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 Certified Home Health Agency conducted on 09/08/2025 to 09/12/2025. A standard re-certification survey was initiated on 09/08/2025. Deficient practices were identified within Level 1 standards in 484.55 Condition and resulting in a partial extended survey on 09/09/2025. The survey consisted of a review of 17 (seventeen) clinical records including 5 (five) discharge records, 8 (eight) personnel records for professional and paraprofessional personnel, 1 (one) contract, and 6 (six) observational home visits. The survey included a review of pertinent policies and procedures, Quality Improvement Meeting minutes for the past 12 months, agency’s Admission Packet, the Emergency Preparedness Plan, and Complaint Log. Pre-survey activities consisted of review on 09/03/2025 date of the agency’s Health Commerce System account, Home Care Registry, potentially avoidable reports for the period 06/02/2024 - 05/30/2025, the Home Health Agency Error Summary Report for 09/01/2024 to 09/01/2025, and the agency’s compliance with report submissions for the 2024 statistical report and the Emergency Drill conducted in 2019. The total number of active patients was 221 (two hundred twenty- one). The Clinical Manager, Branch Director, and staff were interviewed. Findings were reviewed at the exit conference on 09/12/2025. The following deficiencies are identified as a result of the survey: G-0372, G-0374, G-0514, G-0528, G-0536, G-0574, G-0580, G-0590, G-0592, G-0602, G-0606, G-0716, J-0712, J-1132, J-1156, J-1168, J-1172, J-1260, J-1424, J-1444, J- 1456, J-1476, and R-0510.

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on clinical record reviews, the Home Health Agency (HHA) Error Report, and staff interviews, the agency failed to ensure that all completed Outcome and Assessment Information Set assessments (M0090) were transmitted to the State/Centers for Medicare and Medicaid Services when completed. This is evident for one (1) of one (1) clinical record reviewed that required transmission (Patient #16). Failure to ensure that all completed Outcome and Assessment Information Set assessments are transmitted to the Centers for Medicare and Medicaid Services contractor or state within 30 (thirty) days has the potential for negative patient outcomes. Pre-survey review of the "Home Health Agency Error Summary Report" on 09/02/2025 revealed the agency has 280 (two hundred eighty) late submissions of the Outcome and Assessment Information Set assessments (M0090) from 09/01/2024 to 09/01/2025. Patient #16 – This 62-year-old patient with the diagnoses of type 2 diabetes mellitus, enterostomy malfunction, and morbid obesity due to excess calories was admitted to the home care agency on 07/23/2025. Review of the Registered Nurse Outcome and Assessment Information Set Start of Care completed by the Registered Nurse revealed the Outcome and Assessment Information Set Assessment (M0090) was completed on 07/23/2025. Review of the Home Health Agency Error Submission Report provided by the agency on 09/08/2025 at 12:30 PM revealed the patient’s Outcome and Assessment Information Set Assessment (M0090) was submitted on 08/27/2025, 35 (thirty-five) days after the assessment was complete. During interview on 09/11/2025 at 04:07 PM, the Branch Director stated the clinical manager responsible for submitting the Outcome and Assessment Information Set Assessments was unavailable at the time of submission, as a result the agency was behind on submitting the report within the required time frame.

Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient's status at the time of assessment. This STANDARD is not met as evidenced by: Based on review of the agency's Outcome Assessment Information Set (OASIS) submissions, clinical records, and interview with staff for one (1) of seventeen (17) patients (Patient #8), the agency failed to ensure the OASIS data accurately reflects the patient's status at the time of the assessment. Failure to ensure accurate documentation of OASIS data has the potential for negative outcomes. Patient #8 – This 91-year-old patient with diagnoses that include fracture to unspecified neck of left femur and three-part fracture to neck of right humerus was admitted as therapy-only to the home health agency on 05/12/2024 and discharged 07/10/2024. Pre-survey review of the agency’s Outcome and Assessment Information Set (OASIS) submission as reflected on the Internet Quality Improvement and Evaluation System (IQIES) Potentially Avoidable Event Report revealed the patient was listed as having a potentially avoidable event from 05/12/2024 to 07/10/2024 in the category of “emergent care for hypoglycemia/hypoglycemia.” Review of the Physical Therapy (PT) Discharge Data Collection Only- No Visit Made dated 07/10/2024 revealed the PT documented the patient had utilized a hospital emergency department with hospital admission since the most recent start of care for hypo/hyperglycemia and diabetes out of control. Review of the clinical record from 05/12/2024 to 07/10/2024 lacks documentation of the patient being treated at a facility emergency department with subsequent hospitalization. During interview on 09/12/2025 at 09:38 AM, the PT stated the patient went to the emergency department and was hospitalized for uncontrolled diabetes on 07/14/2024 (four days after discharge). The PT incorrectly documented the hospitalization on the discharge documentation dated 07/10/2024.

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 review of clinical records and staff interview for five (5) of seventeen (17) patients (Patient #’s: 1, 6, 10, 13, and 14), the agency failed to ensure the clinician conducted an initial assessment of the patient within forty-eight (48) hours of referral, the patient's return home, or on the physician-ordered start of care date. Failure to conduct the initial assessment within the required time frame has the potential to result in unmet patient needs and negative patient outcomes. The New York Codes, Rules, and Regulations, Title 10, Article 7, Section 763.5(a) Patient Referral and Admission states “The initial patient visit shall be made within twenty-four (24) hours of receipt and acceptance of a community referral or return home from institutional placement unless: (1) the patient’s authorized practitioner orders otherwise; or (2) there is written documentation that the patient or family refuses such a visit.” Patient #1 – This 65-year-old patient with diagnoses that include displaced trimalleolar fracture to left lower leg and displaced bimalleolar fracture to right lower leg was admitted to the home health agency on 08/22/2025. Review of the Referral Summary dated 08/20/2025 revealed the patient was referred to the home health agency for Skilled Nursing (SN), Physical Therapy (PT), and Occupational Therapy (OT) on 08/20/2025. Review of the Client Coordination Note dated 08/20/2025 revealed the RN obtained a verbal order for the SN start of care to occur on 08/22/2025. Review of the clinical record lacks documentation the patient was contacted and requested a delay to the start of care. During interview on 09/12/2025 at 11:34 AM, the Clinical Manager stated there is no documentation the patient was contacted on 08/21/2025 and requested a delay to the start of care visit. Patient #10 – This 72-year-old patient with diagnoses that include hypertensive heart and chronic kidney disease with heart failure and acute on chronic diastolic heart failure was admitted to the home health agency on 12/22/2024 and discharged on 02/07/2025. Review of the Skilled Nursing Facility Post Discharge Plan of Care (agency referral) dated 12/17/2024 revealed the patient was referred to the home health agency on 12/17/2024. Review of the Client Coordination Note dated 12/17/2024 revealed the RN obtained a verbal order for the SN start of care to occur on 12/18/2024. Review of the Client Coordination Note dated 12/20/2024 revealed the RN obtained a verbal order for the SN start of care to occur on 12/22/2024. Review of the clinical record lacks documentation the patient was contacted and requested a delay to the start of care. During interview on 09/12/2025 at 11:05 AM, the Clinical Manager stated the 12/18/2024 start of care was delayed as it was a hemodialysis day for the patient. However, the Clinical Manager stated there is no documentation the patient was contacted 12/19/2024 to attempt to reschedule the start of care visit. Patient #13 – This 88-year-old patient with diagnoses that include bilateral primary osteoarthritis of knee and muscle weakness generalized was admitted as therapy-only to the home health agency on 08/20/2025. Review of the Referral Summary dated 08/15/2025 revealed the patient was referred to the home health agency for PT and OT on 08/15/2025. Review of the Client Coordination Note dated 08/19/2025 revealed the RN documented a verbal order was obtained for a PT start of care visit on 08/20/2025. Review of the clinical record lacks documentation the patient was contacted and requested to delay the start of care to 08/20/2025, five (5) days after the referral was sent. During interview on 09/12/2025 at 10:52 AM, the Clinical Manager/Director of Patient Services stated there is no documentation the patient was contacted and delayed the start of care visit. Patient #6 – This 85-year-old patient with the diagnoses of osteoarthritis of lumbosacral spine, paroxysmal atrial fibrillation, chronic diastolic heart disease, and recurrent falls was admitted to the home care agency on 08/17/2025. Review of the Referral Summary dated 07/24/2025 revealed the patient was referred to the home health agency for Skilled Nursing, Physical Therapy, and Occupational Therapy on 07/24/2025. Review of the Client Coordination Note dated 08/15/2025 revealed the Registered Nurse obtained a verbal order for the SN start of care to occur on 08/17/2025. Review of the clinical record lacks documentation the patient was contacted and requested a delay to the start of care. During interview on 09/09/2025 at 03:46 PM, the Clinical Manager stated start of care was delayed because the agency was waiting on information from the physician’s office. However, the Clinical Manager stated there is no documentation the patient was contacted, and the physician was notified of the delay to the start of care visit. Patient #14 – This 66-year-old patient with the diagnoses of type 2 diabetes mellitus with hyperglycemia, postmenopausal, and essential hypertension was admitted to the home care agency on 08/23/2025. Review of the Referral Summary dated 08/18/2025 revealed the physician ordered the start of care for 08/19/2025 and further indicated that the patient “Needs care tomorrow." Review of the clinical record lacks documentation the patient was contacted and requested a delay to the start of care. During interview on 09/11/2025 at 02:30 PM, the Clinical Manager acknowledged there was a delay to the start of care for the patient but stated they were unsure why the delay occurred.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) 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: (1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview for one (1) of seventeen (17) patients (Patient #10), the agency failed to ensure the initial comprehensive assessment if of sufficient scope to identify patient needs. Failure to ensure the initial comprehensive assessment accurately reflects the patient status and needs has the potential for unmet patient needs and negative patient outcomes. Patient #10 – This 72-year-old patient with diagnoses that include hypertensive heart and chronic kidney disease with heart failure and acute on chronic diastolic heart failure was admitted to the home health agency on 12/22/2024 and discharged on 02/07/2025. A.) Review of the Home Health Certification and Plan of Care from 12/22/2024 to 02/19/2025 revealed an order for humalog junior kwikpen 100-unit (u) per milliliter (ml) subcutaneous three (3) times daily: - no injection for blood sugar 0 to 250; - 4 units for blood sugar 51(251) to 300; - 6 units for blood sugar 301 to 350; - 8 units for blood sugar 351 to 400; and - if blood sugar over 400 hold insulin and call physician (MD). Review of the Registered Nurse (RN) Outcome and Assessment Information Set (OASIS) Admission Visit dated 12/22/2024 revealed the RN documented the patient has diabetes, does not test blood glucose, is unable to report blood glucose reading as has not checked it today and can prepare and administer injectable medication. The documentation lacks an assessment of the diabetic supplies in the home and the patient’s ability to test blood glucoses three times daily to administer sliding scale insulin three times daily. During interview on 09/11/2025 at 02:40 PM, the RN stated being unable to review the identified documentation due to no electronic access to discharged patient records and cannot recall the identified patient. During interview on 09/11/2025 at 02:47 PM, the Clinical Manager/Director of Patient Services stated there is no documentation of how the patient will check blood glucoses and administer insulin per a sliding scale three times daily. B.) Review of the Skilled Nursing Facility Post Discharge Plan of Care (agency referral) dated 12/17/2024 revealed the patient has the following: - a right chest dialysis catheter covered with a dressing; - a pressure area to the coccyx requiring area to be washed, apply Triad cream and dry dressing daily; and - a right arm skin tear requiring cleansing with normal saline and applying a dry non-adherent dressing. Review of the RN OASIS Admission Visit dated 12/22/2024 revealed the RN documented the patient has some bruising to Integumentary and does not have a pressure ulcer, stasis ulcer or surgical wound. The assessment lacks documentation of the presence of the right chest dialysis catheter and dressing status, and the status of the coccyx pressure ulcer and right arm skin tear as identified in the agency referral. During interview on 09/11/2025 at 02:40 PM, the RN stated being unable to review the identified documentation due to no electronic access to discharged patient records and cannot recall the identified patient. During interview on 09/11/2025 at 02:59 PM, the Clinical Manager/Director of Patient Services stated the assessment lacks documentation of the right chest dialysis catheter and dressing, the coccyx pressure ulcer and the right arm skin tear.

