Every finding on record at Tender Loving Care Health Care Services of Nassau Suffolk, LLC

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on a review of compliance reports and staff interviews, it was determined that the Governing Authority failed to submit all required Emergency Response Drill Reports to the New York State Department of Health. Failure to submit emergency reports on Health Commerce System (HCS) as required by the Department has the potential risk for negative outcomes. Findings: The Dear Administrator Letter (DAL) DHCBS 19-05 "Emergency Response Drill" dated 5/10/2019, notified all Licensed Home Care Service Agencies (LHCSAs) of the need for participation in an emergency drill. The letter states: "All LHCSA are required to participate in this drill" and specified "failure to participate will result in a deficiency citation and possible enforcement." On 11/13/2023 request sent to the Division of Home and Community Based Services regarding agency submission of drills on 11/13/2023 as part of the survey prep. The agency submitted 4 of 5 drills. The Emergency Disaster Coordinator during interview on 12/1/2023 at 12: 00.PM, informed surveyor that agency submitted all five (5) drills. The coordinator attempts to reach HERDS and retrieve all reports on HCS was unsuccessful.

The statement of deficiencies represents the results of an extended re-certification and complaint survey of Tender Loving Care Certified Home Health Agency, CCN # 337143 located at 100 Garden City Plaza Suite 100, Garden City, NY 11530 conducted on 11/27/2023 through 12/01/2023. A standard re-certification survey and complaint investigation for IQIES complaint # 96779 was initiated on 11/27/2023. Deficient practices were identified within Level 1 standards in 484.55 Condition and 484.60 Condition resulting in a partial extended survey. Significant findings were identified within the Condition 484.75 (Skilled Professional Services) resulting of further expansion to an Extended Condition level survey. Related Conditions of Participation reviewed were: Quality Assurance Performance Improvement, Infection Control, Emergency Preparedness, The survey consisted of a review of seventeen (17) clinical records, including discharge records, thirteen (13) personnel records for professional and para-professional personnel, contracts, and seven (7) home visits were conducted. Pertinent policies and procedures- Quality Improvement Minutes for the past twelve (12) months, agency’s Admission Packet, the Emergency Preparedness Plan, and the Complaint Log for the past twelve (12) months were reviewed. Pre-survey activities consisted of agency's Health Commerce System Account (HCS) on 11/21/2023, Home Care Worker Registry, Criminal History Record Check, iQIES reports, complaint, Provider History Report, Certification and Survey Provider Enhanced Report for 11/1/2022 to 11/21/2023, the agency compliance with report submissions for the 2023 statistical report and the Emergency Drill conducted for the year 2023. The Administrator/ Director of Patient Services, Clinical Nurse Manager, and staff were interviewed. Findings were reviewed at the exit conference on 12/01/2023. Complaint # 96779 is unsubstantiated. The following deficiencies are identified as a result of the survey: G-536- A review of all current medications. G-0574-Plan of care. G-0578- Conformance with the physician order G-0642-Program Scope G-0658-Performance improvement projects. G-0660- Executive responsibilities. G-700, 702, 706, 716, 718, 726 - Skilled Professional Services State Tags- J-1416- Personnel J-1420- Personnel J-1424- Personnel J-1460- Personnel R- 1020- Responsibilities of a Provider: Required Notify W- 0614- Responsibilities of Home Care Services Entities

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 records review and staff interview, the Agency failed to ensure a comprehensive review of all medication’s patients are taking. This was evident in four (4) of seventeen (17) records reviewed. (Patients #3, #4, #7 # 10). Failure to ensure a comprehensive review of medications, has the potential for negative patient outcome. The findings include: 4) Patient #4 has a start of care date of 11/17/2023 with diagnoses of Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Acute on Chronic Congestive Heart Failure, Type 2 Diabetes Mellitus, Atherosclerotic Heart Disease of native Coronary Artery, Hypothyroidism, and Hyperlipidemia as documented on the “Home Health Certification and Plan of Care” dated 