Every finding on record at Qc-Medi New York, Inc.

The following statement of deficiencies represents the results of a partial extended re-certification survey of CenterWell Home Health - Westbury, a Certified Home Health Agency located at 865 Merrick Ave, Westbury, NY 11590, which was conducted on 12/01/2025 through 12/05/2025. A standard re-certification survey was initiated on 12/01/2025, deficient practices were identified within Level 1 standards in 484.60 Care Planning, Coordination, Quality Care resulting in a partial extended survey. The survey consisted of a review of seventeen (17) clinical records including five (5) discharge records, seven (7) observational home visits, and ten (10) personnel records for professional services. Policies and procedures for the Health Commerce System, Influenza Vaccination, Criminal History Record Check, Home Care Workers Registry, Emergency Preparedness Plan, and Complaint Procedures/Log. The Quality Improvement Meeting minutes for the past 12 months, and patient Admission Packet were also reviewed. The agency has no patient service Contracts for review. Pre-survey activities consisted of review on 11/25/2025 of the agency’s Health Commerce System account, Home Care Registry Agency Profile, Criminal History Record Check Negative Determination report, Emergency Drill conducted 06/11/19 - 06/13/19, Statistical Report submission for the year 2024, and the Certification and Survey Provider Enhanced Reports (CASPER) for the period 09/2024 – 08/2025. The agency reported an unduplicated patient count of 741 and active patient census of 145 as of 12/01/2025. The Branch Manager and Director of Patient Services/Clinical Manager were interviewed. Findings were reviewed at the exit conference on 12/05/2025. The following deficiencies are identified as a result of the survey: G0434 - Participate in care G0572 - Plan of Care G0574 - Plan of Care must include the following G0588 - Reviewed revised by Physician every 60 days G0608 - Coordination of care delivery G0808 - Onsite supervisory visit every 14 days

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 records review and staff interview, the Agency failed to obtain patient consents for skilled services frequency of visits. This was evident in four (4) of seventeen (17) records reviewed (Patients #9, #12, #13, and #14). Failure to consent for skilled services frequency of visits has the potential for negative patient outcomes. The findings are: 1) Patient # 9 has a start of care date of 03/07/2024 with diagnoses of “Encounter for fitting and adjustment of urinary device, Hypo-Osmolality, Hyponatremia, Neuromuscular dysfunction of Bladder, and Urinary Tract Infection as documented on the "Home Health Certification and Plan of Care” for certification period 03/07/2024 – 05/05/2024. The “Home Health Certification and Plan of Care” for certification period 03/07/2024 – 05/05/2024 document orders for Skilled Nurse 1wk2, 1 every 3wk3, 1wk1 (one visit a week for two weeks, one visit every three weeks for three weeks, one visit a week for one week), Physical Therapy 1wk5 (one visit a week for five weeks), Occupational Therapy effective 3/10/24, 1wk1, 2wk3, 1wk4 (one visit a week for one week, two visits a week for three weeks, one visit a week for four weeks). The” Home Care Consent” dated 03/07/24 lacks documented evidence of the Skilled Nurse, Physical Therapy, and Occupational Therapy frequency of visits. The “Home Care Consent” Addendum V2 dated 03/08/24 documents services will be provided for Physical Therapy and Occupational Therapy. There is no documentation of the expected frequency and duration for Physical Therapy and Occupational Therapy services. Survey findings were reviewed on 12/04/2025 at 03:45 PM with the Director of Patient Services/Clinical Manager. No explanation was provided. Interview and survey findings were reviewed on 12/05/2025 at 12:35 PM with the Branch Director and Director of Patient Services/Clinical Manager. Findings were acknowledged. 2) Patient # 12 has a start of care date of 03/20/2025 with diagnoses of "Pressure Ulcer of Sacral Region stage 3, Pressure Ulcer of Left Heel - unstageable, Pressure Ulcer of other sites - unstageable, Pressure Ulcer - other site stage 1, Pressure Ulcer - other site stage 2, and Encounter for fitting urinary device as documented on the "Home Health Certification and Plan of Care” for certification period 03/20/2025 to 05/18/2025. The "Home Health Certification and Plan of Care” for certification period 03/20/2025 to 05/18/2025 document orders for Skilled Nurse 2 wk 9 (two visits a week for nine weeks) and three (3) as needed visits for wound care, Occupational Therapy 1wk5, 0wk1, 1wk1 (one visit a week for five weeks, no visit for one week, one visit a week for one week), Speech Therapy 2wk1, 1wk4 (two visits a week for one week, one visit a week for four weeks) effective 03/23/25 ". The "Home Care Consent” dated 03/20/25 lacks documented evidence of the Skilled Nurse, Occupational Therapy and Speech Therapy frequency of visits. Survey findings were reviewed on 12/02/2025 at 03:20 PM with the Director of Patient Services/Clinical Manager. No explanation was provided. Interview and survey findings were reviewed on 12/03/2025 at 10:30 AM with the Director of Patient Services/Clinical Manager. Findings were acknowledged. 3) Patient #13 has a start of care date of 10/24/2024 with diagnoses of "Nontraumatic Intracranial Hemorrhage, Hypertensive Heart and Chronic Kidney Disease, Heart Failure, and Anemia as documented on the dysfunction of Bladder, and Urinary Tract Infection as documented on the Home Health Certification and Plan of Care” for certification period 10/24/2024 to 12/22/2024. The "Home Health Certification and Plan of Care” for certification period 10/24/2024 to 12/22/2024 document orders for Skilled Nurse 1wk1, 2wk3, 1wk1 (one visit a week for one week, two visits a week for two weeks, one visit a week for one week), Physical Therapy 1wk1, 2wk3, 1wk2, 1 every 2wks2, 1wk1 (one visit a week for one week, two visits a week for three weeks, one visit a week for two weeks, one visit every two weeks for two weeks, one visit a week for one week). The” Home Care Consent” dated 10/24/24 lacks documented evidence of the Skilled Nurse and Physical Therapy frequency of visits. Survey findings were reviewed on 12/02/2025 at 03:00 PM with the Director of Patient Services/Clinical Manager. No explanation was provided. Interview and survey findings were reviewed on 12/04/2025 at 12:35 PM with the Branch Director and Director of Patient Services/Clinical Manager. Findings were acknowledged. 