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 interview with agency staff, two (2) of seventeen (17) clinical records (Patient #'s: 13 and 15) lack documentation of a complete review of all medications the patient currently uses to identify any potential adverse effects, drug reactions, or concerns. Failure to conduct a complete medication review and to ensure the medication regime is appropriate has the potential for patient harm. Patient #13 – This 88-year-old patient with diagnoses that include bilateral primary osteoarthritis of knee and muscle weakness generalized was admitted as therapy-only to the home health agency on 08/20/2025. Review of agency policy entitled “Medication Review and Documentation” revised 10/2024 revealed “If a therapist is not authorized by their state practice act to perform a review of patient medications, the Clinical Manager (or designee) will perform the drug regimen review/medication reconciliation process…..within five days of the Start of Care date.” Review of the Physical Therapy (PT) Outcome and Assessment Information Set (OASIS) Admission visit dated 08/20/2025 revealed the PT documented a drug regimen review was conducted and no issues were found. Review of the Client Medication Report revealed the Registered Nurse conducting the medication review on 09/09/2025, twenty (20) days after the start of care visit. During interview on 09/12/2025 at 10:55 AM, the Clinical Manager/Director of Patient Services acknowledged the drug regimen review failed to be completed by the RN within the required time frame. Patient #15 – This 88-year-old patient with the diagnoses of unspecified mononeuropathy of bilateral lower limbs, hyperlipidemia, and essential hypertension was admitted to the home care agency on 08/20/2025. A.) Review of the Referral Summary dated 08/11/2025 revealed the following orders: -Lidocaine (Lidoderm) 4% adhesive patch medicated use daily as needed for pain. -Melatonin 5 mg (milligram) tablet, one tablet at bedtime. Review of the Home Health Certification and Plan of Care (POC) for certification period 08/20/2025 to 10/18/2025 lacks an order for the Lidocaine and Melatonin. B.) Review of the Home Health Certification and Plan of Care for certification period 08/20/2025 to 10/18/2025 revealed the following orders: -Citalopram 20 mg tablet, one tablet daily for depression. Review of the Referral Summary dated 08/11/2025 lacks the order for the Citalopram. Review of the Physical Therapy Outcome and Assessment Information Set Admission visit dated 08/20/2025 revealed the PT documented a drug regimen review was conducted and no issues were found. During interview on 09/12/2025 at 10:25 AM, the Physical Therapist stated that the discrepancies were not identified during the medication review, so the physician was not notified.

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 review of clinical records and staff interviews for two (2) of seventeen (17) patients (Patient #’s 10 and 17) the agency failed to develop individualized plans of care that are complete and accurate and address the total needs of the patients. Failure to ensure that a comprehensive individualized plan of care is developed has the potential for unmet patient needs. Patient #10 – This 72-year-old patient with diagnoses that include hypertensive heart and chronic kidney disease with heart failure and acute on chronic diastolic heart failure was admitted to the home health agency on 12/22/2024 and discharged on 02/07/2025. A.) Review of the Skilled Nursing Facility (SNF) Post Discharge Plan of Care (agency referral) dated 12/17/2024 revealed the patient is on a renal diet with 1500 milliliter (ml) fluid restriction in a twenty-four (24) hour period due to end stage renal disease and is on hemodialysis. Review of the Home Health Certification and Plan of Care from 12/22/2024 to 02/19/2025 revealed the patient is ordered a cardiac diet. Review of the clinical record lacks documentation regarding the fluid restriction and renal diet ordered in the agency referral. During interview on 09/11/2025 at 02:29 PM, the Clinical Manager stated there is no documentation of follow-up on the dietary orders on the referral. B.) Review of the Home Health Certification and Plan of Care from 12/22/2024 to 02/19/2025 revealed the patient is ordered the following: - to administer sliding scale short acting insulin three (3) times daily; - to administer long-acting insulin once daily; - is documented to not monitor blood sugars in home; and - medications are not available to be viewed in the home. - Skilled Nurse to observe/assess diabetes, identify changes and intervene to minimize complication, teach related diabetes management to include disease process, nutrition, medications, activities, and personal/environment. The plan of care lacks documentation of diabetic supplies used in the home and who manages the diabetes and insulin administration as the patient does not test blood glucoses. During interview on 09/11/2025 at 02:40 PM, the Clinical Manager stated the plan of care fails to specify the identified items. Patient #17 – This 78-year-old patient with diagnoses that include urinary tract infection and type 2 diabetes mellitus was admitted to the home health agency on 07/07/2025. Review of the Home Health Certification and Plan of Care from 07/07/2025 to 09/04/2025 revealed the Registered Nurse (RN) documented the patient is ordered to take insulin glargine- 100 units per ml subcutaneous 26 units daily. Review of the Clinically Significant Medication Issue Coordination Note dated 07/07/2025 revealed the RN documented the basaglar (glargine) insulin is not in the home. The physician was contacted and approves the patient not to take it. Review of the clinical record lacks documentation of an order to discontinue the identified insulin. During interview on 09/12/2025 at 10:21 AM, the RN stated the patient was taking the insulin as ordered and made an error regarding the insulin not being taken and being discontinued when documenting in the identified Coordination Note.

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 interview with agency staff, for two (2) of seventeen (17) patients (Patient #’s: 10 and 17), the agency failed to ensure services and treatments are administered in accordance with physician orders. Failure to provide services and treatments as ordered has the potential to result in poor quality of care. Patient #10 – This 72-year-old patient with diagnoses that include hypertensive heart and chronic kidney disease with heart failure and acute on chronic diastolic heart failure was admitted to the home health agency on 12/22/2024 and discharged on 02/07/2025. A.) Review of the Home Health Certification and Plan of Care from 12/22/2024 to 02/19/2025 revealed orders to assess/instruct on daily weight and keep a log. Notify physician of for weight greater than 158 pounds. Review of the Registered Nurse (RN) Outcome and Assessment Information Set (OASIS) Admission Visit dated 12/22/2024 revealed the RN documented the patient’s weight is 168 pounds. Review of the clinical record lacks documentation the authorized provider was notified of the patient’s weight being greater than 158 pounds. During interview on 09/11/2025 at 02:50 PM, the RN stated being unable to review the identified documentation due to no electronic access to discharged patient records and cannot recall the identified patient. During interview on 09/11/2025 at 02:52 PM, the Clinical Manager stated there is no documentation the physician was notified of the identified weight as ordered. B.) Review of the Home Health Certification and Plan of Care from 12/22/2024 to 02/19/2025 revealed an order to assess/instruct on obtaining daily weight and keeping log. If patient is unable to weigh obtain lower extremity circumference each visit and notify physician of increase of two (2) centimeters (cm) or greater. Review of the RN Subsequent Visit dated 12/26/2024 revealed the RN documented the patient has edema to bilateral lower extremities and patient reports she needs a scale to monitor daily weights. The assessment lacks documentation of a weight or lower extremity circumferences being obtained. During interview on 09/12/2025 at 09:28 AM, the RN stated being unable to review the identified documentation due to no electronic access to discharged patient records and cannot recall the identified patient. During interview on 09/12/2025 at 09:30 AM, the Clinical Manager states there is no documentation of a weight or lower extremity circumferences being obtained during the identified visit. Patient #17 – This 78-year-old patient with diagnoses that include urinary tract infection and type 2 diabetes mellitus was admitted to the home health agency on 07/07/2025. Review of the Home Health Certification and Plan of Care from 07/07/2025 to 09/04/2025 revealed the patient wears a continuous blood glucose monitor and is checking blood sugars twice daily. The licensed professional is to report a fasting blood glucose less than 60 or greater than 250 to the authorized provider. Review of the RN Subsequent Visit dated 08/18/2025 revealed the RN documented the patient reports fasting blood glucoses within the last week ranging from 116 to 260. Review of the clinical record lacks documentation the authorized provider was notified of the fasting blood sugar ranging greater than 250. During interview on 09/12/2025 at 08:44 AM, the RN stated due to an oversight the physician was not notified of the identified glucose ranges being greater than 250.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on review of clinical records and interviews with staff for two (2) of seventeen (17) patients (Patient #’s 4 and 10), the agency failed to ensure the physician is notified of changes in the patient's condition or needs that suggest the plan of care may need to be altered. Failure to promptly notify the physician to changes in the patient's condition or needs that may suggest that outcomes are not being achieved and/or the plan of care should be altered has the potential to result in unmet patient needs and negative patient outcomes. Patient #4 – This 91-year-old patient with the diagnoses of pressure ulcer of sacral region, stage 4, osteomyelitis of vertebral column, and paraplegia was admitted to the home care agency on 08/23/2025. Review of the OT (Occupational Therapy) Add ON Evaluation Visit dated 08/27/2025 revealed the OT documented the patient had edema of the lower extremities. Review of the clinical record lacks documented evidence that the physician was notified of the patient’s lower extremity edema. During an interview on 09/12/2025 at 10:45 AM, the Clinical Manager stated the OT was unavailable for interview and acknowledged there was no documentation in the clinical records that the physician was notified of the patient’s lower extremity edema. Patient #10 – This 72-year-old patient with diagnoses that include hypertensive heart and chronic kidney disease with heart failure and acute on chronic diastolic heart failure was admitted to the home health agency on 12/22/2024 and discharged on 02/07/2025. A.) Review of the Skilled Nursing Facility Post Discharge Plan of Care (agency referral) revealed the patient is ordered to wear oxygen 2 liters per minute via nasal cannula. The frequency of use is not specified. Review of the Registered Nurse (RN) Outcome and Assessment Information Set (OASIS) Admission Visit revealed the RN documented the patient was not using oxygen at the time of the visit and the patient stated they are trying to wean off the oxygen that is ordered. Review of the Home Health Certification and Plan of Care from 12/22/2024 to 02/19/2025 lacks orders for oxygen use. Review of the clinical record lacks documentation the authorized practitioner was reported of the patient self-weaning oxygen use and verified the oxygen orders could be discontinued. During interview on 09/11/2025 at 02:45 PM, the RN stated being unable to review the identified documentation due to no electronic access to discharged patient records and cannot recall the identified patient. During interview on 09/11/2025 at 02:47 PM, the Clinical Manager stated there was no documentation the authorized practitioner was notified of the patient not using the oxygen and discontinuing the use of oxygen. B.) Review of the RN OASIS Admission Visit dated 12/22/2024 revealed the RN documented the patient does not test blood glucose levels and reports taking the injectable medication as prescribed. Review of the Home Health Certification and Plan of Care from 12/22/2024 to 02/19/2025 revealed orders for Humalog junior kwikpen 100 units per milliliter (ml) subcutaneous following the sliding scale three (3) times daily: - no injection for blood sugar 0-250; - 4 units for blood sugars 51 (251) to 300; - 6 units for blood sugars 301 to 350; - 8 units for blood sugar 351 to 400; and - if over blood sugar over 400, hold insulin and call physician. Review of the clinical record lacks documentation the physician was notified the patient is not testing blood glucoses three (3) times daily for sliding scale insulin administration. During interview on 09/11/2025 at 03:10 PM, the RN stated being unable to review the identified documentation due to no electronic access to discharged patient records and cannot recall the identified patient. During interview on 09/11/2025 at 03:12 PM, the Clinical Manager stated there is no documentation the physician was notified of the patient not testing blood glucoses three times daily for sliding scale insulin administration. C.) Review of the Home Health Certification and Plan of Care from 12/22/2024 to 02/19/2025 revealed orders for the following: - Humalog junior kwikpen 100 units per milliliter (ml) subcutaneous following the sliding scale three times daily: - no injection for blood sugar 0-250; - 4 units for blood sugars 51 (251) to 300; - 6 units for blood sugars 301 to 350; - 8 units for blood sugar 351 to 400; and - if over blood sugar over 400, hold insulin and call physician. - Assess/instruct on daily weight and keeping log. Notify physician of weight gain of 2-3 pounds in twenty-four (24) hours or 5 pounds in one week. - Notify authorized practitioner of weight greater than 158 pounds. Review of the RN Subsequent Visit dated 12/26/2024 revealed the RN documented the patient states not having the materials needed to test blood sugar as her continuous meter and supplies are at another location. Additionally, the patient states a scale is needed to perform daily weights. Review of the clinical record lacks documentation the authorized practitioner was notified of the patient not checking blood glucoses to administer sliding scale insulin and inability to perform daily weights as ordered. During interview on 09/12/2025 at 09:20 AM, the Clinical Manager acknowledged there is no documentation the RN notified the physician of the noncompliance with blood glucose checks and daily weights as ordered. During interview on 09/12/2025 at 09:22 AM, the RN stated being unable to view the documentation in a discharged record but should have notified the physician to report the patient not following the plan of care. Patient #10 – This 72-year-old patient with diagnoses that include hypertensive heart and chronic kidney disease with heart failure and acute on chronic diastolic heart failure was admitted to the home health agency on 12/22/2024 and discharged on 02/07/2025. A.) Review of the Skilled Nursing Facility Post Discharge Plan of Care (agency referral) revealed the patient is ordered to wear oxygen 2 liters per minute via nasal cannula. The frequency of use is not specified. Review of the Registered Nurse (RN) Outcome and Assessment Information Set (OASIS) Admission Visit revealed the RN documented the patient was not using oxygen at the time of the visit and the patient stated they are trying to wean off the oxygen that is ordered. Review of the Home Health Certification and Plan of Care from 12/22/2024 to 02/19/2025 lacks orders for oxygen use. Review of the clinical record lacks documentation the authorized practitioner was reported of the patient self-weaning oxygen use and verified the oxygen orders could be discontinued. During interview on 09/11/2025 at 02:45 PM, the RN stated being unable to review the identified documentation due to no electronic access to discharged patient records and cannot recall the identified patient. During interview on 09/11/2025 at 02:47 PM, the Clinical Manager stated there was no documentation the authorized practitioner was notified of the patient not using the oxygen and discontinuing the use of oxygen. B.) Review of the RN OASIS Admission Visit dated 12/22/2024 revealed the RN documented the patient does not test blood glucose levels and reports taking the injectable medication as prescribed. Review of the Home Health Certification and Plan of Care from 12/22/2024 to 02/19/2025 revealed orders for Humalog junior kwikpen 100 units per milliliter (ml) subcutaneous following the sliding scale three (3) times daily: - no injection for blood sugar 0-250; - 4 units for blood sugars 51 (251) to 300; - 6 units for blood sugars 301 to 350; - 8 units for blood sugar 351 to 400; and - if over blood sugar over 400, hold insulin and call physician. Review of the clinical record lacks documentation the physician was notified the patient is not testing blood glucoses three (3) times daily for sliding scale insulin administration. During interview on 09/11/2025 at 03:10 PM, the RN stated being unable to review the identified documentation due to no electronic access to discharged patient records and cannot recall the identified patient. During interview on 09/11/2025 at 03:12 PM, the Clinical Manager stated there is no documentation the physician was notified of the patient not testing blood glucoses three times daily for sliding scale insulin administration. C.) Review of the Home Health Certification and Plan of Care from 12/22/2024 to 02/19/2025 revealed orders for the following: - Humalog junior kwikpen 100 units per milliliter (ml) subcutaneous following the sliding scale three times daily: - no injection for blood sugar 0-250; - 4 units for blood sugars 51 (251) to 300; - 6 units for blood sugars 301 to 350; - 8 units for blood sugar 351 to 400; and - if over blood sugar over 400, hold insulin and call physician. - Assess/instruct on daily weight and keeping log. Notify physician of weight gain of 2-3 pounds in twenty-four (24) hours or 5 pounds in one week. - Notify authorized practitioner of weight greater than 158 pounds. Review of the RN Subsequent Visit dated 12/26/2024 revealed the RN documented the patient states not having the materials needed to test blood sugar as her continuous meter and supplies are at another location. Additionally, the patient states a scale is needed to perform daily weights. Review of the clinical record lacks documentation the authorized practitioner was notified of the patient not checking blood glucoses to administer sliding scale insulin and inability to perform daily weights as ordered. During interview on 09/12/2025 at 09:20 AM, the Clinical Manager acknowledged there is no documentation the RN notified the physician of the noncompliance with blood glucose checks and daily weights as ordered. During interview on 09/12/2025 at 09:22 AM, the RN stated being unable to view the documentation in a discharged record but should have notified the physician to report the patient not following the plan of care. Patient #4 – This 91-year-old patient with the diagnoses of pressure ulcer of sacral region, stage 4, osteomyelitis of vertebral column, and paraplegia was admitted to the home care agency on 08/23/2025. Review of the OT (Occupational Therapy) Add ON Evaluation Visit dated 08/27/2025 revealed the OT documented the patient had edema of the lower extremities. Review of the clinical record lacks documented evidence that the physician was notified of the patient’s lower extremity edema. During an interview on 09/12/2025 at 10:45 AM, the Clinical Manager stated the OT was unavailable for interview and acknowledged there was no documentation in the clinical records that the physician was notified of the patient’s lower extremity edema.

