sequelae of Cerebral Infarction, Hyperlipidemia, Myocardial Infarction, Other Abnormalities of Gait and Mobility documented in the Home Health Certification and Plan of Care for the Certification Period 02/12/2025 to 04/12/2025. The Home Health Certification and Plan of Care for the Certification Period 02/12/2025 to 04/12/2025 documents an order for "SN (Skilled Nursing) 2WK5 (two visits a week for five weeks).” 1WK3 (one visit a week for three weeks); PT (Physical Therapy) 1WK1 (One time a week for one week), 2WK8 (two times a week for eight weeks); OT(Occupational Therapy) effective 02/16/20251WK1 (one time a week for one week); HHA effective 2/16/2025 1wk1( one time a week for one week), 3wk3(three times a week for three weeks)” The Start of Care Assessment by Registered Nurse dated 02/12/24 documents: “Patient will require Skilled Nursing, Physical Therapy, Occupational Therapy, Medical Social Worker, and Home Health Aide Services for ADL (Activities of Daily Living) assistance.” The clinical record documents patient received Skilled Nursing, and Physical Therapy Services. On 04/03/2025 at 03:30PM, the Administrator/Director of Patient Services was interviewed stated: “Home Health Aide Services is not covered by patient’s insurance, and Registered Nurse did mistake by documenting patient's need for Occupational Therapy, and Medical Social Worker services.” The clinical record lacks documented evidence of coordination with patient/caregiver regarding need for Occupational Therapy, Medical Social Worker, and Home Health Aide Services. On 04/03/2025 at 04:30PM, the Administrator/Director of Patient Services, the Assistant Director of Patient Services, and the Chief Executive Officer were interviewed and did not have an explanation for the findings. 2. Patient #3 has a start of care date of 02/26/2025 with diagnoses Peripheral Vascular Disease Unspecified, Spondylopathy in Diseases Classified Elsewhere Lumbar Region, Primary Generalized Osteoarthritis documented in the Home Health Certification and Plan of Care for the Certification Period 02/26/2025 to 04/26/2025. The Home Health Certification and Plan of Care for the Certification Period 02/26/2025 to 04/26/2025 documents an order for "PT (Physical Therapy) Effective (week of) 03/02/2025 1WK1 (one visit a week for one week), 2WK6 (two visits a week for six weeks).” The Physician Order - MD Notification dated 03/14/2025 documents: “PT (Physical Therapist) revisits were not done for the week of 3-10-25 due to patient has a dog and primary PT (Physical Therapist) is allergic. Revisits reassigned to another therapist starting the week of 03-16-25.” The clinical record lacks documented evidence of the agency communicating with the patient/family about the missed physical therapy visits. On 04/03/2025 at 2:25 PM, the Agency's Administrator/Director of Patient Services, the Assistant Director of Patient Services, and the Chief Executive Officer were interviewed. On 04/03/2025 at 4:25 PM, the Chief Executive Officer stated, “we don’t have a note that we informed the family" about the missed physical therapy visits.

This Statement of Deficiencies is a result of an on-site investigation of complaint NY00279826 conducted on 09/01/2021 at Centerlight Certified Home Health Agency, located at 1000 Gates Avenue, Brooklyn, NY 11221 with 935 active patient census to evaluate compliance with Condition of Participation (CoP) 484.55: Comprehensive Assessment of Patients; CoP 484.60: Care Planning, Coordination, Quality of Care; and CoP 484.75: Skilled Professional Services. The agency is found to be in substantial compliance with the Federal Conditions of Participation. Three (3) clinical care records were reviewed and are identified as (Patient #1, #2 and #3). Complaint log, Occurrence log, Fall Report log, Pertinent Policies and Procedures, Current and Discharged census were reviewed. The Director of Patient Services and Director of Quality and Compliance were interviewed. Findings were reviewed at the exit conference on 09/01/2021. The complaint NY00279826 is substantiated. The following standard level deficiencies are identified as a result of the survey: G0526 - Content of the comprehensive assessment G0544 - Update of the comprehensive assessment G0580 - Only as Ordered by a physician G0718 - Communication with physicians