4) Patient #14 has a start of care date of 06/25/2025 with diagnoses of "Alzheimer's Disease, Dementia, Insomnia, and Overactive Bladder as documented on the Home Health Certification and Plan of Care” for certification period 06/25/2025 to 08/23/2025. The Home Health Certification and Plan of Care” for certification period 06/25/2025 to 08/23/2025 document orders for Physical Therapy 1wk2, 2wk2, 1wk3 (one visit a week for two weeks, two visit a week for two weeks, one visit a week for three weeks), Occupational Therapy 1 wk1 (one visit a week for one week) effective 6/29/25". The” Home Care Consent” dated 06/25/25 lacks documented evidence of the Skilled Nurse and Physical Therapy frequency of visits. Survey findings were reviewed on 12/02/2025 at 03:15 PM with the Director of Patient Services/Clinical Manager. No explanation was provided. Interview and survey findings were reviewed on 12/04/2025 at 12:55 PM with the Branch Director and Director of Patient Services/Clinical Manager. Findings were acknowledged.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on clinical records review and staff interview, the Agency failed to ensure that patients receive services and treatments as ordered in the Plan of Care. This was evident in two (2) of seventeen (17) records reviewed (Patients #9 and #12). Failure to ensure that patients receive services and treatments as per the Plan of Care, has the potential for negative patient outcomes. The findings are: 1) Patient # 9 has a start of care date of 03/07/2024 with diagnoses of “Encounter for fitting and adjustment of urinary device, Quadriplegia, Neuromuscular dysfunction of Bladder, and Post-Polio Syndrome" as documented on the "Home Health Certification and Plan of Care” for certification period 08/29/2025 to 10/27/2025. The “Home Health Certification and Plan of Care” for certification period 08/29/2025 to 10/27/2025 document orders for “Skilled Nurse effective 9/14/25 1wk1, 1 every 4wk4, 1wk1 (one visit a week for one week, one visit every four weeks for four weeks, one visit a week for one week), Home Health Aide 1wk1, 2wk8, 1wk1 (one visit a week for one week, two visits a week for eight weeks, one visit a week for one week). Skilled Nurse to teach Indwelling catheter management such as definition, symptom monitoring and intended effects. Skilled Nurse to insert/change/maintain indwelling catheter 16 Fr, 10 milliliter balloon, inflate balloon with 10 milliliter Normal Saline, change every 4 weeks and as needed for dislodgement/stoppage using sterile technique, obtain urine specimen if ordered by Medical Doctor. Skilled Nurse to teach Urinary Tract Infection management such as definition, risk factors, and symptom monitoring. May obtain urine specimen for signs/symptoms of Urinary Tract Infection”. The “Registered Nurse Recertification with Skill” patient assessment dated 08/25/2025, documents “Genitourinary: incontinent, indwelling/suprapubic catheter, at risk for developing a Urinary Tract Infection”. The visit note lacks documented evidence of the indwelling urinary catheter size, urinary output as ordered in the Plan of Care, and catheter urinary meatus care. The “Registered Nurse subsequent visit” note dated 09/16/2025, documents “catheterization performed with no signs and symptoms of infection”. The visit note lacks documented evidence of the indwelling urinary catheter size, urinary output as ordered in the Plan of Care, and catheter urinary meatus care. The “Registered Nurse subsequent visit” note dated 10/15/2025, documents “Performed indwelling catheter insertion/change. Removed old catheter intact without complications. Performed site care using sterile technique. Inserted catheter/10 milliliter ballon using sterile technique, returned 30 milliliters urine straw color”. The visit note lacks documented evidence of the Indwelling catheter size (16 FR) that was inserted as ordered in the Plan of Care. The “Registered Nurse Recertification with Skill” assessment dated 10/27/2025, documents “Genitourinary: incontinent, indwelling/suprapubic catheter, at risk for developing a Urinary Tract Infection”. The visit note lacks documented evidence of the indwelling urinary catheter size, urinary output as ordered in the Plan of Care, and catheter urinary meatus care. Survey findings were reviewed on 12/04/2025 at 03:45 PM with the Director of Patient Services/Clinical Manager. No explanation was provided. Interview and survey findings were reviewed on 12/05/2025 at 12:35 PM with the Branch Director and Director of Patient Services/Clinical Manager. Findings were acknowledged. 2) Patient # 12 has a start of care date of 03/20/2025 with diagnoses of "Pressure Ulcer of Sacral Region stage 3, Pressure Ulcer of Left Heel - unstageable, Pressure Ulcer of other sites - unstageable, Pressure Ulcer - other site stage 1, Pressure Ulcer - other site stage 2, and Encounter for fitting urinary device" as documented on the "Home Health Certification and Plan of Care” for certification period 03/20/2025 to 05/18/2025. The "Home Health Certification and Plan of Care” for certification period 03/20/2025 to 05/18/2025 document orders for "Skilled Nurse 2 wk 9 (two visits a week for nine weeks) and three (3) as needed visits for wound care. Skilled Nurse to insertion of Foley catheter maintain with 14Fr, 10 cubic centimeter balloon, change monthly. Skilled Nurse for administration of bladder irrigation (flush) with 30 milliliters sterile water or Normal Saline as needed for no urine output". The Registered Nurse visit note report date 03/20/2025, genitourinary section documents the patient has "indwelling/suprapubic catheter, at risk for urinary tract infection, dark amber color (urine)". The visit note lacks documentation of the catheter size and balloon size as ordered in the Plan of Care. The Registered Nurse subsequent visit note report date 03/31/2025, documents "Skilled Nurse noted Foley catheter bag hanging from tub siderail preventing flow. Skilled Nurse lowered Foley catheter bag and noted drainage. Skilled Nurse flush catheter and received over 500 cubic centimeters of output". The genitourinary section documents the patient has "indwelling/suprapubic catheter, at risk for urinary tract infection, sediment in urine". The visit note lacks documentation of the catheter size, balloon size, irrigation fluid type and quantity used to flush the catheter, as ordered in the Plan of Care. There is no documentation that the Foley catheter was changed on 03/31/25. The Registered Nurse subsequent visit note report date 04/29/2025, documents "Foley catheter in situ (intact) draining dark amber urine with sediments in tubing. Drainage bag was on top of the bed, informed daytime aide who corrected placement". The genitourinary section documents the patient has "indwelling/suprapubic catheter, at risk for urinary tract infection, sediment in urine". The visit note lacks documentation of the catheter size, balloon size as ordered in the Plan of Care. There is no documentation that the Foley catheter was changed on 04/29/25. Survey findings were reviewed on 12/02/2025 at 03:20 PM with the Director of Patient Services/Clinical Manager. No explanation was provided. Interview and survey findings were reviewed on 12/03/2025 at 10:30 AM with the Director of Patient Services/Clinical Manager. Findings were acknowledged. .