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on a review of clinical records and staff interview for one (1) of seventeen (17) patients (Patient #10), the agency failed to ensure updated plans of care reflect current information from the patient’s updated comprehensive assessment. Failure to ensure the plan of care is updated and revised to reflect patient needs, has the potential to result in negative patient outcomes. Patient #10 – This 72-year-old patient with diagnoses that include hypertensive heart and chronic kidney disease with heart failure and acute on chronic diastolic heart failure was admitted to the home health agency on 12/22/2024 and discharged on 02/07/2025. A.) Review of the Physical Therapy (PT) Safe Stride Add On Visit dated 12/30/2024 revealed the PT documented the patient is non-compliant with oxygen use. The initial oxygen saturation assessed was 81% upon arrival. The patient was instructed to place the oxygen on and the oxygen saturation increased to 93%. Education was provided on the importance of using oxygen at all times. Review of the clinical record lacks orders updating the plan of care regarding oxygen use. During interview on 09/11/2025 at 02:17 PM, the PT stated an order for oxygen was not obtained as the PT assumed the oxygen was previously ordered.

Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on review of clinical records and interview with agency staff, for one (1) of seventeen (17) patients (Patient #1), the agency failed to ensure there was communication with all physicians involved in the patient's care following the patient's physician appointment. Failure to follow-up for physician appointments places patients at risk for negative outcomes and potential for hospital admission. Patient #1 – This 65-year-old patient with diagnoses that include displaced trimalleolar fracture to left lower leg and displaced bimalleolar fracture to right lower leg was admitted to the home health agency on 08/22/2025. Review of the Referral Summary (agency referral) dated 08/20/2025 revealed the patient has a follow-up appointment with their primary care physician on 08/25/2025. Review of the clinical record for the week of 08/24/2025 to 08/30/2025 revealed the patient was seen by the Occupational Therapist (OT) on 08/26/2025 and the Registered Nurse (RN) on 08/28/2025. Review of the OT Add-On Evaluation visit dated 08/26/2025 lacks documentation of follow-up regarding the 08/25/2025 primary care physician appointment. Review of the RN Subsequent Visit dated 08/28/2025 lacks documentation of follow-up regarding the 08/25/2025 primary care physician appointment. During interview on 09/12/2025 at 11:39 AM, the Clinical Manager stated a PointCare Visit Alert Coordination Note was created on 08/20/2025 as a reminder to all clinicians of the 08/25/2025 physician appointment and acknowledged the clinicians failed to follow-up during the identified visits.

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 review and staff interview, for one (1) of seventeen (17) patients (Patient #17) the agency failed to ensure effective communication and coordination of patient care occurred between disciplines. Failure to ensure interdisciplinary communication and coordination of care occurs has the potential to place patients at risk for inappropriate and inadequate care. Patient #17 – This 78-year-old patient with diagnoses that include urinary tract infection and type 2 diabetes mellitus was admitted to the home health agency on 07/07/2025. Review of the New York State (NYS) Licensed Practical Nurse (LPN) Visit dated 08/08/2025 revealed the LPN documented the patient reports seeing the hematologist today, is starting a new medication, polysaccharide iron complex, and is awaiting the medication to be delivered by the pharmacy. Review of the Registered Nurse (RN) Subsequent Visit dated 08/18/2025 revealed this was the first visit that occurred after the 08/08/2025 LPN visit. The visit lacks documentation of follow-up of the new polysaccharide iron complex to ensure the medication is in the home, providing instruction and updating the plan of care with the new medication upon verification. During interview on 09/12/2025 at 08:50 AM, the RN stated they failed to follow-up on the new medication during the 08/18/2025 visit.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on review of clinical records and interviews with agency staff, for one (1) of seventeen (17) patients (Patient #16), receiving skilled nursing services, the Skilled Nurse (SN) failed to prepare or document complete clinical and progress notes. Failure to prepare or document complete clinical and progress notes has the potential for unmet patient needs. Patient #16 – This 62-year-old patient with the diagnoses of type 2 diabetes mellitus, enterostomy malfunction, and morbid obesity due to excess calories was admitted to the home care agency on 07/23/2025. Review of the Licensed Practical Nurse (LPN) Visit Note dated 09/08/2025 revealed the following documentation: Architectural/Home: Patient lives alone.Patient receives assistance from person residing in the home. During interview on 09/12/2025 at 11:38 AM, the Clinical Manager stated the LPN was not available for interview. The Clinical Manager acknowledged the identified documentation was inconsistent and it was unclear if the patient lived alone or with other persons in the home.

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on review of clinical records and interviews with staff, for one (1) of five (5) patients (Patient #4), the agency failed to ensure that a comprehensive assessment consistent with the patient's needs was performed within five (5) calendar days after the Start of Care (SOC). Failure to ensure a comprehensive assessment is complete and accurate has the potential for unmet patient needs and possible negative outcomes. The agency failed to ensure that a comprehensive assessment consistent with the patient's needs was performed within five (5) calendar days after the SOC as evidenced by the following: Patient #4 – This 74-year-old therapy only patient with diagnoses of bilateral primary osteoarthritis of hip, unspecified dementia, anxiety disorder and history of falls was admitted to the home care agency on 10/21/2023. Review of the physician referral for home care dated 10/21/2023 revealed the patient was referred to the agency on 10/21/2023 and requested to be evaluated for Physical Therapy (PT) and Occupational Therapy (OT). Review of the OT Add- On Evaluation dated 10/27/2023 revealed the OT performed an initial assessment of the patient on 10/27/2023 (6 (six) days after the start of care). Review of the clinical record from 10/21/2023 to 10/27/2023 lacks documented evidence the OT attempted to contact the patient. During interview on 11/08/2023 at 09:05 AM, the OT stated the initial visit on 10/27/2023 was when she received the referral to evaluate the patient. During interview on 11/08/2023 at 09:07 AM, the Branch Director stated that he was not aware the visit should have been done within (5) calendar days after SOC.

The following statement of deficiencies represents the results of a partial extended re-certification survey of Centerwell Home Health Agency conducted on 11/14/2022 through 11/18/2022. The survey included a COVID-19 vaccination survey and complaint investigation (59880). A standard re-certification survey was initiated on 11/14/2022. Deficient practices were identified within Level 1 standards in G-574 (Plan of Care) resulting in a partial extended survey. The survey consisted of a review of seventeen (17) clinical records, five (5) discharged records, eight (8) personnel records, one (1) contract, and six (6) observational home visits. The survey included a review of pertinent policies and procedures, Quality Improvement Meeting minutes for the past twelve (12) months, agency's Admission Packet, the Emergency Preparedness Plan, and Complaint Log. The patient census is 224 and the agency reports they have no COVID-19 positive patients. Pre-survey activities consisted of review on 11/09/2022 of the agency's Health Commerce System account, Potentially Avoidable Reports for the period 08/2021 - 07/2022, the agency's compliance with submission of statistical reports, and emergency drills. The Director of Patient Services, Director, and clinical staff were interviewed. Findings were reviewed at the exit conference on 11/21/2022. The allegations in complaint # 59880 were unsubstantiated. The following deficiencies are identified because of the survey: G-0374, G-0526, G-0536, G-0574, G-0576, G-0578, G-0580, G-586, G-0590, G- 0610, G-0706, G-0716, G-718, J-1136, J-1156, J-1328 and L-0002.

Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient's status at the time of assessment. This STANDARD is not met as evidenced by: Based on review of the agency's Outcome Assessment Information Set (OASIS) submissions, clinical records, and interviews with agency for one (1) of seventeen (17) patients (Patient #13), the agency failed to ensure the OASIS data accurately reflects the patient's status at the time of the assessment. Failure to ensure accurate documentation of OASIS data has the potential for negative outcomes. Patient #13 – This 75-year-old patient with diagnoses that include emphysema, hypoxia and interstitial pulmonary disease was admitted to the home health agency on 10/30/2022. Review of the PT (Physical Therapy) OASIS (Outcome and Assessment Information Set) Admission Visit Note dated 10/30/2022 revealed the PT documented the following regarding medications: - (M2030) Management of injectable medications: Patient’s current ability to prepare and take all prescribed injectable medications reliably and safely: 3- Unable to take injectable medication unless administered by another person. Review of the clinical record lacks orders for any injectable medications. The agency failed to ensure the OASIS documentation accurately reflects the patient's status at the time of the assessment. During interview on 11/18/2022 at 11:27 AM, the PT stated the patient was not taking any injectable medications and the identified OASIS question was answered incorrectly.