11/17/2023 to 01/15/2024. The “Home Health Certification and Plan of Care” dated 11/17/2023 to 01/15/2024 documents orders for “Skilled Nurse (SN) 1wk1, 2wk2, 1wk1 (1 time per week for 1 week, 2 times per week for 2 weeks, 1 time per week for 1 week); Physical Therapy (PT) effective 11/19/2023 2wk3, 1wk3 (2 times per week for 3 weeks, 1 time per week for 3 weeks; Occupational Therapy (OT) effective 11/19/2023 1wk1 (1 time per week for 1 week). Medications: Metformin 1,000 milligrams tablet 2 times daily.” The “Visit Note Report- Registered Nurse Oasis Admission” dated 11/17/2023 documents “Interventions provided- Skilled nurse to observe and assess medications to identify immediate needs and intervene to minimize complication to make patient safe until next visit. Details/comments: Reviewed meds”. The “Visit Note Report” dated 11/20/2023 completed by the Registered Nurse indicates “no medication discrepancies, issues or non-compliance found”. The “Visit Note Report” dated 11/27/2023 completed by the Licensed Practical Nurse indicates “no medication discrepancies, issues or non-compliance found”. During a Home Visit on 11/29/2023 at 10:00AM, when asked about her medications, the patient stated, “I take so many- pills for diabetes, insulin, aspirin and a whole bunch of other things.” The medication list provided by the Assisted Living facility dated 11/27/2023 documents the patient’s current medications include: ASA 81 milligrams Daily, Atorvastatin 40 milligrams Daily, Levothyroxine 50 micrograms Daily, Multivitamin 1 tab Daily, Lispro insulin sliding scale, Ferrous sulfate 324 milligrams Daily, Furosemide 20 milligrams Daily, and Metformin 1,000 milligrams twice daily. The clinical record does not accurately identify the medications the patient is currently taking. On 11/30/2023 at 3:50 PM, the Administrator and Director of Patient Services were interviewed and did not provide an explanation for the findings. 2) Patient #3 start of care 10/20/2023 with diagnoses of Laceration to right elbow, Hypertension Heart Disease with Heart Failure, Chronic Obstructive Pulmonary Disease, Acute Respiratory with Hypoxia and Hypercapnia, Anemia, Dependence on Supplemental Oxygen, Anxiety and Major Depression as documented on the "Home Health Certification and Plan of Care" for certification period 10/20/2023-12/18/2023. The Home Health Certification and Plan of Care certification period 10/20/2023-12/18/2023 documents an order for “Skilled Nurse 1wk1, 2wk4 (1 time per week for 1 week, 2 times per week for 4weeks); Physical Therapy effective 10/29/2023 1wk1, 2wk2, 1wk3 (1 times per week for week, 2 time per week for 2 weeks, 1 time per week for 3 weeks; Occupational Therapy effective 10/29/2023 1wk1 (1 time per week for 1 week). Medications: Albuterol inhaler 90mcg (micrograms) daily, Aspirin 81mg (milligram) I tablet daily, Atenolol 25 milligram 2 tablets daily, Breo Ellipta 100 micrograms inhalation daily, Cetirizine 10 milligram daily, Buspirone 5milligram I tablet daily, Ipratropium 0.5 milligram -Albuterol 3 milligram Nebulization every 6 hours, Symbicort 160 milligram Inhaler every 12 hours, and Trazadone 50 milligram 1tablet daily.” The “Visit Note Report- Registered Nurse Oasis Admission” dated 11/17/2023 documents “Interventions provided- Skilled Nurse to observe and assess medications to identify immediate needs and intervene to minimize complication to make patient safe until next visit. Details/comments: Reviewed meds”. The Licensed Practical Nurse “Visit Note Reports” dated 10/24/23, 10/27/23, 10/31/23, 11/02/23 and 11/07/23 indicates “no medication discrepancies, issues or non-compliance found”. “Visit Note Report” dated 11/17/2023 completed by the Registered Nurse indicates “no medication discrepancies, issues or non-compliance found”. During a Home Visit on 11/28/2023 at 11:00AM, Surveyor found discrepancies between the Agency “Client Medication Report and the Assisted Living medication “order summary report”. The medication list provided by the Assisted Living dated 11/28/23 documents the patient’s current medications include: Bipap Oxygen therapy at 3 Liters/minute at bedtime and as needed, Potassium Chloride ER tablet 20 meq (milliequivalent) daily, Saline Mist Nasal Solution 0.65%, Carvedilol 6.25 milligram tablet, Cholecalciferol 50 milligram Capsule, Docusate Sodium 100 milligram capsule and Budesonide inhalation suspension 0.5ML/2MG(milliter/milligram). The clinical record lacks documented evidence of the patient's current and accurate medication regimen. 