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical records review and staff interviews, the Agency failed to establish individualized Plans of Care for all services and treatments. This was evident in two (2) of seventeen (17) records reviewed (#9 and #12). Failure to establish individualized Plans of Care, has the potential for negative patient outcomes. The findings are: 1) Patient # 9 has a start of care date of 03/07/2024 with diagnoses of “Encounter for fitting and adjustment of urinary device, Quadriplegia, Neuromuscular dysfunction of Bladder, and Post-Polio Syndrome" as documented on the "Home Health Certification and Plan of Care” for certification period 08/29/2025 to 10/27/2025. The “Home Health Certification and Plan of Care” for certification period 08/29/2025 to 10/27/2025 document orders for “Skilled Nurse effective 9/14/25 1wk1, 1 every 4wk4, 1wk1 (one visit a week for one week, one visit every four weeks for four weeks, one visit a week for one week), Home Health Aide 1wk1, 2wk8, 1wk1 (one visit a week for one week, two visits a week for eight weeks, one visit a week for one week). Skilled Nurse to insert/change/maintain indwelling catheter 16 Fr, 10 milliliter balloon, inflate balloon with 10 milliliter Normal Saline, change every 4 weeks and as needed for dislodgement/stoppage using sterile technique, obtain urine specimen if ordered by Medical Doctor. Skilled Nurse to teach Urinary Tract Infection management such as definition, risk factors, and symptom monitoring. May obtain urine specimen for signs/symptoms of Urinary Tract Infection”. The Plan of Care lack orders for Home Health Aide supervision every 14 days, urinary catheter meatus care and the frequency of urinary meatus care to be performed. It should be noted that the patient is at risk for developing Urinary Tract Infection. Survey findings were reviewed on 12/04/2025 at 03:45 PM with the Director of Patient Services/Clinical Manager. No explanation was provided. Interview and survey findings were reviewed on 12/05/2025 at 12:35 PM with the Branch Director and Director of Patient Services/Clinical Manager. Findings were acknowledged. 2) Patient # 12 has a start of care date of 03/20/2025 with diagnoses of "Pressure Ulcer of Sacral Region stage 3, Pressure Ulcer of Left Heel - unstageable, Pressure Ulcer of other sites - unstageable, Pressure Ulcer - other site stage 1, Pressure Ulcer - other site stage 2, and Encounter for fitting urinary device" as documented on the "Home Health Certification and Plan of Care” for certification period 03/20/2025 to 05/18/2025. The "Home Health Certification and Plan of Care” for certification period 03/20/2025 to 05/18/2025 document orders for "Skilled Nurse 2 wk 9 (two visits a week for nine weeks) and three (3) as needed visits for wound care. Skilled Nurse to insertion of Foley catheter maintain with 14Fr, 10 cubic centimeter balloon, change monthly". The Plan of Care lacks an order for urinary catheter meatus care and the frequency of urinary meatus care to be performed. It should be noted that the patient is at risk for developing Urinary Tract Infection. Survey findings were reviewed on 12/02/2025 at 03:20 PM with the Director of Patient Services/Clinical Manager. No explanation was provided. Interview and survey findings were reviewed on 12/03/2025 at 10:30 AM with the Director of Patient Services/Clinical Manager. Findings were acknowledged. .

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, the Agency failed to ensure that the Plan of Care is reviewed and revised every sixty (60) days. This was evident in one (1) of seventeen (17) records reviewed (Patient #13). Failure to review and revise the Plan of Care every sixty (60) days, has the potential for negative patient outcomes. The findings are: 1) Patient #13 has a start of care date of 10/24/2024 with diagnoses of "Nontraumatic Intracranial Hemorrhage, Hypertensive Heart and Chronic Kidney Disease, Heart Failure, and Anemia as documented on the Home Health Certification and Plan of Care” for certification period 10/24/2024 to 12/22/2024. The "Home Health Certification and Plan of Care” for certification period 10/24/2024 to 12/22/2024 document orders for "Skilled Nurse 1wk1, 2wk3, 1wk1 (one visit a week for one week, two visits a week for two weeks, one visit a week for one week), Physical Therapy 1wk1, 2wk3, 1wk2, 1 every 2wks2, 1wk1 (one visit a week for one week, two visits a week for three weeks, one visit a week for two weeks, one visit every two weeks for two weeks, one visit a week for one week)." The Registered Nurse OASIS Admission assessment is dated 10/24/2024. Physical Therapy visits are dated 10/25/24 - 11/20/24. The "Client Coordination Note Report" documents discharge 11/21/24, the patient's son request Physical Therapy cancelled. Skilled Nurse visits are dated 10/29/24 - 12/20/24. The Registered Nurse subsequent visit dated 12/17/25 documents "Skilled Nurse provided wound care to multiple sites which patient tolerated well. Per Assisted Living Staff patient still not on Hospice". Licensed Practical Nurse visit is dated 12/20/2024. The "Client Coordination Note Report" dated 12/23/24 documents "Interdisciplinary Team conference 12/18/24. Reviewed summary of assessment/plan for past 14 days, Discharge". The clinical record lacks documented evidence of a discharge assessment or recertification assessment conducted prior to 12/22/24 certification end date. The patient was readmitted on 12/26/2024 with a new start of care date of 12/26/24 - 02/23/2025. The Agency did not review and revise the Plan of Care once every sixty (60) days. Survey findings were reviewed on 12/02/2025 at 03:00 PM with the Director of Patient Services/Clinical Manager. No explanation was provided. Interview and survey findings were reviewed on 12/04/2025 at 12:35 PM with the Branch Director and Director of Patient Services/Clinical Manager. Findings were acknowledged. A second interview was conducted on 12/04/25 2025 at 01:30 PM with the Director of Patient Services/Clinical Manager who reported that patient was pending discharge to Hospice that did not occur. Agency discharged patient at end of certification period. New certification episode opened 12/26/24.