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 review of clinical records and interview with agency staff for five (5)) of seventeen (17) patients (Patient #’s: 4, 7, 9, 12 and 13), the agency failed to ensure the comprehensive assessment is consistent and accurately reflects the patient's status and needs. Failure to ensure comprehensive assessments accurately reflect the patient status and needs has the potential for unmet patient needs and the potential for negative patient outcomes. Review of the agency policy entitled “Wound Care Assessment and Clinical Oversight” revised 11/2022 revealed “Wound assessments will be performed every visit and include general observations, drainage amount and type, wound bed appearance and surrounding skin condition. At least once weekly, the assessment will include wound measurements (length x width x depth in centimeters).” Patient #4 – This 67-year-old patient with diagnoses that include aftercare following left below the knee amputation, diabetes mellitus type 2 and essential hypertension was admitted to the home health agency on 10/23/2022. Review of the Home Health Certification and Plan of Care for certification period 10/23/2022 to 12/21/2022 revealed the following orders: - Skilled Nurse (SN) to perform/ teach incision/ suture site care to left BKA (below knee amputation): cleanse with normal saline, apply xeroform, cover with gauze, secure with kerlix/ ace wrap/ tape using clean/ aseptic technique. Change dressing every other day and PRN (as needed) soiling/ dislodgement. A.) Review of the RN (Registered Nurse) OASIS (Outcome and Assessment Information Set) Admission Visit Note dated 10/23/2022 revealed the RN documented the following wound assessment: - Integumentary assessment findings: Closed surgical incision; - Location of closed incision: Left leg residual limb (BKA site); - Indicate type of incision closure: Staples and sutures; - Length of closed incision in CM (centimeters): 17; - Is exudate present? Yes; - Describe exudate color/ amount: small serosanguinous. The wound assessment lacks an assessment of the open, draining wound bed to include measurements of length, width and depth. The agency failed to ensure the comprehensive assessment is consistent and accurately reflects the patient's status and needs. During interview on 11/18/2022 at 12:53 PM, the RN stated being unaware that the draining incision required a more detailed wound assessment. B.) Review of the clinical record revealed the patient received one (1) SN visit the week of 10/30/2022 to 11/05/2022 on 11/02/2022. Review of the SN Subsequent Visit Note dated 11/02/2022 lacks documented evidence a wound assessment of the left BKA site was completed. The agency failed to ensure the comprehensive assessment is consistent and accurately reflects the patient's status and needs. During interview on 11/18/2022 at 12:31 PM, the Director of Patient Services (DPS) stated the clinician had taken a photo of the wound that included the wound measurements but failed to document a wound assessment in the identified visit, as is the expectation. C.) Review of the Client Coordination Note dated 10/24/2022 revealed the RN documented the patient currently has no working glucometer and is not taking prescribed sliding scale insulin due to being unable to monitor blood sugars. Review of the clinical record revealed the patient did not have a working glucometer in the home from 10/23/2022 until 11/11/2022. Review of the OT (Occupational Therapy) Subsequent Visit Note dated 11/11/2022 revealed the OT documented the patient had obtained a new glucometer and the reported fasting blood glucose reading was 190. The visit lacks an assessment of the glucometer to ensure all supplies for use are available, the machine is coded correctly and a report to the RN of the new glucometer being in the patient’s home. The agency failed to ensure the comprehensive assessment is consistent and accurately reflects the patient's status and needs. During interview on 11/18/2022 at 01:44 PM, the DPS stated the OT was unavailable for interview. The DPS stated the OT should have notified the RN of the glucometer being in the home so the RN would follow-up. Patient #7 - This 74-year-old patient with diagnoses that include parkinson’s disease, hypertensive chronic kidney disease and anemia was admitted to the home health agency on 10/08/2022. Review of the physician referral for home care dated 10/03/2022 revealed the patient uses a CPAP (continuous positive airway pressure) machine at bedtime for sleep enhancement. Review of the RN OASIS Admission Visit Note dated 10/08/2022 lacks an assessment of the patient’s use of the CPAP machine. The agency failed to ensure the comprehensive assessment is consistent and accurately reflects the patient's status and needs. During interview on 11/18/2022 at 02:01 PM, the DPS stated the RN no longer is employed by the agency. The DPS stated the patient uses a CPAP and it should have been assessed at the identified visit. Patient #12 – This 78-year-old therapy only patient with diagnoses that include aftercare following right total knee arthroplasty, osteoarthritis and anemia was admitted to the home health agency on 12/02/2021. This patient is listed on the agency's Potentially Avoidable Event Patient Listing Report dated 12/02/2021 to 01/13/2022 for development of a urinary tract infection (UTI). A.) Review of the Physical Therapy Subsequent Visit Note dated 12/16/2021 revealed the Physical Therapy Assistant (PTA) documented the patient went to an urgent care facility on 12/11/2021 for UTI symptoms and was started on SMZ-TMP (sulfamethoxazole and trimethoprim) 800-160 milligram (mg) tablet daily for three (3) days. Review of the Client Coordination Note dated 12/16/2021 revealed the PTA documented the patient reported having continued UTI symptoms. The PTA directed the patient to contact the primary care physician and offered Skilled Nursing services, which the patient declined. The PTA communicated the information to the primary PT and Clinical Manager. Review of the PT Subsequent Visit Note dated 12/20/2021 revealed the PTA documented the primary care physician had ordered another course of SMZ- TMP 800- 160 mg on 12/17/2021 and the patient was to take one (1) tabled by mouth twice daily for seven (7) days. Review of the Client Coordination Note dated 12/22/2021 revealed the Clinical Manager documented the patient called agency and reported concerns the UTI is not resolved following a three (3) day course of antibiotics prescribed 12/11/2022. The Clinical Manager left a message for the primary care physician’s office of the patient’s concerns. Review of the clinical record revealed the patient received Physical Therapy visits between 12/02/2021 and 01/01/2022 on the following dates: 12/02/2021, 12/07/2021, 12/23/2021, 12/28/2021 and 12/30/2021. Review of the clinical record revealed the patient received PTA visits between 12/02/2021 and 01/01/2022 on the following dates: 12/07/2021, 12/09/2021, 12/16/2021 and 12/20/2021. Review of the PT and PTA visits between 12/07/2021 and 01/01/2022 lack assessments of the patient’s genitourinary system. The agency failed to ensure the comprehensive assessment is consistent and accurately reflects the patient's status and needs. During interview on 11/18/2022 at 10:28 AM the Director stated it is not in the PTA scope of practice to complete genitourinary assessments unless instructed by the Physical Therapist. During interview on 11/18/2022 at 11:53 AM, the PT stated he believed the PTA could complete urinary assessments if indicated. The PT stated he could not recall why a GU assessment was not completed during the identified PT visits. B.) Review of the Client Coordination Note dated 12/06/2021 revealed the Clinical Manager documented the patient called the agency and reported not having a bowel movement in the week since surgery. The Clinical Manager instructed the patient to contact the physician and recommended warm prune juice to help stimulate her bowels. Review of the PT Supervisory Only Visit Note dated 12/07/2021 lacks an assessment of the patient’s gastrointestinal (GI) system. Review of the PTA Subsequent Visit Note dated 12/07/2021 lacks a GI assessment. Review of the Client Coordination Note dated 12/22/2021 revealed the Clinical Manager documented the patient called the agency, reported having ongoing nausea, denied vomiting and reported the anti-nausea medication prescribed was not helping. The Clinical Manager notified the physician of the patient’s symptoms. Review of the PT Reassessment Visit Note dated 12/23/2021 lacks a GI assessment. The agency failed to ensure the comprehensive assessment is consistent and accurately reflects the patient's status and needs. During interview on 11/18/2022 at 10:29 AM the Director stated it is not in the PTA scope of practice to complete gastrointestinal assessments unless instructed by the Physical Therapist. During interview on 11/18/2022 at 11:54 AM, the PT stated he believed the PTA could complete GI assessments if indicated. The PT stated he could not recall why a GI assessment was not completed during the identified PT visits. Patient #13 – This 75-year-old therapy only patient with diagnoses that include emphysema, hypoxia and interstitial pulmonary disease was admitted to the home health agency on 10/30/2022. Review of the Home Health Certification and Plan of Care for certification period 10/30/2022 to 12/28/2022 revealed the following orders: PT to monitor/ manage diabetes, client monitors BS (blood sugar) 1-2 x (one to two times) daily in home setting. Notify MD (physician) of reading outside of ordered parameters of FBS (fasting blood sugar) (greater than) 300. Review of the PT OASIS Admission Visit Note dated 10/30/2022 lacks a diabetic assessment to include a recorded or obtained blood sugar result. The agency failed to ensure the comprehensive assessment is consistent and accurately reflects the patient's status and needs. During interview on 11/18/2022 at 11:24 AM, the PT stated the patient refused to test the blood sugar but he failed to document this. Patient #9 – This 59-year-old patient with diagnoses that include spina bifida with paraplegia, depression and type II diabetes mellitus without complications was admitted to the home care agency on 01/15/2022. Review of the Home Health Certification and Plan of Care for certification period 01/15/2022 to 03/15/2022 revealed the following orders: - Skilled Nurse (SN) to perform/teach wound care to STG 4 (stage) pressure injury wound to right thigh: cleanse with wound cleanser, apply plain packing strip to wound bed. Cover with ABD pad, secure with tape. Change dressing every other day. Review of the Client Coordination Note dated 01/19/2022 revealed the RN documented the following wound assessment: Wound picture taken, and measurements obtained- 2.0 x 3.0 x 0.2, Undermining 3-5 O’clock position 0.3 centimeters (cm). The wound assessment lacks an assessment of the open wound to include drainage. The agency failed to ensure the comprehensive assessment is consistent and accurately reflects the patient's status and needs. During interview on 11/18/2022 at 12:13 PM, the RN stated she missed documenting the drainage from the wound.