3) Patient #7 with start of care 10/12/2023 with diagnoses of Malignant Neoplasm of left Female Breast, Abscess of the Breast and Nipple, Urinary Tract Infection, Alzheimer’s Disease, Essential Hypertension, Anemia and Type 2 Diabetes as documented on the "Home Health Certification and Plan of Care" for certification period 10/12/2023 - 12/10/2023. The Home Health Certification and Plan of Care for certification period 10/12/2023-12/10/2023 documents orders for Skilled Nurse 1WK2, 2WK3 (1 time per week for 2 week, 2 times per week for 3 weeks; Physical Therapy effective 10/15/2023 2wk3, 1wk1, 2WK3,1WK4 (1 time per week for 1 week, 2 times per week for 3 weeks, 1 time per week for 4 weeks). Medications include: Alogliptin 12.5 milligram tablet 2 times daily, Farxiga 10 milligram 1 tablet daily, Furosemide 20 milligram 1 tablet daily, Glimepiride 4 milligram 1 tablet daily and Risperidone 0.25 milligram 1 tablet daily. The “Visit Note Report- Registered Nurse Oasis Admission” dated 10/12/2023 documents “Interventions provided- Skilled Nurse to observe and assess medications to identify immediate needs and intervene to minimize complication to make patient safe until next visit. Details/comments: Reviewed meds”. During a Home Visit on 11/29/2023 at 1.00PM, the Surveyor found discrepancies between the Agency “Client Medication Report and the Assisted Living medication “order summary report”. The medication list provided by the Assisted Living dated 11/29/23 documents the patient’s current medications to include: Anastrozole 1MG (Milligram) tablet daily, Probiotics 20MG (milligram) capsule twice daily and Vitamin D3 50MCG (microgram)1 tablet daily. The Licensed Practical Nurse ‘Visit Note Reports’ dated 10/17/23, 10/27/23, 10/31/23, 11/0723 and 11/14/2023 indicates “no medication discrepancies, issues or non-compliance found”. The “Visit Note Report” dated 10//23/23, 11/03/23, 11/10/23 and 11/29/2023 completed by the Registered Nurse indicates “no medication discrepancies, issues or non-compliance found”. The clinical record lacks documented evidence of the patient's current medications. On 11/30/2023 at 3:00 PM, the Administrator/ Director of Patient Services was interviewed, and no explanation provided. 1) Patient #10 has a start of care date of 05/30/2023 with diagnoses of Unspecified Open Wound Left Knee, Hypertensive Chronic Kidney Disease stage 1, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease as documented on the "Home Health Certification and Plan of Care" for certification period 05/30/2023 to 07/28/2023. The patient has a discharge date of 07/28/2023. The referral dated 05/30/2023 documents requested services for "Skilled Nurse, Physical Therapy and Occupational Therapy. The patient's medications include: " Humulin NPH Kwickpen 100 units/ml, inject "15 units" into the skin nightly", and "Insulin Aspar Prot-Insulin Aspart 100 units/ml (70/30) subcutaneous pen, dose inject "8 units" into the skin 3 (three) times daily before meals". The "Registered Nurse Oasis Admission" dated 05/30/2023, the Registered Nurse documents the patient’s medications to include "Humulin 70/30 U-100 Insulin 100 units/ml subcutaneous suspension, dose "1 unit", and "Insulin Aspar Prot-Insulin Aspart 100 units/ml (70/30) subcutaneous pen, dose "1 ml (milliliter)". The "Home Health Certification and Plan of Care" for certification period 05/30/2023 to 07/28/2023 documents and order for "Skilled Nurse 2wk1, 1wk3 two visit a week for one week, one visit a week for three weeks), Physical Therapy 2 wk6 (two visit a week for six weeks, and Occupational Therapy 1wk1 (one visit a week for one week". Skilled Nurse to "assess evaluate and develop an individualized Plan of Care". Skilled Nurse for instruction in "Diabetic Care to include diet Low Carb, skin care, and symptoms of hypo/hyperglycemia, proper administration of Diabetic medication". Medications: "Humulin 70/30 U-100 Insulin 100 units/ml subcutaneous suspension, dose "1 unit" daily", and “Insulin Aspar Pro-Insulin Aspar 100 units/ml (70/30) subcutaneous pen, dose "1 unit" daily". The clinical record lacks documented evidence that the Skilled Nurse perform a comprehensive review of the patient's current Diabetic medications and accurate Insulin dosage, route and frequency, in order to identify any potential adverse effects and ineffective drug therapy. The survey findings and interview were conducted with the Director of Patient Services on 11/29/2023 at 03:57 PM. No explanation was provided.