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 records review and staff interview, the Agency failed to coordinate the patient's wound and catheter care. This was evident in two (2) of seventeen (17) records reviewed (Patient #12 and #13). Failure to coordinate patients wound and catheter care has the potential for negative patient outcomes. The findings are: 1) Patient # 12 has a start of care date of 03/20/2025 with diagnoses of "Pressure Ulcer of Sacral Region stage 3, Pressure Ulcer of Left Heel - unstageable, Pressure Ulcer of other sites - unstageable, Pressure Ulcer - other site stage 1, Pressure Ulcer - other site stage 2, and Encounter for fitting urinary device" as documented on the "Home Health Certification and Plan of Care” for certification period 03/20/2025 to 05/18/2025. The "Home Health Certification and Plan of Care” for certification period 03/20/2025 to 05/18/2025 document orders for Skilled Nurse 2 wk 9 (two visits a week for nine weeks) and three (3) as needed visits for wound care. Skilled Nurse to perform wound care treatments to Left lateral heel pressure injury, left posterior heel pressure injury, coccyx pressure injury, mid-back pressure injury, right scapula pressure injury, left medial foot. (It should be noted that there are six (6) pressure injuries listed for wound care treatments). Skilled Nurse to insertion of Foley catheter maintain with 14Fr, 10 cubic centimeter balloon, change monthly". The Registered Nurse wound care assessment visit note dated 03/20/2025 documents the patient has a total of eight (8) wounds noted to the left heel, coccyx, mid-back, scapula, left foot lateral mid edge, left foot post edge. The genitourinary section documents the patient has "indwelling/suprapubic catheter, at risk for urinary tract infection, dark amber color (urine)". There is no documented evidence of the foley catheter size, balloon size and date the foley catheter was changed. The Registered Nurse subsequent visit note report date 03/31/2025, documents "Skilled Nurse noted Foley catheter bag hanging from tub siderail preventing flow. Skilled Nurse lowered Foley catheter bag and noted drainage. Skilled Nurse flush catheter and received over 500 cubic centimeters of output". The genitourinary section documents the patient has "indwelling/suprapubic catheter, at risk for urinary tract infection, sediment in urine". There is no documented evidence of the foley catheter size, balloon size and the date the foley catheter was changed. The Registered Nurse subsequent visit notes report date 04/29/2025, documents "Foley catheter in situ (intact) draining dark amber urine with sediments in tubing. Drainage bag was on top of the bed, informed daytime aide who corrected placement". The genitourinary section documents the patient has "indwelling/suprapubic catheter, at risk for urinary tract infection, sediment in urine". There is no documented evidence of the foley catheter size, balloon size and the date the foley catheter was changed. The clinical record lacks documented evidence of coordination of care related to wound numbering, urinary output /sediments in urine, and Foley catheter monthly change as per the Plan of Care. Survey findings were reviewed on 12/02/2025 at 03:20 PM with the Director of Patient Services/Clinical Manager. No explanation was provided. Interview and survey findings were reviewed on 12/03/2025 at 10:30 AM with the Director of Patient Services/Clinical Manager. Findings were acknowledged. 2) Patient #13 has a start of care date of 10/24/2024 with diagnoses of "Nontraumatic Intracranial Hemorrhage, Hypertensive Heart and Chronic Kidney Disease, Heart Failure, and Anemia as documented on the Home Health Certification and Plan of Care” for certification period 10/24/2024 to 12/22/2024. The "Home Health Certification and Plan of Care” for certification period 10/24/2024 to 12/22/2024 document orders for "Skilled Nurse 1wk1, 2wk3, 1wk1 (one visit a week for one week, two visits a week for two weeks, one visit a week for one week), Physical Therapy 1wk1, 2wk3, 1wk2, 1 every 2wks2, 1wk1 (one visit a week for one week, two visits a week for three weeks, one visit a week for two weeks, one visit every two weeks for two weeks, one visit a week for one week)." The Registered Nurse subsequent visit dated 12/17/25 documents "Skilled Nurse provided wound care to multiple sites which patient tolerated well. Per Assisted Living Staff patient still not on Hospice". The "Client Coordination Note Report" dated 12/23/24 documents "Interdisciplinary Team conference 12/18/24. Reviewed summary of assessment/plan for past 14 days, Discharge". The clinical record lacks documented evidence of a discharge assessment. The patient was readmitted on 12/26/2024 with a new start of care date of 12/26/24 - 02/23/2025. The clinical record lacks documented evidence of coordination of patient services to ensure continuing of patient services while awaiting Hospice evaluation. Survey findings were reviewed on 12/02/2025 at 03:00 PM with the Director of Patient Services/Clinical Manager. No explanation was provided. Interview and survey findings were reviewed on 12/04/2025 at 12:35 PM with the Branch Director and Director of Patient Services/Clinical Manager. Findings were acknowledged.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, the Agency failed to perform onsite supervision of the Home Health Aide every fourteen (14) days. This was evident in review of one (1) of two (2) records with Home Health Aide services (Patient #9). Failure to perform onsite supervision of the Home Health Aide has the potential for negative patient outcomes. The findings are: 1) Patient # 9 has a start of care date of 03/07/2024 with diagnoses of “Encounter for fitting and adjustment of urinary device, Quadriplegia, Neuromuscular dysfunction of Bladder, and Post-Polio Syndrome" as documented on the "Home Health Certification and Plan of Care” for certification period 08/29/2025 to 10/27/2025. The “Home Health Certification and Plan of Care” for certification periods 08/29/2025 - 10/27/2025 and 10/28/2025 - 12/26/2025 document orders for “Skilled Nurse effective 9/14/25 1wk1, 1 every 4wk4, 1wk1 (one visit a week for one week, one visit every four weeks for four weeks, one visit a week for one week), Home Health Aide 1wk1, 2wk8, 1wk1 (one visit a week for one week, two visits a week for eight weeks, one visit a week for one week). Home Health Aide services are dated 08/29/25, 09/01/25, 09/05/25, 09/08/25, 09/12/25, 09/15/25, 09/19/25, 09/22/25, 09/26/25, 10/03/25, 10/06/25, 10/10/25, 10/13/25, 10/17/25, 10/20/25, 10/24/25, 10/31/25, 11/03/25, 11/07/25, 11/14/25. Home Health Aide supervision is dated 08/25/25 and 10/27/25. The "Visit Note Report" dated 09/16/25, 10/15/25, and 11/24/25 lack documented evidence of Home Health Aide supervision. The clinical record lacks documented evidence of supervisory assessment of Home Health Aide services being provided no less frequently than every 14 days. Survey findings were reviewed on 12/04/2025 at 03:45 PM with the Director of Patient Services/Clinical Manager. No explanation was provided. Interview and survey findings were reviewed on 12/05/2025 at 12:35 PM with the Branch Director and Director of Patient Services/Clinical Manager. Findings were acknowledged.