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, agency policy and procedure, and interview with agency staff, for nine (9) of seventeen (17) clinical records (Patient #’s: 3, 4, 5, 10, 11, 12, 13, 14, 15) lack documented evidence of a complete review of all medications the patient currently uses to identify any potential adverse effects, drug reactions, or concerns. Failure to conduct a complete medication review and to ensure the medication regime is appropriate has the potential for the patient harm. Review of the agency policy entitled “Medication Review and Documentation revised 10/2022 revealed the following: “A drug regime review and medication reconciliation will include all patient medications and be performed during the initial comprehensive assessment…When conducting medication assessments, Clinical Associates must examine medication bottles and review medication lists from the physician/ allowed practitioner and/ or inpatient facility within the last 30 (thirty) days and compare to home medications. Clinical Associate follow-up with the physician/ allowed practitioner is required for all medication discrepancies….Medication review for therapy only cases will be performed by the therapists. If potential clinically significant issues are identified, the therapist will notify the patient’s physician/ allowed practitioner and communicate actions to a nurse clinical manager. The Clinical Manager will review the Medication Profile and provide signature on Plan of Care for the initial review.” Patient #3 – This 70-year-old patient with diagnoses that include unspecified bacterial pneumonia, chronic obstructive pulmonary disease and non-hodgkins lymphoma was admitted to the home health agency on 10/22/2022. A.) Review of the Facility Discharge Medication Instructions dated 10/21/2022 revealed the patient was ordered to take the following medications: - Budesonide 0.25 mg (milligram)/ 2 ml (milliliter) MDI (multi dose inhaler) inhale two (2) times per day; and - Nitroglycerin (Nitrostat) 0.4 mg tab (tablet) by mouth every 5 (five) minutes as needed for 3 (three) times process if chest pain. Review of the Home Health Certification and Plan of Care for certification period 10/22/2022 to 12/20/2022 lacks orders for the identified medications. Review of the clinical record lacks documented evidence of clarification of the medication discrepancies. The RN failed to identify and reconcile all medication discrepancies identified in the referral for services and the POC. During interview on 11/18/2022 at 01:10 PM, the Registered Nurse (RN) stated using the facility medication instructions during the reconciliation and was unaware of the identified discrepancies. B.) Review of the Home Health Certification and Plan of Care for certification period 10/22/2022 to 12/20/2022 revealed the following medication orders: - Flonase Allergy Relief 50 mcg (microgram)/ Actuation Nasal Spray, give 2 (two) sprays to each nostril daily; and - Ventolin HFA 90 mcg/ actuation aerosol inhaler, give 2 (two) puffs as needed (PRN) every 4 (four) hours for SOB (shortness of breath). Review of the facility referral, Discharge Medication Instructions dated 10/21/2022 lacks orders for the identified medications. Review of the clinical record lacks documented evidence of clarification of the medication discrepancies. The RN failed to identify and reconcile all medication discrepancies identified in the referral for services and the POC. During interview on 11/18/2022 at 01:12 PM, the Registered Nurse (RN) stated using the facility medication instructions during the reconciliation and was unaware of the identified discrepancies. C.) Review of the Home Health Certification and Plan of Care for certification period 10/22/2022 to 12/20/2022 revealed the following medication orders: - Hydrocodone 5 mg- Acetaminophen 325 mg tablet, 1 (one) tablet oral every 6 (six) hours/ PRN (as needed) for pain, do not exceed 4 (four) tablets in 24 (twenty-four) hours; and - Tylenol Extra Strength 500 mg tablet, 2 (two) tablets oral every 6 (six) hours as needed for pain, maximum daily dose acetaminophen 3000 mg from all sources. Based on the prescribed dosage, if the patient was administered the Acetaminophen (Tylenol) as ordered, the patient could have received 5,300 mg in twenty-four (24) hours (2,300 mg above the ordered maximum daily dose). Review of the RN OASIS (Outcome and Assessment Information Set) Admission Visit Note dated 10/22/2022 revealed the RN documented the following under the Medication Understanding Changes: - Hydrocodone 5 mg- Acetaminophen 325 mg Tablet- patient/ caregiver with no understanding of purpose, directions for use and side effects/ interactions; and - Tylenol Extra Strength 500 mg, 2 (two) tablets- patient/ caregiver with no understanding of purpose, directions for use and side effects/ interactions. Review of the clinical record lacks documented evidence of clarification of Acetaminophen dosages based on maximum daily dose guidelines. The RN failed to identify and reconcile all medication discrepancies identified in the POC. During interview on 11/18/2022 at 01:07 PM, the RN stated she did not clarify with the physician that the tylenol if taken as ordered, would exceed the ordered maximum daily dosage. Patient #4 – This 67-year-old patient with diagnoses that include aftercare following left below the knee amputation, diabetes mellitus type 2 and essential hypertension was admitted to the home health agency on 10/23/2022. Review of the Home Health Certification and Plan of Care for certification period 10/23/2022 to 12/21/2022 revealed an order for Fexofenadine 60 mg tablet, 0.5 tablet oral daily. Review of the physician office note dated 08/12/2022 (used to perform drug regimen review) lacks an order for Fexofenadine. Review of the clinical record lacks documented evidence of clarification of the medication discrepancy. The RN failed to identify and reconcile the medication discrepancy identified in the referral for services and the POC. During interview on 11/18/2022 at 12:44 PM, the RN stated she used the identified physician office note to reconcile the medications and was unaware of the medication discrepancy. Patient #5 – This 91-year-old therapy only patient with diagnoses that include hypertensive heart and chronic kidney disease, heart failure and atrial fibrillation was admitted to the home health agency on 10/29/2022. Review of the Assisted Living Facility Medication Administration Record (MAR) dated 10/03/2022 revealed a medication order for Dry Eye Relief Drops Solution 0.2- 0.2- 1 % (percent) (Glycerin Hypromellose- PEG 400) Instill 1 (one) drop in both eyes every 12 (twelve) hours as needed for dry eye relief. Review of the Home Health Certification and Plan of Care for certification period 10/29/2022 to 12/27/2022 lacks an order for Dry Eye Relief Drops. Review of the clinical record lacks documented evidence of clarification of the medication discrepancy. The Physical Therapist (PT) failed to identify and reconcile the medication discrepancy identified in the referral for services and the POC. During interview on 11/18/2022 at 10:12 AM, the PT stated she made an error and did not include the identified medication on the POC. Patient #12 – This 78-year-old therapy only patient with diagnoses that include aftercare following right total knee arthroplasty, osteoarthritis and anemia was admitted to the home health agency on 12/02/2021. Review of the Home Health Certification and Plan of Care for certification period 12/02/2021 to 01/30/2022 revealed an order for Tramadol 50 mg tablet, 1 (one) tablet oral every 6 (six) hours as needed (PRN) for arthritis. Review of the facility Discharge Instructions dated 12/01/2021 lacks an order for Tramadol. Review of the clinical record lacks documented evidence of clarification of the medication discrepancy. The PT failed to identify and reconcile the medication discrepancy identified in the referral for services and the POC. During interview on 11/18/2022 at 11:50 AM, the PT stated he failed to clarify the Tramadol discrepancy but should have done so. Patient #13 – This 75-year-old therapy only patient with diagnoses that include emphysema, hypoxia and interstitial pulmonary disease was admitted to the home health agency on 10/30/2022. A.) Review of the physician referral for services dated 10/20/2022 revealed the patient is ordered to take Carafate (Sulcralfate) 1 gm (gram) tablet on an empty stomach orally every 6 (six) hours. Review of the Home Health Certification and Plan of Care for certification period 10/30/2022 to 12/28/2022 lacks an order for Carafate. Review of the clinical record lacks documented evidence of clarification of the medication discrepancy. The PT failed to identify and reconcile the medication discrepancy identified in the referral for services and the POC. During interview on 11/18/2022 at 11:14 PM, the PT stated being unable to recall why the identified discrepancy was not clarified. B.) Review of the physician referral for services dated 10/20/2022 revealed the patient is ordered to take the following medications: - Sotalol HCL 80 mg tablet take 1 (one) tablet every 12 (twelve) hours orally 2x (two times) daily; and - Tyvaso Starter (Treprostinil) 0.6 mg/ ml (milliliter) solution 1 (one) inhalation every 4 (four) hours inhalation four times a day. Review of the Home Health Certification and Plan of Care for certification period 10/30/2022 to 12/28/2022 revealed orders for: - Sotalol 80 mg tablet, 1 (one) tablet oral every 12 (twelve) hours as needed for tachycardia; and - Tyvaso 1.74 mg/ 2.9 ml (0.6 mg/ ml) solution for nebulization every 4 (four) hours as needed for shortness of breath. Review of the clinical record lacks documented evidence of clarification of the medication discrepancies. The PT failed to identify and reconcile medication discrepancies identified in the referral for services and the POC. During interview on 11/18/2022 at 11:17 AM, the PT stated he failed to clarify the identified medication discrepancies in error. Patient #14 – This 80-year-old therapy only patient with diagnoses that include fracture of right humerus, right orbital floor fracture and diabetes mellitus type 2 was admitted to the home health agency on 10/31/2022. Review of the rehabilitation facility referral for services dated 09/23/2022 revealed the patient had allergies to Codeine, Levaquin and Oxycontin. Review of the Home Health Certification and Plan of Care for certification period 10/31/2022 to 12/29/2022 revealed the following: - Allergies: NKA (no known allergies). Review of the clinical record lacks documented evidence of clarification of the allergy discrepancies. The PT failed to identify and reconcile allergy discrepancies identified in the referral for services and the POC. During interview on 11/18/2022 at 08:55 AM, the PT stated the allergy discrepancy was overlooked in error and was not clarified. Patient #15 – This 80-year-old patient with diagnoses that include major depressive disorder, polycythemia and constipation was admitted to the home health agency on 10/28/2022. A.) Review of the facility Discharge Medication Instructions (included in the referral for services) dated 10/21/2022 revealed the patient had an allergy to Penicillin. Review of the Home Health Certification and Plan of Care for certification period 10/28/2022 to 12/26/2022 revealed the following: - Allergies: NKA. Review of the clinical record lacks documented evidence of clarification of the allergy discrepancy. The RN failed to identify and reconcile the allergy discrepancy identified in the referral for services and the POC. During interview on 11/18/2022 at 09:45 AM, the RN stated she clarified the allergy discrepancy with the physician but failed to document this. B.) Review of the facility Discharge Medication Instructions (included in the referral for services) dated 10/21/2022 revealed the patient is ordered to take Sertraline HCL (Zoloft) 50 mg by mouth daily. Review of the Home Health Certification and Plan of Care for certification period 10/28/2022 to 12/26/2022 revealed the patient is ordered to take the following medications in addition to Sertraline: - B Complex- Vitamin B 12 tablet, 1 (one) tablet oral daily; - Multivitamin 50 Plus tablet, 1 (one) tablet oral daily; and - Tylenol Extra Strength 500 mg tablet, 2 (two) tablets oral every 8 (eight) hours as needed (PRN) pain. MDD (maximum daily dose) acetaminophen 3000 mg/ 24 hours from all sources. Review of the clinical record lacks documented evidence of clarification of the medication discrepancies. The RN failed to identify and reconcile medication discrepancies identified in the referral for services and the POC. During interview on 11/18/2022 at 09:50 AM, the RN stated the identified medication discrepancies were clarified with the physician but she failed to document this. Patient #10 – This 83-year-old patient with diagnoses that include skin ulcer of sacrum, unspecified ulcer stage, anemia, and chronic pain due to injury was admitted to the home health agency on 03/28/2022. A.) Review of the Home Health Certification and Plan of Care for certification period 03/28/2022 to 05/26/2022 revealed the following medication orders: - Motrin IB (ibuprofen) 200 mg give two (2) tablets by mouth every 8 (eight) hours/PRN (as needed) pain; - Nitrofurantoin Macrocrystal capsule 100 mg give 1 (one) capsule by mouth every 12 (twelve) hours; -Oxycodone-Acetaminophen tablet 5-325 mg give 1 (one) tablet by mouth every 12 (twelve) hours/PRN pain; and -Systane Complete solution 0.6 % (percent) eye drops apply 1 (one) drop to both eyes as needed/PRN dry eyes. Review of the physician referral for services dated 03/16/2022 lacks orders for the identified medications. Review of the clinical record lacks documented evidence of clarification of the medication discrepancies. The Registered Nurse (RN) failed to identify and reconcile all medication discrepancies identified in the referral for services and the plan of care (POC). During interview on 11/18/2022 at 09:28 AM, the RN stated she reconciled the medications, but failed to clarify the discrepancy with the physician. B.) Review of the physician referral for services dated 03/16/2022 revealed the following orders: - Triamcinolone 0.1% cream apply topically two times a week, and - Fluorometholone 0.1% suspension apply 1(one) drop to affected eye twice daily. Review of the Home Health Certification and Plan of Care for certification period 03/28/2022 to 05/26/2022 lacks an order for the identified medication. Review of the clinical record lacks documented evidence of clarification of the medication discrepancy. The RN failed to identify and reconcile all medication discrepancies identified in the referral for services and the POC. During interview on 11/18/2022 at 09:28 AM, the RN stated she reconciled the medications, but failed to clarify the discrepancy with the physician. Patient #11 – This 67-year-old patient with diagnoses that include pressure ulcer of left lower back, stage 4, paraplegia, and neuromuscular dysfunction of bladder, unspecified was admitted to the home health agency on 07/01/2021. Review of the Home Health Certification and Plan of Care for the certification period 07/01/2021 to 08/29/2021 revealed an order for Desvenlafaxine ER tablet 50 mg give 1(one) tablet by mouth daily for anxiety and depression. Review of the physician referral for services dated 06/29/2021 lacks an order for the identified medication. Review of the clinical record lacks documented evidence of clarification of the medication discrepancy. The Registered Nurse (RN) failed to identify and reconcile all medication discrepancies identified in the referral for services and the plan of care (POC). During interview on 11/18/2022 at 03:00 PM, the Director of Patient Services (DPS) stated the clinician was unavailable to interview. The DPS stated the clinician failed to clarify the discrepancy with the physician.