Content of the comprehensive assessment CFR(s): 484.55(c) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: This STANDARD is not met as evidenced by: Based on clinical record review, and staff interviews, the agency failed to ensure that the comprehensive assessment accurately reflect the patient's status. This was evident for one (1) of three (3) clinical records reviewed. (Patient#1) Failure to ensure that the comprehensive assessment accurately reflect the patient's status, has the potential for negative patient outcomes. The Findings Are: 1.Patient #1 has a Start of Care date of 03/25/2021 with the following diagnoses "Pathological Fracture, Right Femur, Subs for FX with Routh Heal, End Stage Renal Disease, Chronic Atrial Fibrillation, Peripheral Vascular Disease, Pressure Ulcer of Sacral region, stage 4, Pressure Ulcer of Right Buttock, stage 2" documented on the Home Health Certification and Plan of Care dated 03/25/2021 to 05/23/2021 and 05/24/2021 to 07/22/2021. The Hospital Record documents:"Date of Admission 03/16/2021; Wound Care RN -Initial Noted signed by RN 03/22/2021 Reason for consult/referral: Moisture Associated Dermatitis. ...Non Pressure Injury assessment: Non Pressure Injury: Assessment and recommendation. Patient seen in PACU. She needs assistance to turn. Patient is functionally incontinent. In the gluteal cleft there is a partial thickness open area that patient informed she has had. She states that it opens and closes and her doctor prescribes an anti viral ointment for it. ..." The RN Initial Assessment dated 03/25/2021 documents:" Integumentary: Was Integumentary assessed? Yes Indicate Integumentary assessment Findings: No problems identified..." The clinical record lacks documented evidence of the gluteal cleft area being assessed on 03/25/2021. There is no documented evidence that the comprehensive assessment accurately reflects the patient's integumentary status. On 09/01/2021 at 6:00 pm, the Director of Patient Services and Director of Quality and Compliance were 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 three (3) clinical records reviewed. (Patient#1) 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 #1 has a Start of Care date of 03/25/2021 with the following diagnoses "Pathological Fracture, Right Femur, Subs for FX with Routh Heal, End Stage Renal Disease, Chronic Atrial Fibrillation, Peripheral Vascular Disease, Pressure Ulcer of Sacral region, stage 4, Pressure Ulcer of Right Buttock, stage 2" documented on the Home Health Certification and Plan of Care dated 03/25/2021 to 05/23/2021 and 05/24/2021 and 07/22/2021. The Physician Order dated 04/26/2021 documents: "New wound care order/cleanse partial thickness ulcer to right buttocks and coccyx with gentle soap and water, apply thin layer of zinc oxide based moisture barrier, cover with dry dressing daily. May use soft moist wash cloth with moisturizing skin oil to remove excess skin paste if needed. CG(caregiver) is repositioning patient every 2 hours from ulcer, avoid dragging patient in bed, avoid prolong sitting no more than one hour at a time. CG may continue to use previous orders until new treatment is obtained. SN to assess site at every visit. CG to perform wound care on non nursing visit days." The SN(Skilled Nurse) notes dated 04/30/2021 documents: "Wound assessment: Anatomical View Wound #/ Location/Type Question Answer #1 - RT(right) -Low buttock, RT Partial Thickness skin loss ..." The SN notes dated 05/03/2021 documents:"Wound assessment: Anatomical View Wound #/ Location/Type Question Answer #1 - RT-Low buttock, RT Partial Thickness skin loss ..." The SN notes dated 05/10/2021 documents:"Wound assessment: Anatomical View Wound #/ Location/Type Question Answer #1 - RT-Low buttock, RT Partial Thickness skin loss ..." The SN notes dated 05/18/2021 documents: "Wound assessment: Anatomical View Wound #/ Location/Type Question Answer #1 - RT-Low buttock, RT Partial Thickness skin loss ..." There is no documented evidence of the coccyx area being assessed by the SN on 04/26/2021, 4/30/2021, 05/03/2021, 05/10/2021 and 05/18/2021 for the Certification Period dated 03/25/2021 to 05/23/2021. The clinical record lacks documented evidence of the skilled nurse updating the comprehensive assessment for the wound. On 09/01/2021 at 6:00 pm, the Director of Patient Services and Director of Quality and Compliance were 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 provided as ordered by a physician for each patient. This was evident for one (1) of three (3) clinical records reviewed.(Patient#1) Failure to ensure all treatments are provided as ordered by the physician has the potential for negative patient outcomes. The findings are: 1.Patient #1 has a Start of Care date of 03/25/2021 with the following diagnoses "Pathological Fracture, Right Femur, Subs for FX with Routh Heal, End Stage Renal Disease, Chronic Atrial Fibrillation, Peripheral Vascular Disease, Pressure Ulcer of Sacral region, stage 4, Pressure Ulcer of Right Buttock, stage 2" documented on the Home Health Certification and Plan of Care dated 03/25/2021 to 05/23/2021. The Physician Order dated 4/26/2021 documents: " New wound care order/cleanse partial thickness ulcer to right buttocks and coccyx with gentle soap and water, apply thin layer of zinc oxide based moisture barrier, cover with dry dressing daily. May use soft moist wash cloth with moisturizing skin oil to remove excess skin paste if needed. CG in repositioning patient every 2 hours from ulcer, avoid dragging patient in bed, avoid prolonger sitting no more than one hour at a time. CG may continue to use previous orders until new treatment is obtained. SN to asses site at every visit. CG to perform wound care on non nursing visit days. " The SN(Skilled Nurse) visit note dated 4/30/2021 documents:":"Wound