The following statement of deficiencies represents the results of a re-certification survey and a focus COVID -19 infection control survey of Kindred at Home – Westbury d/b/a Centerwell Home Health , ID# 337289 located at 865 Merrick Avenue Suite 340, Westbury, NY 11590, on 11/07//22 to 11/16/22. The agency reports a patient census of one hundred and eighty-six (186). A Standard re-certification survey was initiated on 11/07/2022. Deficient practices were identified within Level 1 standards 484.60 Care planning, coordination of services, quality of care and 484.75 Skilled Professional Services resulting in a Partial Extended Survey. The survey consisted of a review of seventeen (17) clinical records including seven (7) observational visits, five (5) discharge records, eleven (11) personnel records for professional and paraprofessional personnel, one (1) contract , pertinent policies and procedures, review of the Quality Management Program meeting minutes for the past 12 months, PIP (Performance Improvement Projects), the agency’s admission packet, the Emergency Preparedness Plan, and the Complaint Log. Pre-survey activities consisted of a review on 11/4/22 of the agency's Health Commerce System Account, the agency’s iQIES (Internet Quality Improvement and Evaluation System) Reports – OASIS Reports for the period 7/ 2021 to 7/ 2022 and the agency’s compliance with submissions for the Statistical report and the 2019 Emergency Preparedness Drill. Interviews were conducted throughout the survey with the Administrator and the Director of Patient Services (DPS). The findings were reviewed at the Exit Conference on 11/16/22. The following deficiencies are identified as a result of the survey: G0536: A review of all current medications G 0574 Plan of care must include the following G 0578 Conformance with physician orders G 0586 Review and revision of the plan of care G 0716 Preparing clinical notes J 1260 Governing Authority J 1304 Contracts J 1440 Personnel L 0002 Acceptable Infection Ctl Procedure

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on clinical record review and home visit observations, the agency failed to ensure a review of all the current patient medications. This was evident in three (3) of seven (7) home visits conducted. (Patients # 2, #3 and #6). Failure to ensure a review of patients' current medications, has the potential for negative patient outcome. The findings are: 1. Patient # 2 has a start of care date of 09/28/2022 with diagnoses of Unspecified Dementia, Diverticulosis of Intestines, Essential Hypertenson and Atherosclerosis Heart Disease as documented in the "Home Health Certification and Plan of Care" dated 09/28/2022 to 11/26/2022. The "Home Health Certification and Plan of Care" dated 09/28/2022 to 11/26/2022 documents an order for "PT (Physical Therapy" 1 wk 1, 2 wk 2, 1 wk 2, ( one visit a week for oe week, two visits a week for two weeks, one visit a week for two weeks). PT to "evaluate/assess and develop Physical Therapy plan of care to be signed by the Physician". Medication listing includes "Aspirin 81 mg (milligram) chewable one tablet daily oral, Atorvastatin 10 mg one tablet at bedtime daily, Centrum silver 300 mcg (microgram) one tablet daily oral, Citopram 10 mg one tablet daily oral, Clopidogrel 75 mg one tablet daily oral, Donepezil 10 mg one tablet at bedtime oral, Lasartan 50 mg one tablet at bedtime oral, Melatonin 5 mg one tablet at bedtime oral, Memantine 5 mg one tablet daily oral, Pantoprazole 40 mg one tablet daily oral, Ranolazine 1000 mg ER (Extended Realease) one tablet at bedtime oral, and Tylenol Extra Strenght 500 mg two tablets as needed every 6 hours as needed". The clinical record documents PT visits conducted on 10/19/22 and 10/25/22. A Home Visit (HV) was conducted on 11/07/2022 with the Agency's PT. During the HV, the patient's medications were reviewed by the PT and Surveyor. Medication discrepancies were identified for "Myrbetriq 50 mg , extended release, one tablet daily oral, start date of 10/12/22". The Agency failed to ensure a review of the patient's current medication in order to identify any potential adverse effects, drug reactions, side effects, drug interactions, and noncompliance with drug regimen. The survey findings were reviewed with the Branch Manager, Clinical Managers (CM) on 11/10/2022 at 12:45 PM. The CM was interviewed on 11/10/2022 at 02:20 PM and acknowledged the findings. 2. Patient #3 has a start of care date of 10/24/22 with diagnoses of Type 2 Diabetes with Peripheral Angipathy, Nennous Inssuficiency, Lymphedema, Hypertensive Heart Disease with Heart Failure as documented on the "Home Health Certification and Plan of Care" dated 10/24/2022 - 12/22/2022. The "Home Health Certification and Plan of Care" dated 10/24/2022 - 12/22/2022 documents an order for "PT (Physical Therapy" 1 wk 5, 1 every 2 wk 4" (one visit a week for five weeks, one visit every two weeks for four weeks). Medication lisitng includes "Albuterol Sulfate 4 mg one daily, Escitalopra 10 mg one tablet daily oral, Folate 400 mcg (microgram) one tablet daily oral and Tramadol100 mg one tablet every eight hours oral." The clinical record documents PT visits conducted on 10/24/22 and 11/01/22. A Home Visit (HV) was conducted on 11/07/2022 with the Agency's PT. During the HV, the patient's medications were reviewed by the PT and Surveyor. Medication discrepancies were identified for the following medications that the patient is not taking: Albuterol Sulfate 4 mg one tablet oral, Escitalopram 10 mg tablet , Folate 400 mcg one tablet daily oral and Tramadol100 mg one tablet every eight hours oral". The Agency failed to ensure a review of the patient's current medication in order to identify any potential adverse effects, drug reactions, side effects, drug interactions, and noncompliance with drug regimen. The survey findings were reviewed with the Branch Manager, Clinical Managers (CM) on 11/09/2022 at 03:00 PM. The CM was interviewed on 11/10/2022 at 11:50 AM and acknowledged the findings. 