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 review of clinical records and staff interviews for five (5) of seventeen (17) patients (Patient #’s: 3, 7, 12, 13 and 14), the agency failed to develop individualized plans of care (POCs) that are complete and accurate and address the total needs of the patients. Failure to ensure that a comprehensive individualized plan of care is developed has the potential for unmet patient needs. Patient #3 – This 70-year-old patient with diagnoses that include unspecified bacterial pneumonia, chronic obstructive pulmonary disease and non-hodgkins lymphoma was admitted to the home health agency on 10/22/2022. A.) Review of the RN (Registered Nurse) OASIS (Outcome and Assessment Information Set) Admission Visit Note dated 10/22/2022 revealed the patient had a right BKA (below the knee amputation) in 2019. Due to the COVID-19 pandemic, the patient’s therapy was shut down and impaired his use of a prosthetic to the right lower extremity. Patient currently is wheelchair bound. Review of the Home Health Certification and Plan of Care for certification period 10/22/2022 to 12/20/2022 revealed orders for Skilled Nurse (SN) to provide management of congestive heart failure, client to weigh daily and log readings on DME (durable medical equipment) scale and SN to notify authorized provider if patient’s weight is greater than 131 pounds. The agency failed to develop individualized POCs that are complete and accurate and address the total needs of the patients. During interview on 11/18/2022 at 01:14 PM, the RN stated the patient was unable to get weighed and she incorrectly entered the weight monitoring orders on the POC. B.) Review of the RN OASIS Admission Visit Note dated 10/22/2022 revealed the following regarding the patient’s intravenous access device: - Indicate type of infusion access: Port, implanted, Vascular Access Port, - Indicate port site assessment: No problems; - Indicate responsible party for management of port: Infusion Center; - Indicate port insertion date: 11/2021; - Indicate port non- coring needle insertion date: Not accessed; and - Indicate port location: Right Chest. Review of the Home Health Certification and Plan of Care for certification period 10/22/2022 to 12/20/2022 lacks specification of the patient having a right implanted Vascular Access Device, identification of the management and care of the port and the status of the port being unaccessed. The agency failed to develop individualized POCs that are complete and accurate and address the total needs of the patients. During interview on 11/18/2022 at 01:12 PM, the RN stated being unaware that the port information and management needed to be included on the POC. Patient #7 - This 74-year-old patient with diagnoses that include parkinson’s disease, hypertensive chronic kidney disease and anemia was admitted to the home health agency on 10/08/2022. A.) Review of the RN OASIS Admission Visit Note Report dated 10/08/2022 revealed the patient has the following durable medical equipment available in the home: cane, grab bars and tub chair. Review of the Home Health Certification and Plan of Care for certification period 10/08/2022 to 12/06/2022 lacks specification of a tub chair and grab bars as supplies available in the home. The agency failed to develop individualized POCs that are complete and accurate and address the total needs of the patients. During interview on 11/18/2022 at 01:55 PM, the Director of Patient Services (DPS) stated the RN no longer is employed by the agency. The DPS stated the POC failed to specify the identified supplies available for patient use in the home. B.) Review of the physician referral for home care dated 10/03/2022 revealed the patient uses a CPAP (continuous positive airway pressure) machine at bedtime for sleep enhancement. Review of the PT (Physical Therapy) Add- On Evaluation Visit Note dated 10/14/2022 revealed the patient has a CPAP machine in the home which is inconsistently worn at HS (bedtime). Review of the Home Health Certification and Plan of Care for certification period 10/08/2022 to 12/06/2022 lacks specification of the CPAP to include compliance, settings and management. The agency failed to develop individualized POCs that are complete and accurate and address the total needs of the patients. During interview on 11/18/2022 at 02:01 PM, the DPS stated the RN who developed the POC is no longer employed by the agency. The DPS stated the patient had a CPAP in the home for use and this should have been included on the POC. Patient #12 – This 78-year-old therapy only patient with diagnoses that include aftercare following right total knee arthroplasty, osteoarthritis and anemia was admitted to the home health agency on 12/02/2021. A.) Review of the Home Health Certification and Plan of Care for certification period 12/02/2021 to 01/30/2022 revealed the following medication orders: - Fioricet 50 mg (milligram) – 300 mg- 40 mg capsule, 1 (one) capsule as needed/ PRN headaches; - Ondansetron HCL 4 mg/ 5 ml (milliliter) oral solution, 4 mg oral as needed/ PRN nausea; - Tizanidine 2 mg tablet, 1 (one) tablet oral as needed/ PRN muscle spasms; and - Zorvolex 18 mg capsule, 1 (one) capsule oral as needed/ PRN arthritis. The identified orders lack the frequency to administer the PRN medications. The agency failed to develop individualized POCs that are complete and accurate and address the total needs of the patients. During interview on 11/16/2022 at 02:15 PM, the DPS acknowledged the medication orders were incomplete and lack the PRN frequency to be administered. B.) Review of the facility Discharge Instructions dated 12/01/2021 revealed the patient is status post right robotic assisted total knee arthroplasty occurring on 11/30/2021. The patient is to keep dressing on right knee clean, dry and intact. Dressing may be removed post op day 7 (12/06/2021) and if no drainage may shower. Review of the Home Health Certification and Plan of Care for certification period 12/02/2021 to 01/30/2022 lacks orders for the right knee dressing to include duration to remain in place, when dressing to be removed and shower instructions once dressing removed. The agency failed to develop individualized POCs that are complete and accurate and address the total needs of the patients. During interview on 11/18/2022 at 11:48 AM, the PT stated being unaware the identified orders need to be included on the POC. Patient #13 – This 75-year-old therapy only patient with diagnoses that include emphysema, hypoxia and interstitial pulmonary disease was admitted to the home health agency on 10/30/2022. A.) Review of the Home Health Certification and Plan of Care for certification period 10/30/2022 to 12/28/2022 revealed the patient is ordered to take the following nebulized medications: - Albuterol Sulfate 2.5 mg/ 3 ml (0.083%) solution for nebulization, 3 (three) ml by inhalation every 6 (six) hours as needed/ PRN for shortness of breath; and - Tyuvaso 1.74 mg/ 2.9 ml (0.6 mg/ ml) solution for nebulization, 1 (one) inhalation every 4 (four) hours as needed/ PRN for shortness of breath. Review of the Home Health Certification and Plan of Care for certification period 10/30/2022 to 12/28/2022 lacks an order for the nebulizer machine used to administer the identified medications. The agency failed to develop individualized POCs that are complete and accurate and address the total needs of the patients. During interview on 11/18/2022 at 11:20 AM, the PT stated the patient had a nebulizer machine in the home and he mistakenly left this out of the POC. B.) Review of the PT OASIS Admission Visit Note dated 10/30/2022 revealed the patient has a rolling walker in the home available for use. Review of the Home Health Certification and Plan of Care for certification period 10/30/2022 to 12/28/2022 lacks a supply order for the rolling walker. C.) Review of the PT OASIS Admission Visit Note dated 10/30/2022 revealed the patient uses 6 (six) liters of continuous Oxygen. Review of the Home Health Certification and Plan of Care for certification period 10/30/2022 to 12/28/2022 lacks specification of Oxygen safety precautions. The agency failed to develop individualized POCs that are complete and accurate and address the total needs of the patients. During interview on 11/18/2022 at 11:20 AM, the PT stated he mistakenly left the rolling walker and the Oxygen safety precautions out of the POC and they should be added. Patient #14 – This 80-year-old therapy only patient with diagnoses that include fracture of right humerus, right orbital floor fracture and diabetes mellitus type 2 was admitted to the home health agency on 10/31/2022. Review of the PT OASIS Admission Visit Note dated 10/31/2022 revealed the following: - Fasting blood sugar reading: 169; - Indicate type of injectable therapy: Insulin; - Can patient prepare medication and self inject? No; and - Is a Caregiver able and willing to perform injections? Yes. Review of the Home Health Certification and Plan of Care for certification period 10/31/2022 to 12/29/2022 lacks orders for blood glucose testing frequencies, diabetic supplies, blood glucose parameters to notify provider if goes outside of parameters and specification of who manages diabetic care. The agency failed to develop individualized POCs that are complete and accurate and address the total needs of the patients. During interview on 11/18/2022 at 09:00 AM, the PT stated the assisted living facility manages all the patient’s diabetic care but he failed to specify this and include the identified diabetic orders on the POC.

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 review of clinical records and interviews with agency staff for seven (7) of seventeen (17) patients (Patient #’s 3, 4, 5, 7, 9, 10 and 12), the agency failed to provide services in accordance with physician orders and the Plan of Care (POC). Failure to ensure patient care is provided in accordance with physician orders has the potential for patients to receive poor quality care and for health care needs to go unmet. HV Patient #3 – This 70-year-old patient with diagnoses that include unspecified bacterial pneumonia, chronic obstructive pulmonary disease and non-hodgkins lymphoma was admitted to the home health agency on 10/22/2022. Review of the Home Health Certification and Plan of Care for certification period 10/22/2022 to 12/20/2022 revealed orders for Skilled Nurse to provide skilled teaching/ reinforcement of management of congestive heart failure in the home setting including diet, medication therapy and activities permitted/ restrictions. Client to weigh daily and log readings on DME (durable medical equipment scale). Review of the RN (Registered Nurse) Subsequent Visit Note dated 10/26/2022 lacks documented evidence of a weight being obtained or recorded during the assessment visit. Review of the SN (Skilled Nurse) Subsequent Visit Notes dated 11/04/2022 and 11/09/2022 lack documented evidence of a weight being obtained or recorded during the assessment visit. The agency failed to provide services in accordance with physician orders. During an observational home visit that occurred on 11/15/2022 at 10:00 AM, the patient was noted to have a right below the knee amputation (BKA), no prosthetic for the right BKA, and was observed sitting in a wheelchair. The Surveyor inquired with the patient and patient’s spouse how daily weights were obtained. The patient’s spouse stated the patient is unable to be weighed. During interview on 11/18/2022 at 01:15 PM, the RN stated the POC should not have included orders for the patient to be weighed daily as he is unable to stand. During interview on 11/18/2022 at 09:07 AM, the Director of Patient Services (DPS) stated the POC was updated on 11/16/2022, discontinuing daily weights. Patient #4 – This 67-year-old patient with diagnoses that include aftercare following left below the knee amputation, diabetes mellitus type 2 and essential hypertension was admitted to the home health agency on 10/23/2022. Review of the Home Health Certification and Plan of Care for certification period 10/23/2022 to 12/21/2022 revealed the following wound care orders: SN to perform/ teach incision/ suture site care to left BKA- cleanse with normal saline, apply xeroform, cover with gauze, secure with kerlix/ ace wrap/tape using clean/ aseptic technique every other day and PRN (as needed) for soiling/ dislodgement. Review of the RN OASIS (Outcome and Assessment Information Set) Admission Visit Note dated 10/23/2022 lacks documented evidence of wound care being performed to the left BKA site. The agency failed to provide services in accordance with physician orders. During interview on 11/18/2022 at 12:53 AM, the RN stated the patient was discharged to home with no dressing supplies. Dressing Supplies were delivered to the home at the end of the identified visit. The RN stated performing the ordered wound care but failed to document this. Patient #5 – This 91-year-old therapy only patient with diagnoses that include hypertensive heart and chronic kidney disease, heart failure and atrial fibrillation was admitted to the home health agency on 10/29/2022. Review of the Home Health Certification and Plan of Care for certification period 10/29/2022 to 12/27/2022 revealed orders for the licensed professional to report to the authorized provider a weight reading greater than 141 pounds. Review of the Physical Therapy (PT) Subsequent Visit Notes dated 11/08/2022, 11/10/2022 and 11/15/2022 revealed the patient had complaints of lightheadedness during the three (3) visits. The Visit Notes lack documented evidence of a weight being obtained or recorded. The agency failed to provide services in accordance with physician orders. During interview on 11/18/2022 at 10:00 AM, the Physical Therapy Assistant stated the patient was not weighed due to being lightheaded during the identified visits but she failed to document this being the reason the weights were not obtained. Patient #7 - This 74-year-old patient with diagnoses that include parkinson’s disease, hypertensive chronic kidney disease and anemia was admitted to the home health agency on 10/08/2022. A.) Review of the Home Health Certification and Plan of Care for certification period 10/08/2022 to 12/06/2022 revealed Skilled Nurse orders for 1 wk 2 (one visit a week for two weeks), 1 every 2 wk 2 (one visit every two weeks for two weeks), 1 every 3 wk 6 (one visit every three weeks for six weeks). Review of the clinical record revealed the patient received SN visits on 10/08/2022, 10/14/2022 and 10/25/2022. The clinical record lacks documented evidence of a SN visit occurring the week of 11/06/2022 to meet the ordered frequency or the patient refusal of a visit for that week. The agency failed to provide services in accordance with physician orders. During interview on 11/18/2022 at 01:58 PM, the DPS stated the patient should have had a SN visit during the identified week and cannot identify a reason this did not occur. B.) Review of the Home Health Certification and Plan of Care for certification period 10/08/2022 to 12/06/2022 revealed orders for the licensed professional to report to the authorized provider weight readings greater than 149 pounds. Review of the RN Subsequent Visit Note dated 10/14/2022 lacks documented evidence of a weight being obtained or recorded. Review of the PT Add- On Evaluation Visit Note dated 10/14/2022 lacks documented evidence of a weight being obtained or recorded. Review of the PT 2nd (second) Evaluation Visit Note dated 10/19/2022 lacks documented evidence of a weight being obtained or recorded. Review of the RN Subsequent Visit Note dated 10/25/2022 lacks documented evidence of a weight being obtained or recorded. Review of the PT Subsequent Visit Notes dated 10/27/2022, 11/03/2022 and 11/10/2022 lack documented evidence weights being obtained or recorded. The agency failed to provide services in accordance with physician orders. During interview on 11/18/2022 at 10:15 AM, the DPS stated the patient was dizzy during the identified visits but the clinicians failed to document this being the reason weights were not obtained. Patient #12 – This 78-year-old therapy only patient with diagnoses that include aftercare following right total knee arthroplasty, osteoarthritis and anemia was admitted to the home health agency on 12/02/2021. Review of the facility Discharge Instructions dated 12/01/2021 revealed the patient is status post right robotic assisted total knee arthroplasty occurring on 11/30/2021. The patient is to keep dressing on right knee clean, dry and intact. Dressing may be removed post op day 7 (12/06/2021) and if no drainage may shower. Review of the PT Supervisory Only Visit dated 12/07/2021 lacks documented evidence of removal of the right knee dressing or an assessment of the right knee incision post dressing removal. Review of the PTA (Physical Therapy Assistant) Subsequent Visit Note dated 12/07/2021 revealed the following regarding the anterior mid- patellar right surgical incision: - Change in status: None; - Wound Assessed: No, covered by non- removable dressing or device; - Wound care provided: Wound care not provided, covered by non- removable dressing or device. The agency failed to provide services in accordance with physician orders. During interview on 11/18/2022 at 11:52 AM, the PT stated being unable to recall why he did not track and remove the surgical dressing as ordered. Patient #9 – This 59-year-old patient with diagnoses that include spina bifida with paraplegia, depression and type II diabetes mellitus without complications was admitted to the home care agency on 01/15/2022. Review of the Home Health Certification and Plan of Care for certification period 01/15/2022 to 03/15/2022 revealed orders for Skilled Nurse to instruct/reinforce in intermittent self-catheterization with 14 (fourteen) French straight tip catheter. Review of the RN Subsequent Visit Note dated 01/19/2022 lacks documented evidence of any instruction/reinforcement being done or recorded during the assessment visit. Review of the SN Subsequent Visit Notes dated 01/21/2022, 01/25/2022 and 01/27/2022 lack documented evidence of any instruction/reinforcement being done or recorded during the assessment visit. The agency failed to provide services in accordance with physician orders. During interview on 11/18/2022 at 02:53 PM, the DPS stated the clinician was unavailable to interview. The DPS added the clinician failed to document any instruction/reinforcement of intermittent self-catheterization in the clinical records. Patient #10 – This 83-year-old patient with diagnoses that include skin ulcer of sacrum, unspecified ulcer stage, anemia, and chronic pain due to injury was admitted to the home health agency on 03/28/2022. Review of the Home Health Certification and Plan of Care for certification period 03/28/2022 to 05/26/2022 revealed orders for Skilled Nurse to teach related to altered cardiovascular status including disease process, nutrition, medications, activities, personal/environmental factors, and to report weight gain of two to three pounds/day or five pounds /week. Review of the RN Subsequent Visit Note dated 04/01/2022 lacks documented evidence of a weight being obtained or recorded during the assessment visit. Review of the SN Subsequent Visit Notes dated 04/05/2022 and 04/11/2022 lack documented evidence of a weight being obtained or recorded during the assessment visit. The agency failed to provide services in accordance with physician orders. During interview on 11/18/2022 at 02:08 PM, the DPS stated the clinician was unavailable to interview. The DPS added there were no weights documented for the identified dates.