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 home visit observations, record review and staff interview, the Agency failed to establish individualized Plans of Care that includes License Practical Nurse services, treatments, and patient's Rehabilitation Potential. This is evident in seven (7) of seventeen (17) clinical records reviewed. (Patients #2, #3, #5, #6, #7, #9, #10). Failure to establish comprehensive Plans of Care, has the potential for negative patient outcome. The findings include: 6) Patient #5 has a start of care date of 09/12/2023 with diagnoses of Aphasia following cerebral infarction, Apraxia following cerebral infarction, Spinal Stenosis, Essential Hypertension, and Hypothyroidism as documented on the “Home Health Certification and Plan of Care” dated 09/12/2023 to 11/10/2023. The “Visit Note Report- RN OASIS Assessment” dated 09/12/2023 documents “Client’s mental status: Alert, Other (specify); Indicate other mental status: Pt had a Cerebrovascular Accident (CVA) and has aphasia. Skilled Nurse is unable to determine patients orientation”. The “Home Health Certification and Plan of Care” dated 09/12/2023 to 11/10/2023 documents “Functional limitations: endurance, ambulation”. There is no documented evidence of the functional limitation of speech in the plan of care. The plan of care is not individualized and indicative of the patient’s functional status. The Administrator and Director of Patient Services were interviewed and findings reviewed on 11/29/2023 at 3:50PM. No explanation was provided. 7) Patient #6 has a start of care date of 01/26/2023 with diagnoses of Pressure Ulcer of Left Ankle- Stage 2, Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, Benign Neoplasm of Cerebral Meninges, Essential Hypertension, Epilepsy and Hyperlipidemia as documented on the “Home Health Certification and Plan of Care” dated 11/22/2023 to 01/20/2024. The “Visit Note Report- Registered Nurse Recert with Skill” dated 11/202/2023 documents “Abnormal Findings in Eyes Assessment- Diabetic retinopathy, bilateral”. During a Home Visit on 11/30/2023 at 12:00PM, when asked to sign the consent for the visit, the patient stated, “I am blind, I cannot see the paper”. The “Home Health Certification and Plan of Care” dated 11/22/2023 to 01/20/2024 documents “Functional limitations: incontinence, endurance, ambulation”. There is no documented evidence of the functional limitation of sight in the plan of care. The plan of care is not individualized and indicative of the patient’s functional status. On 11/30/2023 at 4:30 PM, the Administrator and Director of Patient Services were interviewed and did not provide an explanation for the findings. 3) Patient #2 with a start of care 10/26/2023 diagnoses of Scoliosis, Raynaud’s Syndrome, Indwelling Catheter, Foot drop, Atrial Fibrillation, Hypertension, Polyneuropathy, Asthma and Spinal Stenosis as documented on the "Home Health Certification and Plan of Care" for certification period 10/26/2023 -12/24/2023. The Home Health Certification and Plan of Care for certification period 10/26/2023-12/24/2023 documents an order for Register Nurse to "observe, assess, evaluate, and develop an individualized plan of care. Registered Nurse to observe and assess". License Practical Nurse to "observe for risk for falls and instruct in falls prevention, home safety, medication management infection prevention and nutrition management". Skilled Nurse "Management of Indwelling Urinary catheter including insertion of 16 French, instill 10cc (cubic centimeter) of solution into balloon every month and PRN (as needed) for leakage, blockage, dislodgement or malfunction”. The “Visit Note Report” Assessment note dated 11/08/23 were conducted by an Licensed Practical Nurse and documents in narrative note” Skilled Nurse observed patient private showed competency in flushing catheter with zero difficulty and verbalized understanding in catheter care in the importance of keeping tubing entrance sterile”. The Plan of Care lacks an order for the Licensed Practical Nurse visit frequency and specific treatments for the Licensed Practical Nurse to perform. There is no documented evidence that the Plan of Care is complete. The Agency did not establish an individualized Plan of Care that includes specific treatments for Licensed Practical Nurse services. 4) Patient #3 start of care 10/20/2023 with diagnoses of Laceration to right elbow, Hypertension Heart Disease with Heart Failure, Chronic Obstructive Pulmonary Disease, Acute Respiratory with Hypoxia and Hypercapnia, Anemia, Dependence on Supplemental Oxygen, Anxiety and Major Depression as documented on the "Home Health Certification and Plan of Care" for certification period 10/20/2023-12/18/2023. The Home Health Certification and Plan of Care for certification period 10/20/2023-12/18/2023 documents an order for Registered Nurse to "observe, assess, evaluate, and develop an individualized plan of care. Registered Nurse to observe and assess, Licensed Practical Nurse to "observe for risk for falls and instruct in falls prevention, home safety, medication management infection prevention and nutrition management". Skilled Nurse to "monitor co-morbid conditions as listed on Plan of Care and any new conditions that present themselves during this episode to identify changes and intervene to minimize complications". The “Registered Nurse OASIS Admission” dated 10/20/2023 documents abnormal findings patient in hearing assessment, indicating “hearing difficulty and location of hearing is right and left”. Under respiratory findings indicates” no abnormal findings”. During a Home Visit on 11/28/2023 at 11:00AM, when surveyor was speaking to patient and asked to sign the consent for the visit, the patient stated, “I don’t hear what you’re saying, lost my left hearing aid device”. Patient was observed with Oxygen (O2) via nasal cannula by Oxygen concentrator on home visit and uses Bipap Oxygen therapy as documented on patient current medication list at the Assisted Living Facility (ALF). The “Visit Note Reports” dated 10/24/23, 10/27/23, 10/31/23, 11/02/23 and 11/07/23, the Licensed Practical Nurse documents “no supplemental oxygen” with vital signs and under Respiratory assessment indicates “no abnormal findings”. The Plan of Care lacks an order for the Licensed Practical Nurse visit frequency, Bipap machine and Oxygen dosage, route and frequency. The Agency did not establish an individualized Plan of Care. 5) Patient #7 with start of care 10/12/2023 with diagnoses of Malignant Neoplasm of left Female Breast, Abscess of the Breast and Nipple, Urinary Tract Infection, Alzheimer’s Disease, Essential Hypertension, Anemia and Type 2 Diabetes as documented on the "Home Health Certification and Plan of Care" for certification period 10/12/2023-09/24/2023. The Home Health Certification and Plan of Care for certification period 10/12/2023-09/24/2023 documents an order for Register Nurse to "observe, assess, evaluate, and develop an individualized plan of care. Registered Nurse to observe and assess, License Practical Nurse to "observe for risk for falls and instruct in falls prevention, home safety, medication management infection prevention and nutrition management". Skilled Nurse to "perform wound Care to open wound to left breast twice a week and PRN (as needed) for dislodged and soiled dressing”. The ‘Visit Note Reports’ dated 10/17/23, 10/27/23, 10/31/23, 11/0723 and 11/14/2023 were conducted by an Licensed Practical Nurse documenting preforming “wound assessment”. The Agency did not establish an individualized Plan of Care that includes specific treatments for Licensed Practical Nurse services. The Agency failed to ensure that the Skilled Nurse perform the care and services as per the Plan of Care. The survey findings were reviewed with the Administrator and Director of Patient Services on 11/30/2023 at 3:00PM. No explanation was provided. 1) Patient #9 has a start of care date of 08/06/2023 with diagnoses including Hypertension Heart and Chronic Kidney Disease with Heart Failure stage 1, Chronic Diastolic Heart Failure, and Type 2 Diabetes Mellitus as documented on the “Home Health Certification and Plan of Care” for certification period 08/06/2023 to 10/04/2023. The “Home Health Certification and Plan of Care” (POC) for certification period 08/06/2023 to 10/04/2023 documents an order for “SkilledNurse 2wk1, 1wk5, 1 every 2wk2, 1wk1 (two visits a week for one week, one visit a week for five weeks, one visits every two weeks for two weeks). "Registered Nurse to observe and assess, License Practical Nurse observe for risk for falls and instruct in fall prevention, home safety, medication management, infection prevention and nutrition management". Treatments include: "Cardiovascular System: Skilled Nurse to assess and teach related to altered cardiovascular status to minimize complications and reduce hospitalization. Heart Failure: Skilled Nurse to assess cardiovascular system to identify signs of decompensation and intervene to minimize the severity of fluid overload, assess patient ability to monitor and recall daily weights and vital signs. Hypertension management: Skilled Nurse to assess/teach warning signs and symptoms to avoid hospitalization. Atrial Fibrillation: SN to assess/teach warning signs and symptoms to avoid hospitalization. Respiratory system: Skilled Nurse to assess and teach related altered respiratory status to minimize complications and reduce hospitalization. Diabetic management: Skilled Nurse for instructions of Diabetic care include diet, skin care, signs and symptoms of hypo/hyperglycemia, proper administration of Diabetic medication". The POC lacks an order for the Licensed Practical Nurse visit frequency and specific treatments for the Licensed Practical Nurse to perform. There is no documented evidence that the Plan of Care is complete. The Agency did not establish an indiividualized Plan of Care that includes specific treatments for Licensed Practical Nurse services. The survey findings were reviewed with the Administrator, Director of Patient Services on 11/28/2023 at 03:40PM. No explanation was provided. 2) Patient #10 has a start of care date of 05/30/2023 with diagnoses of Unspecified Open Wound Left Knee, Hypertensive Chronic Kidney Disease stage 1, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease as documented on the "Home Health Certification and Plan of Care" for certification period 05/30/2023 to 07/28/2023. The patient has a discharge date of 07/28/2023. The referral dated 05/30/2023 documents requested services for Skilled Nurse, Physical Therapy and Occupational Therapy. The patient's medications include: " Humulin NPH Kwickpen 100 units/ml, inject "15 units" into the skin nightly", and "Insulin Aspar Prot-Insulin Aspart 100 units/ml (70/30) subcutaneous pen, dose inject "8 units" into the skin 3 (three) times daily before meals". The "Registered Nurse Oasis Admission" dated 05/30/2023, the Registered Nurse documents the patient’s medications to include "Humulin 70/30 U-100 Insulin 100 units/ml subcutaneous suspension, dose "1 unit", and "Insulin Aspar Prot-Insulin Aspart 100 units/ml (70/30) subcutaneous pen, dose "1 ml (milliliter)". The "Home Health Certification and Plan of Care" for certification period 05/30/2023 to 07/28/2023 documents and order for "Skilled Nurse 2wk1, 1wk3 two visit a week for one week, one visit a week for three weeks), Physical Therapy 2 wk6 (two visit a week for six weeks, and Occupational Therapy 1wk1 (one visit a week for one week". Skilled Nurse to "assess evaluate and develop an individualized Plan of Care". Skilled Nurse for instruction in "Diabetic Care to include diet Low Carb, skin care, and symptoms of hypo/hyperglycemia, proper administration of Diabetic medication". Medications: "Humulin 70/30 U-100 Insulin 100 units/ml subcutaneous suspension, dose "1 unit" daily", and “Insulin Aspar Pro-Insulin Aspar 100 units/ml (70/30) subcutaneous pen, dose "1 unit" daily". The Plan of Care lacks an order of the patient's current and accurate Insulin dosage, route and frequency. The Plan of Care is not individualized to include all medications. The survey findings and interview were conducted with the Director of Patient Services on 11/29/2023 at 03:57 PM. No explanation was provided.