3. Patient #6 has a start of care date of 08/10/2022 with diagnoses of Bilateral Primary osteoarthritis, Paroxysmal Atrial Fibrillation and Hypertensive Heart as documented on the "Home Health Certification and Plan of Care" dated 10/28/2022 to 12/26/2022. The "Home Health Certification and Plan of Care" dated 10/28/2022 to 12/26/2022 documents an order for "PT (Physical Therapy" 2 wk 4, 1 wk 4" (two visits a week for four weeks, one visit a week for four weeks) and OT (Occupational Therapy) 1 wk 4, 1 wk 1 ( one visit a week for four weeks and one visit a week for one week). Prescribed medications include "Albuterol Sulfate 90 mcg (microgram) aerosol inhalor one puff as needed, Breo Ellipta 200 mcg-25 mcg dose powder one inhalation daily". The clinical record documents PT and OT visits conducted on 11/04/22 and 11/07/22. and OT visit conducted 11/4/22. A Home Visit (HV) was conducted on 11/08/2022 with the Agency's OT. During the HV, the patient's medications were reviewed by the OT and Surveyor. Medication discrepancies were identified for : Albuterol Sulfate 90 mcg (microgram) aerosol inhalor was discontinued as of "10/25/22", and Breo Ellipta 200 mcg-25 mcg dose powder one inhalation daily was discontinued as of "10/25/22". The Agency failed to ensure a review of the patient's current medication to identify discontinued medications and noncompliance with drug regimen. The survey findings were reviewed with the Branch Manager, Clinical Managers (CM) on 11/09/2022 at 03:20 PM. The CM was interviewed on 11/10/2022 at 12:15 PM and acknowledged the findings.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview this agency failed to ensure each patient's individualized plan of care included orders for all pertinent patient care treatments, patient specific nutritional requirements and patient/ caregiver specific education. This was evident for two (2) of seventeen (17) clinical records reviewed. (Patient #2 and #4). Failure to ensure each patient's individualized plan of care documents all specific patient care orders, treatments and education has the potential for negative patient outcomes. The findings are: 1. Patient # 2 has a start of care date of 09/28/2022 with diagnoses of Unspecified Dementia, Diverticulosis of Intestines, Essential Hypertenson and Atherosclerosis Heart Disease as documented in the "Home Health Certification and Plan of Care" dated 09/28/2022 - 11/26/2022. The "Home Health Certification and Plan of Care" dated 09/28/2022 - 11/26/2022 documents an order for "PT (Physical Therapy" 1 wk 1, 2 wk 2, 1 wk 2, ( one visit a week for oe week, two visits a week for two weeks, one visit a week for two weeks). PT to "evaluate/assess and develop Physical Therapy plan of care to be signed by the Physician". Medication listing includes "Aspirin 81 mg (milligram) chewable one tablet daily oral, Atorvastatin 10 mg one tablet at bedtime daily, Centrum silver 300 mcg (microgram) one tablet daily oral, Citopram 10 mg one tablet daily oral, Clopidogrel 75 mg one tablet daily oral, Donepezil 10 mg one tablet at bedtime oral, Lasartan 50 mg one tablet at bedtime oral, Melatonin 5 mg one tablet at bedtime oral, Memantine 5 mg one tablet daily oral, Pantoprazole 40 mg one tablet daily oral, Ranolazine 1000 mg ER (Extended Realease) one tablet at bedtime oral, and Tylenol Extra Strenght 500 mg two tablets as needed every 6 hours as needed". The Plan of Care lacks an order for the PT to assess and instruct the patient and caregiver on the current medications dosage, route, frequency, therapeutic and side effects and drug to drug interactions. The survey findings were reviewed with the Branch Manager, Clinical Managers (CM) on 11/10/2022 at 12:45 PM. The CM was interviewed on 11/10/2022 at 02:20 PM and acknowledged the findings. 2. Patient #4 has a start of care date of 08/08/2020 with diagnoses of Pressure Ulcer of Left Buttock Stage 2, Unspecified Dementia , Hypertensive Heart Disease and Unspecified Heart Failure as documented on the "Home Health Certification and Plan of Care" dated 10/07/2022 to 12/05/2022. The "Home Health Certification and Plan of Care" dated 10/07/2022 to 12/05/2022 documents an order for "SN (Skilled Nurse) effective 10/09/2022 1 wk 4 (one visit a week for four weeks), SN to "evaluate and develop Plan of Care to be countersigned by the Physician". SN to "assess /evaluate co-morbid conditions". Nutritional Requirements: "NAS" (No Added Salt). A Home Visit was conducted on 11/08/2022 with the Agency's SN. During interview with the patient's daughter/caregiver other on 11/08/2022 at 01:45 PM, the daughter reports that patient's medications are administered through the "PEG (Percutaneous Endoscopic Gastrostomy) tube, and PEG feedings include "Jevity 8 ounces five times a day, PEG is flushed with water after each feed and medication administration". The Plan of Care (POC) lacks an order for the patient specific Nutritional/Dietary requirement through the PEG tube feeding with Jevity and amount/quantity of water flush after each feed. The POC lacks an order for the PEG tube care and treatment and the PEG tube flush with water after medication adminisitration". The Agency failed to assess /evaluate the patient's co-morbid condition of PEG tube feeding and failed to establish an individualized Plan of Care that includes pertinent patient care treatments and Nutritional requirements. The survey findings were reviewed with the Branch Manager, Clinical Managers (CM) on 11/08/2022 at 03:30 PM. The CM was interviewed on 11/10/2022 at 12:10 PM, and acknowledged the findings.