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 interview with agency staff, for four (4) of seventeen (17) patients (Patient #'s 4, 6, 12 and 17), the agency failed to ensure services and treatments are administered in accordance with physician orders. Failure to administer services and treatments without a physician's order has the potential to result in poor quality of care. Patient #4 – This 67-year-old patient with diagnoses that include aftercare following left below the knee amputation, diabetes mellitus type 2 and essential hypertension was admitted to the home health agency on 10/23/2022. Review of the PT (Physical Therapist) Add- On Evaluation Visit Note dated 10/25/2022 revealed the following pain assessment documentation: - Indicate pain location: L (left) knee; - Indicate what relieves pain: Ice/ heat and medications. Review of the clinical record lacks orders for the application of ice and heat. The PT failed to obtain orders for the use of ice and heat. During interview on 11/18/2022 at 11:34 AM, the PT stated he failed to obtain orders for the use of ice and heat. Patient #12 – This 78-year-old therapy only patient with diagnoses that include aftercare following right total knee arthroplasty, osteoarthritis and anemia was admitted to the home health agency on 12/02/2021. A.) Review of the Client Coordination Note dated 12/06/2021 revealed the PT documented advising the patient to apply ice to her knee for 15-20 (fifteen to twenty) minutes and patient verbalized understanding of this. Review of the PTA (Physical Therapy Assistant) Subsequent Visit Notes dated 12/07/2021, 12/09/2021 and 12/16/2021 revealed the PTA documented the patient uses ice/ heat and medications to relieve pain. Review of the PT Reassessment Visit Note dated 12/23/2021 and the PT Subsequent Visit dated 12/30/2021 revealed the patient uses ice/ heat and medications to relieve pain. Review of the clinical record lacks orders for the application of ice and/ or heat. The PT failed to obtain orders for the use of ice and heat. During interview on 11/18/2022 at 11:57 AM, the PT stated being unaware the application of ice and/ or heat required orders for use on the POC. B.) Review of the PTA Subsequent Visit Note dated 12/09/2021 revealed the following: “PT contacted provider and spoke with nurse 12/07/2021 who suggested that Pt. (patient) take Oxycodone once in morning and once before bed, then alternate Tramadol/ Acetaminophen during the day for pain control. They also suggested Milk of Magnesia with hot prune juice to produce a bowel movement.” Review of the clinical record lacks an order for Milk of Magnesia. The PT failed to obtain an order for Milk of Magnesia. During interview on 11/18/2022 at 10:40 AM, the Director of Patient Services (DPS) stated there was not an order on file for the patient’s use of Milk of Magnesia. HV Patient #6 – This 60-year-old patient with diagnoses that include morbid obesity, status post fall and diabetes mellitus type 2 was admitted to the home health agency on 10/21/2022. Review of the PT (Physical Therapist) Add- On Evaluation Visit Note dated 10/24/2022 revealed the following pain assessment documentation: - Indicate pain location: Legs, shoulders and neck; - Indicate what relieves pain: Ice/ heat, medications, and sleep/rest. Review of the clinical record lacks orders for the application of ice and heat. The PT failed to obtain orders for the use of ice and heat. During interview on 11/18/2022 at 01:47 PM, the Director of Patient Services (DPS) stated the clinician was unavailable to interview and added there was not an order on file for the use of ice and heat. Patient #17 – This 77-year-old patient with diagnoses that include aftercare following left total knee replacement, chronic osteoarthritis and polyneuropathy was admitted to the home health agency on 10/30/2022. Review of the RN (Registered Nurse) OASIS (Outcome and Assessment Information Set) Admission Visit Note dated 10/30/2022 revealed the following pain assessment documentation: - Indicate pain location: L (left) knee; - Indicate what relieves pain: Change of weight bearing, distraction, Ice/ heat, and medications. Review of the PT (Physical Therapist) Add- On Evaluation Visit Note dated 11/02/2022 revealed the PT documented the patient uses ice/ heat and medications to relieve pain. Review of the clinical record lacks orders for the application of ice and heat. The clinicians failed to obtain orders for the use of ice and heat. During interview on 11/18/2022 at 10:51 AM, the RN stated he failed to obtain orders for the use of ice and heat. During interview on 11/18/2022 at 11:08 AM, the PT stated he failed to obtain orders for the use of ice and heat.