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 home visit observations, clinical records review and staff interviews, the Agency failed to ensure that pertinent services and treatments are performed in accordance to the Physician's Order. This was evident in nine (9) of seventeen (17) records reviewed. (Patients #1, #2, #3, #4, #6, #7, #9, #13 and #14). Failure to ensure that pertinent patient services and treatments are performed, has the potential for negative patient outcome. The findings include: 6) Patient #1 has a start of care date of 07/15/2023 with diagnoses of Pressure Ulcer of Right Ankle Stage 2, Type 2 Diabetes Mellitus without complications, Essential Hypertension, Alzheimer’s Disease, and Hypothyroidism as documented on the “Home Health Certification and Plan of Care” dated 11/12/2023 to 01/10/2024. The “Home Health Certification and Plan of Care” dated 11/12/2023 to 01/10/2024 documents orders for “Skilled Nurse (SN) 3wk4, 2every5wk5 (3 times per week for 4 weeks, 2 times per 5 weeks for 5 weeks); Skilled nurse to perform/teach patient/caregiver wound care to the pressure injury stage 2 to the right lateral malleolus as follows: Cleanse would with normal saline, pat to dry, may apply skin barrier to periwound as needed (prn) to prevent maceration, apply puracol to the wound, cover with gauze dressing, followed by kling, tape and net”. Interim orders dated 11/22/2023 documents: “Patient’s right lateral malleolar wound remains closed. Patient will need 1 Skilled Nurse visit/week for 2 more weeks for assessment and observation for early signs and symptoms of wound reopening. Skilled Nurse effective 11/26/2023 1wk2, 2every5wk5 (1 time per week for 2 weeks, 2 times per 5 weeks for 5 weeks)”. The “Visit Note Report” completed by the Licensed Practical Nurse on 11/13/2023 lacks documented evidence the skilled nurse performed/taught patient/caregiver wound care to the pressure injury stage 2 in accordance with the physician orders. The “Visit Note Report” documents “scab present, protective dressing applied”. The “Visit Note Report” completed by the Registered Nurse on 11/22/2023 lacks documented evidence the skilled nurse performed/taught patient/caregiver wound care to the pressure injury stage 2 in accordance with the physician orders. During a Home Visit with the Registered Nurse on 11/29/2023, the surveyor observed a scab on the patient’s right lateral malleolar wound. The surveyor observed the Registered Nurse assess the wound and did not observe a dressing being applied. The “Visit Note Report” completed by the Registered Nurse on 11/29/2023 lacks documented evidence of wound care being completed as ordered. The Agency failed to ensure that the Skilled Nurse performed the care and services as per the Plan of Care. The survey findings were reviewed with the Administrator and Director of Patient Services on 11/29/2023 at 3:55PM. No explanation was provided. 7) Patient #4 has a start of care date of 11/17/2023 with diagnoses of Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Acute on Chronic Congestive Heart Failure, Type 2 Diabetes Mellitus, Atherosclerotic Heart Disease of native Coronary Artery, Hypothyroidism, and Hyperlipidemia as documented on the “Home Health Certification and Plan of Care” dated 11/17/2023 to 01/15/2024. The “Home Health Certification and Plan of Care” dated 11/17/2023 to 01/15/2024 documents orders for “Skilled Nurse (SN) 1wk1, 2wk2, 1wk1 (1 time per week for 1 week, 2 times per week for 2 weeks, then 1 time per week for 1 week); Physical Therapy (PT) effective 11/19/2023 2wk3, 1wk3 (2 times per week for 3 weeks, 1 time per week for 3 weeks; Occupational Therapy (OT) effective 11/19/2023 1wk1 (1 time per week for 1 week). Registered Nurse (RN) to assess/teach, Licensed Practical Nurse (LPN) to observe/teach cardiopulmonary system to identify signs of decompensation and intervene to minimize the severity of fluid overload. Observe patient ability to monitor and record daily weights and vital signs, including pulse ox and Blood Pressure; record patient reported weight, or weigh patient as needed. Report increased edema or weight gain of >2 lbs (pounds) in 1 day or >5 lbs (pounds) in 1 week or 5 lbs (pounds) or more over target weight. May measure abdominal girth if unable to weigh. Scales and Blood Preesure monitor to be provided as needed.” The “Registered Nurse OASIS Admission” note dated 11/17/2023 documents a patient weight of 152 lbs. The “Visit Note Report” completed by the Registered Nurse on 11/20/2023 lacks documented evidence of a current patient weight or documentation of the self-monitored vital signs. The “Visit Note Report” completed by the Licensed Practical Nurse on 11/24/2023 lacks documented evidence of a current patient weight or documentation of the self-monitored vital signs. The record lacks documented evidence the skilled nurse educated the patient about the cardiovascular system to identify decompensation. The Agency failed to ensure that the Skilled Nurse performed the care and services as per the Plan of Care. The survey findings were reviewed with the Administrator and Director of Patient Services on 11/30/2023 at 3:50PM. No explanation was provided. 