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to ensure services/ treatments are being provided in accordance with the physician orders. This was evident for four (4) of seventeen (17) clinical records reviewed (Patients # 1, # 4, # 12, and #17). Failure to ensure patient services / treatments are provided in accordance with the physician orders has the potential for negative patient outcome. The findings are: . 4. Patient #12 has a start of care date of 7/8/22 with diagnosis: “Unsp. Open Wound of Right Great Toe W/O Damage to Nail, Subs” documented on the Home Health Certification and Plan of Care for the Certification Period 9/16/22 to 11/14/22. The Agency's Home Health Order documents: “ Order Date: 9/29/22 12:41PM : Order Description: Verbal Orders received from the Physician: SN to cleanse wound #5 right great toe trauma wound with saline, pat dry prepare peri wound with skin prep and prep and drape, fill entire cavity with black foam bridge from toe to thigh then cover tubing with transparent tape apply negative pressure 125 MMHG continuously three times a week maintaining clean aseptic technique until healed or MD changes orders. SN provide a wound care and education on wound vac to patient and spouse.” The Agency's Home Health Order documents: “ Order Date:10/5/22 2:10 PM : Order Description: Received by Physician : DC Wound Vac. SN to cleanse with NS and Pat dry apply Puracol and cover with DCD 3XWeekly until healed .” The Visit Note Report documents: “Visit Date: 10/07/22 : In Home Time Began: 10/07/22 11:45AM : Wound #5 : Wound Care Provided: Right great toe Trauma right great toe trauma wound with saline, pat dry prepare peri wound with skin prep and prep and drape, fill entire cavity with black foam bridge from toe to thigh then cover tubing with transparent tape apply negative pressure 125 MMHG continuously three times a week maintaining clean aseptic technique until healed or MD changes orders.” The clinical record lacks documented evidence of SN services being provided in accordance with the physician’s order dated 10/05/22. The Visit Note Report documents: “Visit Date:10/10/22 : In Home Time Began: 10/31/22 05:22 PM : Wound #1 – Heel Left – PU (Pressure Ulcer Stage 111 Reactivated 10/31/22 : Change In Status: Reactivated Wound Recurrence : Wound care provided: Cleansed with wound cleaner applied iodosorb , covered with DSD wrapped with kling secured with tape. The Agency's Home Health Order documents: “ Order Date:10/31/22 5:22 PM : Order Description: verbal order from Physician for wound #1- left heel unstageable PU: Cleansed with wound cleaner applied iodosorb , covered with DSD wrapped with kling secured with tape TIW (three times a week and PRN for dislodgement or soiling using aseptic technique until healed or MD changes order - Caregiver may perform wound care on days SN not in home.” The Visit Note Report documents: “Visit Date:11/02/22 : In Home Time Began: 11/02/22 11:07 AM : There is no documented evidence of wound care being provided for wound #1. The clinical record lacks documented evidence of wound care being provided for wound #1 in accordance with the physician’s orders. On 11/16/22 at 1:15PM the Director of Patient Services was interviewed and did not provide an explanation for the findings. 1. Patient #1 has a start of care date of 09/02/2022 with diagnoses of Pressure Ulcer of other site, Essential Hypertension, Chronic Obstructive Pulmonary Disease as documented on "Home Health Certification and Plan of Care" dated 11/01/22 to 12/30/22. The "Home Health Certification and Plan of Care" dated 11/01/22 to 12/30/22 documents an order for "SN (Skilled Nurse) 2wk1, 3wk8 (two visit a week for one week, three visits a week for eight weeks). SN to "evaluate and develop Plan of Care to be countersigned by the Physician". Medication orders include "Aricept 10 mg tablet one tablet po (per oral) daily, Fluticasone Furoate 100 mcg Vilantor 25 mch inhalation powder, Folic Acid 400 mg one tablet po daily, Gabapentin 100 mg one capsule po daily, Larsartan 50 mg one tablet daily, Meloxicam 15 mg one tablet po daily as needed, Pravasatin 20 mg one tablet po daily and Vitamin D3 take 25 mcg one tablet po daily". A Home Visit (HV) was conducted on 11/07/2222 with the Agency's Skilled Nurse. During the HV, the SN reviewed the patients' medications. Medication discrepancies were identified for "Ferrous Sultate 325 mg one tablet daily oral", with a start date of 10/22/22 and "Nystatin Powder 100,00 units topical powder apply to skin redness daily as needed, with a start date of 10/27/2022. The SN "Visit Note Report" dated 10/28/22, 11/02/22 and 11/04/22 lack documented evidence that the SN performed medication reconciliation to include "Ferrous Sultate 325 mg one tablet daily oral", with a start date of 10/22/22 and "Nystatin Powder 100,00 units topical powder apply to skin redness daily as needed". The agency failed to ensure the patient's medication regimen include all pertinent medications that conforms with the Physician’s orders The survey findings were reviewed with the Branch Manager, Clinical Managers (CM) on 11/09/2022 at 03:30 PM. The CM acknowledged the findings. 