assessment:... Wound care provided: Skilled Nurse to perform/teach wound care to righ buttock and coccyx wounds: Clean with periwash, apply triad hydrophilic paste to open area and cover with allevyn foam daily and prn. Patients daughter to perform wound care on non SN visit days. No change to wound care orders. Wound care provided as per MD orders." The SN visit note dated 5/03/2021 documents:"Wound assessment:... Wound care provided: Skilled Nurse to perform/teach wound care to righ buttock and coccyx wounds: Clean with periwash, apply triad hydrophilic paste to open area and cover with allevyn foam daily and prn. Patients daughter to perform wound care on non SN visit days. No change to wound care orders." The SN visit note dated 5/10/2021 documents:"Wound assessment:... Wound care provided: Skilled Nurse to perform/teach wound care to righ buttock and coccyx wounds: Clean with periwash, apply triad hydrophilic paste to open area and cover with allevyn foam daily and prn. Patients daughter to perform wound care on non SN visit days. No change orders." The SN visit note dated 5/13/2021 documents:"Wound assessment:... Wound care provided: Skilled Nurse to perform/teach wound care to righ buttock and coccyx wounds: Clean with periwash, apply triad hydrophilic paste to open area and cover with allevyn foam daily and prn. Patients daughter to perform wound care on non SN visit days. No change to wound care orders. Awaiting new order confirmation. The SN visit note dated 5/18/2021 documents:"Wound assessment:... Wound care provided: Skilled Nurse to perform/teach wound care to righ buttock and coccyx wounds: Clean with periwash, apply triad hydrophilic paste to open area and cover with allevyn foam daily and prn. Patients daughter to perform wound care on non SN visit days. Cleanse with NS(normal saline), pat dry, apply medi honey and moist gauze to wound bed, cover with DD, ABD pad, secure with tape. The Narrative documents: Wound Care updated as and provided as per MD orders. Wound care provided as follows, until recommendation confirmed: Partial thickness ulcer to right buttocks coccyx: Treatment: Cleanse with NS(normal saline), pat dry, apply medi honey and moist gauze to wound bed, cover with DD, ABD pad, secure with tape." The Physician order dated 05/21/2021 documents: "Order Description: 1) Stage 4 ulcer to coccyx order to cleance with normal saline, pat dry, apply medi honey and moist gauze to wound bed, cover with DD(dry dressing), ABD pad, secure with tape. MD confirmed orders and etiology. 2) Stage 2 pressure ulcer prevention to right buttock order to cleance with normal saline, pat dry, apply medi honey and moist gauze to wound bed, cover with DD, ABD(extra absorbent sterile) pad, secure with tape. MD confirmed orders and etiology." The SN visit note dated 5/21/2021 documents:"Wound assessment:Wound#1... Wound care provided: Skilled Nurse to perform/teach wound care to righ buttock and coccyx wounds: Clean with periwash, apply triad hydrophilic paste to open area and cover with allevyn foam daily and prn. Patients daughter to perform wound care on non SN visit days." There is no documented evidence of the SN(Skilled Nurse) administering wound treatment only as ordered by the physician on the following dates: 04/26/2021, 04/30/2021, 05/03/2021, 05/10/2021, 05/13/2021, 05/18/2021 and 05/21/2021. On 09/01/2021 at 6:10 pm, the Director of Patient Services and Director of Quality and Compliance were 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 one (1) of three (3) clinical records reviewed. (Patients#2). Failure to ensure ongoing communication with all physicians is maintained has the potential for negative patient outcome. The Findings are: 1.Patient #2 has a start of care date 07/30/2021 with the diagnosis: " Pressure Ulcer of the sacral Region Stage 3" documented on the Home Health Certification and Plan of Care for Certification Period 07/30/2021 to 9/27/2021. The Home Health Certification and Plan of Care documents: "HHA Effective 08/01/2021 3D x 4H x 3WKS ( Three (3) days a week for four (4) hours for three (3) weeks)." The HHA eXchange Duty Sheet documents: "Week 7/31/2021 - 8/6/2021: Week ending: 08/06/2021: 8/6 TimeIn: 14:00 - TimeOut: 18:00 -Total Hours: 04:00." There is no documented evidence that Patient#2 received services three (3) days a week for four (4) hours for three (3) weeks)." There is no documented evidence that ongoing communication was maintained with Patient #2's physician regarding the missed visits. On 9/1/2021 2:00PM the Director of Quality was interviewed and did not provide an explanation for the finding. On 9/1/2021 at approximately 4:00PM the Director of Quality provided a Client Coordination Note Report documenting: :Note Date: 09/01/2021 3:56: 23 PM Note: Late entry - T/C made to office of client's PCP (Primary Care Physician) Message relayed concerning Missed HHA Visits for W/O (week of) 8/1/2021. The Centerlight Certified Home Health Agency Order documents: "Order Date: 9/1/2021 3:57 PM Order Description: 2 Missed Home Health Aide Visits Week of 8/1/21."