8) Patient #6 has a start of care date of 01/26/2023 with diagnoses of Pressure Ulcer of Left Ankle- Stage 2, Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, Benign Neoplasm of Cerebral Meninges, Essential Hypertension, Epilepsy and Hyperlipidemia documented on the “Home Health Certification and Plan of Care” dated 09/23/2023 to 11/21/2023 and 11/22/2023 to 01/20/2024. The “Home Health Certification and Plan of Care” dated 09/23/2023 to 11/21/2023 documents an order for “Skilled Nurse (SN) effective 09/24/2023 2wk5 (2 times per week for 5 weeks). Registered Nurse to observe and assess, Licensed Practical Nurse to observe for risk for falls and instruct in fall prevention, home safety, medication management, infection prevention, and nutrition management”. The “Home Health Certification and Plan of Care” dated 11/22/2023 to 01/20/2024 documents an order for “Skilled Nurse (SN) 1wk1, 2wk4, 3PRN (1 time per week for 1 week, 2 times per week for 4 weeks, and 3 as needed). Registered Nurse (RN) to observe and assess, Licensed Practical Nurse (LPN) to observe for risk for falls and instruct in fall prevention, home safety, medication management, infection prevention, and nutrition management”. The “Visit Note Report” completed by the Registered Nurse on 10/23/2023 lacks documented evidence the skilled nurse provided instruction on fall prevention, home safety, medication management, infection prevention, and nutrition management. The “Visit Note Report” completed by the Registered Nurse on 10/27/2023 lacks documented evidence the skilled nurse provided instruction on fall prevention, home safety and nutrition management. The “Visit Note Report” completed by the Registered Nurse on 11/09/2023 lacks documented evidence the skilled nurse provided instruction on fall prevention, home safety, medication management, infection prevention, and nutrition management. The “Visit Note Report” completed by the Licensed Practical Nurse on 11/16/2023 lacks documented evidence the skilled nurse provided instruction on fall prevention, home safety, medication management, and infection prevention. The “Visit Note Report” completed by the Licensed Practical Nurse on 11/23/2023 lacks documented evidence the skilled nurse provided instruction on fall prevention, home safety, medication management, and nutrition management. The “Visit Note Report” completed by the Licensed Practical Nurse on 11/27/2023 lacks documented evidence the skilled nurse provided instruction on medication management, infection prevention, and nutrition management. The Agency failed to ensure that the Skilled Nurse performed the care and services as per the Plan of Care. The survey findings were reviewed with the Administrator and Director of Patient Services on 11/30/2023 at 4:30PM. No explanation was provided. 9) Patient #13 has a start of care date of 08/08/2023 with diagnoses of Orthopedic Aftercare, Type 2 Diabetes Mellitus with diabetic neuropathy arthropathy, Hypertensive Heart Disease with Heart Failure, Systolic Heart Failure, and Atrial Fibrillation as documented on the “Home Health Certification and Plan of Care” dated 08/08/2023 to 10/06/2023. The “Home Health Certification and Plan of Care” dated 08/08/2023 to 10/06/2023 documents an order for “Skilled Nurse (SN) 1wk4 (1 time per week for 4 weeks), Physical Therapy (PT) 1wk2 (1 time per week for 2 weeks), 2wk3 (2 times per week for 3 weeks), 1wk2 (1 time per week for 2 weeks); Occupational Therapy (OT) 1wk1 (1 time per week for 1 week), 2wk4 (2 times per week for 4 weeks), 3PRN (as needed). Skilled nurse for instructions of diabetic care to include: diet, skin care, signs and symptoms of hypo/hyperglycemia; proper administration of diabetic medication. Skilled nurse to instruct on diabetic foot care and monitor for skin lesions on lower extremities. Blood glucose testing perform by pt. Skilled nurse to assess patient/caregiver ability to perform and record blood glucose testing as ordered and to report to physician glucose readings greater than 285 or less than 85. Skilled nursing to instruct patient on importance of HGBA1C (Hemoglobin A1C) monitoring, kidney function test, eye and foot exams." The “Visit Note Report” completed by the Licensed Practical Nurse on 08/16/2023 lacks documented evidence that the Licensed Practical Nurse instructed Diabetic Care to include blood glucose monitoring, diet, skin care, signs and symptoms of hypo/hyperglycemia, proper administration of diabetic medication, diabetic foot care and importance HgBA1C (Hemoglobin A1C) monitoring, kidney function test, eye and foot exams”. The “Visit Note Report” completed by