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 review of clinical records and interviews with agency staff for two (2) of seventeen (17) patients (Patient #’s 4 and 8), the agency failed to ensure the Plan of Care (POC) is reviewed and revised to reflect the patient's current status. Failure to ensure the POC is updated and revised to reflect patient needs, has the potential to result in negative patient outcomes. HV Patient #4 – This 67-year-old patient with diagnoses that include aftercare following left below the knee amputation, diabetes mellitus type 2 and essential hypertension was admitted to the home health agency on 10/23/2022. Review of the Home Health Certification and Plan of Care for certification period 10/23/2022 to 12/21/2022 revealed the following: Patient has had difficulty controlling diabetes with frequent hyperglycemia and has followed with Endocrinology. Patient does not currently have a glucometer in the home as it was misplaced while she was in hospital. Patient unable to monitor blood sugars, resulting in not taking her sliding scale insulin as taken pre-hospitalization. Review of the OT (Occupational Therapy) Subsequent Visit Note dated 11/11/2022 revealed the following: - A documented fasting blood sugar reading of 190; - A report that the patient obtained a replacement glucometer but had not taken her morning insulin at the time of the OT visit; and - “Care Coordination, Indicate if you communicated with other disciplines involved in this case: No.” Review of the clinical record revealed the next visit provided by the agency occurred on 11/15/2022 and was a joint visit with the Licensed Practical Nurse (LPN), Director of Patient Services (DPS) and the Surveyor. During observational home visit occurring on 11/15/2022 at 09:30 AM, the patient was observed to check her blood glucose during the visit with the newly obtained glucometer. The patient verbalized she had resumed taking short acting sliding scale insulin in addition to her ordered scheduled insulin as of 11/09/2022 when a new glucometer was obtained. The Surveyor reported to the LPN that the following is not ordered for the patient: - Sliding scale insulin orders; - Frequency of blood glucose testing; and - Blood glucose parameters to monitor and report to authorized practitioner if fall outside of ordered parameters. The LPN verbalized follow-up with the authorized practitioner would occur regarding the identified issues. Review of the Verbal Order dated 11/15/2022 revealed the LPN reported to the physician the patient has resumed taking sliding scale insulin in addition to scheduled insulin and obtained orders for the sliding scale insulin. (The verbal order lacks blood glucose parameters to follow and report if outside of identified parameters). The agency failed to update the Plan of Care to reflect the patient's change in status. During interview on 11/18/2022 at 12:35 PM, the DPS stated the physician should have been contacted and the POC updated on 11/11/2022 when the change in status was noted by the agency. Patient #8 – This 95-year-old patient with diagnoses that include pneumonia, urinary tract infection and essential hypertension was admitted to the home health agency on 05/22/2021. Review of the facility Discharge Summary dated 05/28/2021 revealed the patient had an observational facility stay from 05/25/2021 to 05/28/2021 due to acute respiratory failure secondary to pneumonia. The patient was discharged on new home Oxygen at 2 L (liters) continuous via nasal cannula. A.) Review of the PT (Physical Therapy) Add- On Evaluation Visit Note dated 05/30/2021 revealed the patient was utilizing Oxygen at 2 L at rest and 4 L with exertion. Review of the clinical record from 05/28/2021 to 07/20/2021 lacks orders for Oxygen. The agency failed to update the Plan of Care to reflect the patient's change in status. During interview on 11/18/2022 at 02:25 PM, the DPS acknowledged the agency failed to obtain orders for Oxygen during the identified period. B.) Review of the Home Health Certification and Plan of Care for certification period 05/22/2021 to 07/20/2021 revealed orders for HHA (Home Health Aide) effective 05/23/2021 of 1 wk 3 (one time per week for three weeks). Review of the clinical record revealed the first HHA service visit, provided by the LPN, occurred on 06/03/2021 (twelve days after the start of care). The agency failed to update the Plan of Care to reflect the patient's change in status. During interview on 11/18/2022 at 02:27 PM, the DPS stated the aide orders failed to be updated after the patient was hospitalized 5/25/2021 to 05/28/2021 to reflect a new visit frequency. C.) Review of the Aide Care Plan dated 05/22/2021 lacks documented evidence of being updated to include new oxygen instructions and precautions upon re-hospitalization 05/25/2022 to 05/28/2022. The agency failed to update the Aide Plan of Care to reflect the patient's change in status. During interview on 11/18/2022 at 02:29 PM, the DPS acknowledged the aide care plan failed to get updated with the new Oxygen instructions and precautions after the patient’s re-hospitalization. D.) Review of the RN (Registered Nurse) Recert (Recertification) With Skill Visit Note dated 07/16/2021 revealed the patient is utilizing Oxygen at 2 L continuously via nasal cannula. Review of the clinical record from 07/20/2021 09/18/2021 (duration of second certification period) lacks orders for Oxygen therapy. The agency failed to update the Plan of Care to reflect the patient's change in status. During interview on 11/18/2022 at 02:32 PM, the DPS stated the RN who performed the recertification assessment no longer works for the agency. The DPS acknowledged the agency failed to obtain orders for Oxygen therapy during the identified period.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on review of clinical records and interviews with agency staff, for two (2) of seventeen (17) patients (Patient #'s: 4 and 7), the agency failed to ensure the physician is notified of changes in the patient's condition or needs that suggest that the Plan of Care (POC) may need to be altered. Failure to promptly notify the physician to changes in the patient's condition or needs that may suggest that outcomes are not being achieved and/or the POC should be altered has the potential to result in unmet patient needs and negative patient outcomes. HV Patient #4 – This 67-year-old patient with diagnoses that include aftercare following left below the knee amputation, diabetes mellitus type 2 and essential hypertension was admitted to the home health agency on 10/23/2022. Review of the Home Health Certification and Plan of Care for certification period 10/23/2022 to 12/21/2022 revealed the following: Patient has had difficulty controlling diabetes with frequent hyperglycemia and has followed with Endocrinology. Patient does not currently have a glucometer in the home as it was misplaced while she was in hospital. Patient unable to monitor blood sugars, resulting in not taking her sliding scale insulin as taken pre-hospitalization. Review of the OT (Occupational Therapy) Subsequent Visit Note dated 11/11/2022 revealed the following: - A documented fasting blood sugar reading of 190; - A report that the patient obtained a replacement glucometer but had not taken her morning insulin at the time of the OT visit; and - “Care Coordination, Indicate if you communicated with other disciplines involved in this case: No.” During observational home visit with the Licensed Practical Nurse (LPN) and Director of Patient Services (DPS) occurring on 11/15/2022 at 09:30 AM, the patient was observed to check her blood glucose during the visit with the newly obtained glucometer. The patient verbalized she had resumed taking short acting sliding scale insulin in addition to her ordered scheduled insulin as of 11/09/2022 when a new glucometer was obtained. The Surveyor reported to the LPN that the following is not ordered for the patient: - Sliding scale insulin orders; - Frequency of blood glucose testing; and - Blood glucose parameters to monitor and report to authorized practitioner if fall outside of ordered parameters. The LPN verbalized follow-up with the authorized practitioner would occur regarding the identified issues. Review of the clinical record lacks documented evidence the agency updated the physician of the change in status until identified by the Surveyor six (6) days later. The agency failed to ensure the physician is notified of changes in the patient's condition or needs that suggest that the POC may need to be altered. During interview on 11/18/2022 at 12:35 PM, the DPS stated the physician should have been contacted on 11/11/2022 when the change in status was noted by the agency. Patient #7 - This 74-year-old patient with diagnoses that include parkinson’s disease, hypertensive chronic kidney disease and anemia was admitted to the home health agency on 10/08/2022. Review of the Home Health Certification and Plan of Care for certification period 10/08/2022 to 12/06/2022 revealed orders for the Licensed Professional to report vital signs falling outside the following established parameters: - Systolic BP (blood pressure) (greater than) 150; and - Diastolic BP 90. Review of the Physical Therapy (PT) Subsequent Visit Note dated 11/03/2022 revealed the Physical Therapy Assistant (PTA) documented the following “Patient’s BP initially 70/40. Patient demonstrated activity including gait and transfers. Following activities patient’s BP increases to 80/50. All other vitals within parameters. No complaint of light headedness, dizziness or feeling off. All meds taken this date. Supervising PT to call physician.” Review of the clinical record lacks documented evidence the physician was notified of the identified blood pressure readings being outside the ordered parameters. The agency failed to ensure the physician is notified of changes in the patient's condition or needs that suggest that the POC may need to be altered. During interview on 11/18/2022 at 10:17 AM, the PT stated the physician was notified of the identified blood pressure readings but she failed to document this.

Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on review of clinical records and staff interview for one (1) of seventeen (17) patients (Patient #4) the agency failed to ensure the Skilled Nurse (SN) provided the patient’s caregiver with appropriate education regarding the care and services identified in the plan of care (POC). Specifically, the SN failed to provide the patient’s caregiver with the appropriate education to perform wound care. Failure to provide appropriate education has the potential to result in the patient receiving inadequate care and could result in patient harm. Patient #4 – This 67-year-old patient with diagnoses that include aftercare following left below the knee amputation, diabetes mellitus type 2 and essential hypertension was admitted to the home health agency on 10/23/2022. Review of the Home Health Certification and Plan of Care for certification period 10/23/2022 to 12/21/2022 revealed the following wound care orders: Skilled Nurse to perform/ teach incision/ suture site care to left BKA (below the knee amputation). Cleanse with Normal Saline, apply Xeroform (petrolatum based dressing), cover with gauze, secure with kerlix/ ace wrap and tape using clean/ aseptic technique. Change dressing every other day and PRN (as needed) for soiling/ dislodgement. May use equivalent products. Once taught, patient/ caregiver to perform on days Skilled Nurse is not in home. Review of the SN Subsequent Visit Note dated 10/25/2022 revealed the Licensed Practical Nurse (LPN) documented the following: “Patient states her Niece is a Nurse and can be here next Wednesday (11/01/2022) to allow Nurse to educate and observe her change dressing.” Review of the clinical record revealed the next SN visit the patient received occurred on 11/02/2022 (eight days after the last documented wound care was completed). Review of the SN Subsequent Visit Note dated 11/02/2022 revealed the LPN performed the patient’s wound care as ordered. Review of the clinical record lacks documented evidence the patient’s caregiver was instructed and demonstrated the patient’s wound care. The agency failed to ensure the patient/caregiver was instructed and able to successfully re-demonstrate wound care as ordered. During interview on 11/18/2022 at 12:26 PM, the LPN stated the patient’s niece began changing the patient’s bandage on 10/27/2022 but this was not documented.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on review of clinical records and interview with agency staff for one (1) of seventeen (17) patients (Patient #4), the agency failed to ensure ongoing interdisciplinary assessments and communication between skilled professionals occurred to meet the patient's needs and goals. Failure to ensure there are ongoing interdisciplinary assessments and communication has the potential for negative patient outcomes. Patient #4 – This 67-year-old patient with diagnoses that include aftercare following left below the knee amputation, diabetes mellitus type 2 and essential hypertension was admitted to the home health agency on 10/23/2022. Review of the Home Health Certification and Plan of Care for certification period 10/23/2022 to 12/21/2022 revealed orders for following: - SN (Skilled Nurse) 2wk1 (two times per week for one week), 1wk8 (one visit per week for eight weeks); - PT (Physical Therapy 1wk1 (one visit per week for one week); - OT (Occupational Therapy) 1wk1 (one time per week for one week) and - Clinical Summary: Patient has had difficulty controlling diabetes with frequent hyperglycemia and has followed with Endocrinology. Patient does not currently have a glucometer in the home as it was misplaced while she was in hospital. Patient unable to monitor blood sugars, resulting in not taking her sliding scale insulin as taken pre-hospitalization. Review of the OT (Occupational Therapy) Subsequent Visit Note dated 11/11/2022 revealed the following: - A documented fasting blood sugar reading of 190; - A report that the patient obtained a replacement glucometer but had not taken her morning insulin at the time of the OT visit; and - “Care Coordination, Indicate if you communicated with other disciplines involved in this case: No.” The OT failed to provide interdisciplinary communication to the RN regarding changes in the patient’s diabetic management. During interview on 11/18/2022 at 12:36 PM, the Director of Patient Services (DPS) stated the OT should have notified the RN of the diabetic management changes that were noted.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on review of clinical records and interviews with agency staff, for three (3) of seventeen (17) patients (Patient #’s 4, 8 and 13), the agency failed to ensure clinicians prepare and document complete and accurate clinical and progress notes. Failure to prepare or document complete clinical and progress notes has the potential for unmet patient needs. Patient #4 – This 67-year-old patient with diagnoses that include aftercare following left below the knee amputation, diabetes mellitus type 2 and essential hypertension was admitted to the home health agency on 10/23/2022. Review of the OT (Occupational Therapy) Subsequent Visit dated 11/11/2022 revealed the following documentation: - Fasting Blood Sugar reading: 190; and - Indicate most current reported blood glucose level: Hasn’t checked BS (blood sugar). The documentation is inconsistent. It is unclear if the patient’s blood sugar reading was obtained. During interview on 11/18/2022 at 01:40 PM, the Director of Patient Services (DPS) stated the OT was unavailable for interview. The DPS stated the OT’s identified documentation was unclear. Patient #8 – This 95-year-old patient with diagnoses that include pneumonia, urinary tract infection and essential hypertension was admitted to the home health agency on 05/22/2021. Review of the OT Recert (Recertification) Add- On Evaluation dated 07/19/2021 revealed the patient had compression knee high stockings for use in the home with 15-20 mmHg (millimeters of mercury). Review of the clinical record lacks orders for the use of compression stockings. The documentation is inconsistent. It is unclear if the patient wears compression stockings. During interview on 11/18/2022 at 02:34 PM, the DPS stated the OT is not available for interview. The DPS stated being unaware of the patient’s use of compression stockings and believes they were documented on in error. Patient #13 – This 75-year-old therapy only patient with diagnoses that include emphysema, hypoxia and interstitial pulmonary disease was admitted to the home health agency on 10/30/2022. Review of the Home Health Certification and Plan of Care for certification period 10/30/2022 to 12/28/2022 revealed the patient takes the following to treat diabetes mellitus type 2: - Glimepiride 4 mg (milligram) tablet, 1 (one) tablet oral daily; and - Metformin 850 mg tablet, 1.5 (one and one-half) tablets oral daily. Review of the PT (Physical Therapy) OASIS (Outcome and Admission Information Set) Admission Visit Note dated 10/30/2022 revealed the following: - Select the pharmacological treatment the patient is currently taking: Injectable therapy; - Indicate type of injectable therapy: Insulin; - Is patient taking injectable medication as prescribed? Yes; and - Can the patient prepare medication and self inject? Yes. The documentation is inconsistent. It is unclear if the patient takes injectable insulin to manage his diabetes mellitus type 2. During interview on 11/18/2022 at 11:26 AM, the PT stated the patient does not take insulin and he made an error in his documentation.

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 for one (1) of seventeen (17) clinical records (Patient #12) the agency failed to ensure agency staff communicated with the patient's physician regarding a missed patient visit. Failure to communicate with the physician involved in the patient's care has the potential for unmet patient needs and negative outcomes. Patient #12 – This 78-year-old therapy only patient with diagnoses that include aftercare following right total knee arthroplasty, osteoarthritis and anemia was admitted to the home health agency on 12/02/2021. Review of the Home Health Certification and Plan of Care for certification period 12/02/2021 to 01/30/2022 revealed orders for PT (Physical Therapy) 1wk1 (one time per week for one week), 2wk3 (two times per week for three weeks). Review of the clinical record revealed the patient received a PT visit for the week of 12/12/2021 to 12/18/2021 on 12/16/2021. (PT visit frequency is for two visits a week for this week). Review of the Client Coordination Note dated 12/14/2021 revealed the Physical Therapy Assistant (PTA) documented the patient reports going to an orthopedic appointment on 12/14/2021 and requests no PT visit on 12/14/2021. The PTA notified the primary PT and primary PT to contact physician with report. Review of the clinical record lacks documented evidence the primary PT notified the primary care physician of the missed visit and falling outside the ordered agency visit frequency. The agency failed to ensure agency staff communicated with the patient's ordering physician regarding the missed visit. During interview on 11/18/2022 at 11:41 AM, the PT stated the primary care physician was not notified regarding the identified missed visit.