2. Patient #4 has a start of care date of 08/08/2020 with diagnoses of Pressure Ulcer of Left Buttock Stage 2, Unspecified Dementia, Hypertensive Heart Disease and Unspecified Heart Failure as documented on the "Home Health Certification and Plan of Care" dated 10/07/2022 to 12/05/2022. The "Home Health Certification and Plan of Care" dated 10/07/2022 to 12/05/2022 documents an order for "SN (Skilled Nurse) effective 10/09/2022 1 wk. 4 (one visit a week for four weeks), SN to "assess /evaluate co-morbid conditions". Nutritional Requirements: "NAS" (No Added Salt). A Home Visit was conducted on 11/08/2022 with the Agency's SN. During interview with the patient's daughter/caregiver other on 11/08/2022 at 01:45 PM, the daughter reports that patient's medications are administered through the "PEG (Percutaneous Endoscopic Gastrostomy) tube, and PEG feedings include "Jevity 8 ounces five times a day, PEG is flushed with water after each feed and medication administration". The SN "Visit Note Reports" dated 10/11/22, 10/18/22, 10/25/22, and 11/03/22 lack documented evidence that the patient has a PEG tube, receives PEG tube feeding of Jevity 8 ounces five times a day and PEG tube flush after feedings and medication administration. The Agency failed to conform with the Physician's Order to assess the patient's Nutritional requirement and PEG tube feeding and treatments. The survey findings were reviewed with the Branch Manager, Clinical Managers (CM) on 11/08/2022 at 03:30 PM. The CM was interviewed on 11/10/2022 at 12:10 PM and acknowledged the findings. 3. Patient #17 has a start of care date of 01/14/2022 with diagnoses of Type 2 Diabetes Mellitus, Pain in Right Knee, Pain in Left Knee and Unspecified Asthma as documented on the "Home Health Certification and Plan of Care" dated 01/04/2022 to 03/04/2022. The patient has a discharge date of 3/3/22 from the agency. The "Home Health Certification and Plan of Care" dated 01/04/2022 to 03/04/2022 documents an order for "MSW (Medical Social Worker). The clinical record lacks documented evidence of MSW visits conducted from start of care date of 01/04/2022 to discharge date of 03/03/2022. The agency failed to provide MSW services in conformance to the Physician's Orders. The survey findings were reviewed with the Branch Manager, Clinical Managers (CM) on 11/14/2022 at 03:40 PM. The CM was interviewed on 11/15/2022 at 11:00 AM and acknowledged the findings

Review and revision of the plan of care CFR(s): 484.60(c) Standard: Review and revision of the plan of care. This STANDARD is not met as evidenced by: Based on clinical record review and staff interview the agency failed to ensure the patient’s Plan of Care (POC) is reviewed, revised and includes the patient's current medication regime. This was evident in one (1) of seventeen (17) clinical records reviewed (Patient # 6). Failure to ensure the plan of care is reviewed and revised has the potential for negative patient outcome. The findings are: 1. Patient #6 has a start of care date of 08/10/2022 with diagnoses of Bilateral Primary osteoarthritis, Paroxysmal Atrial Fibrillation and Hypertensive Heart as documented on the "Home Health Certification and Plan of Care" dated 10/28/2022 to 12/26/2022. The "Home Health Certification and Plan of Care" dated 10/28/2022 to 12/26/2022 documents an order for "PT (Physical Therapy" 2 wk 4, 1 wk 4" (two visits a week for four weeks, one visit a week for four weeks) and OT (Occupational Therapy) 1 wk 4, 1 wk 1 ( one visit a week for four weeks and one visit a week for one week). Prescribed medications include "Albuterol Sulfate 90 mcg (microgram) aerosol inhaler one puff as needed, Breo Ellipta 200 mcg-25 mcg dose powder one inhalation daily". A Home Visit (HV) was conducted on 11/08/2022 with the Agency's OT. During the HV, the patient's medications were reviewed by the OT and Surveyor. Medication discrepancies were identified for : Albuterol Sulfate 90 mcg (microgram) aerosol inhalor was discontinued as of "10/25/22", and Breo Ellipta 200 mcg-25 mcg dose powder one inhalation daily was discontinued as of "10/25/22". The clinical record lacks documented evidence that the Plan of Care was reviewed and revised to include the current medication regimen and identify discontinued medications including Albuterol Sulfate and Breo Ellipta that were discontinued on 10/25/22 prior to the recertification period of 10/28/22. The survey findings were reviewed with the Branch Manager, Clinical Managers (CM) on 11/09/2022 at 03:20 PM. The CM was interviewed on 11/10/2022 at 12:15 PM and acknowledged the findings.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview the agency failed to ensure all clinical notes accurately describe and documents the care being performed by each staff. This was evident for one (1) of five (5) discharge records reviewed. (Patient #16). Failure to ensure all clinical notes accurately documents the care being performed has the potential for negative patient outcome. The findings are: 1. Patient # 16 has a start of care date of 06/16/2021 with diagnoses of Type 2 Diabetes Mellitus, Venous Insufficiency, Disorder of the Skin and Subcutaneous Tissue, and Hypertensive Chronic Kidney Disease as documented on the "Home Health Certification and Plan of Care" dated 02/22/2022 to 04/11/2022. The patient has a discharge date of 04/07/2022 from the Agency. The "Home Health Certification and Plan of Care" dated 02/22/2022 to 04/11/2022 documents an order for "SN (Skilled Nurse) 1 wk 1, 2 wk 2, 1 wk 6, 1 PRN (one visit a week for one wee, two visit a week for two weeks, one visit a week for six weeks and one as needed visit). SN to "observe/assess Pulmonary system, observe/assess Genitourinary system, observe/assess Intergumentary system". The "Visit Note Report" dated 02/11/22, 02/18/22, 02/22/22, and 03/25/22, the Licensed Practical Nurse (LPN) documents "assessment of Pulmonary system, assessment of Genitourinary system, and assessment of Intergumentary system". It should be noted that "assessment of patients are out of the Scope of Practice of LPN level of care. The Agency failed to ensure that patient care services are provided in accordance to the licensure and scope of task for the Skilled Nurse services. The survey findings were reviewed with the Branch Manager, Clinical Managers (CM) on 11/14/2022 at 04:00 PM. The CM was interviewed on 11/15/2022 at 10:52 AM and acknowledged the findings.