the Licensed Practical Nurse on 09/08/2023 lacks documented evidence that the Licensed Practical Nurse instructed Diabetic Care to include blood glucose monitoring, diet, skin care, signs and symptoms of hypo/hyperglycemia, proper administration of diabetic medication, diabetic foot care and importance HgBA1C (Hemoglobin A1C) monitoring, kidney function test, eye and foot exams”. The “Visit Note Report” completed by the Licensed Practical Nurse on 09/21/2023 lacks documented evidence that the Licensed Practical Nurse instructed Diabetic Care to include blood glucose monitoring, diet, skin care, signs and symptoms of hypo/hyperglycemia, proper administration of diabetic medication, diabetic foot care and importance HgBA1C (Hemoglobin A1C) monitoring, kidney function test, eye and foot exams”. The “Visit Note Report” completed by the Licensed Practical Nurse on 09/28/2023 lacks documented evidence that the Licensed Practical Nurse instructed Diabetic Care to include blood glucose monitoring, diet, skin care, signs and symptoms of hypo/hyperglycemia, proper administration of diabetic medication, diabetic foot care and importance HgBA1C (Hemoglobin A1C) monitoring, kidney function test, eye and foot exams”. The Agency failed to ensure that the Skilled Nurse performed the care and services as per the Plan of Care. The survey findings were reviewed with the Director of Patient Services on 12/01/2023 at 3:45PM. No explanation was provided. 3) Patient #2 with a start of care 10/26/2023 diagnoses of Scoliosis, Raynaud’s Syndrome, Indwelling Catheter, Foot drop, Atrial Fibrillation, Hypertension, Polyneuropathy, Asthma and Spinal Stenosis as documented on the "Home Health Certification and Plan of Care" for certification period 10/26/2023-12/24/2023. The "Home Health Certification and Plan of Care" for certification period 10/26/2023-12/24/2023 documents an order for “Skilled Nurse 1wk1, 2wk4 (1 time per week for 1 week, 2 times per week for 4weeks); Physical Therapy (effective 10/29/2023 1wk1, 2wk2, 1wk3 (1 times per week for week, 2 time per week for 2 weeks, 1 time per week for 3 weeks; Occupational Therapy effective 10/29/2023 1wk1 (1 time per week for 1 week). "Register Nurse to observe, assess, evaluate, and develop an individualized plan of care. Registered Nurse to "observe and assess, License Practical Nurse) to observe for risk for falls and instruct in falls prevention, home safety, medication management infection prevention and nutrition management". Skilled Nurse for "Management of Indwelling Urinary catheter including insertion of 16 French, instill 10cc of solution into balloon every month and PRN (as needed) for leakage, blockage, dislodgement or malfunction”. The “Visit Note Report” Assessment note dated 11/08/23 were conducted by an Licensed Practical Nurse and documents in narrative note "Skilled Nurse observed patient private Aide showed competency in flushing catheter with zero difficulty and verbalized understanding in catheter care in the importance of keeping tubing entrance sterile”. The Plan of Care lacks an order for the Licensed Practical Nurse visit frequency and specific treatments for the Licesned Practical Nurse to perform. There is no documented evidence that the Plan of Care is complete. The Agency did not establish an individualized Plan of Care that includes specific treatments for Licesned Practical Nurse services. 4) Patient #3 start of care 10/20/2023 with diagnoses of Laceration to right elbow, Hypertension Heart Disease with Heart Failure, Chronic Obstructive Pulmonary Disease, Acute Respiratory with Hypoxia and Hypercapnia, Anemia, Dependence on Supplemental Oxygen, Anxiety and Major Depression as documented on the "Home Health Certification and Plan of Care" for certification period 10/20/2023-12/18/2023. The Home Health Certification and Plan of Care for certification period 10/20/2023-12/18/2023 documents an order for Register Nurse to "observe, assess, evaluate, and develop an individualized plan of care. Registered Nurse to observe and assess, Licesed Practical Nurse to "observe for risk for falls and instruct in falls prevention, home safety, medication management infection prevention and nutrition management". Skilled Nurse to "monitor co-morbid conditions as listed on Plan of Care and any new conditions that present themselves during this episode to identify changes and intervene to minimize complications". The “Registered Nurse OASIS Admission” dated 10/20/2023 documents abnormal findings in hearing assessment, indicating “hearing difficulty and location of hearing is right and left”. Under respiratory findings indicates” no abnormal findings”. During a Home Visit on 11/28/2023 at 11:00AM, when surveyor was speaking to patient and asked to sign the consent for the visit, the patient stated, “I don’t hear what you’re saying, lost my left hearing aid device”. Patient noted using Oxygen(O2) via nasal cannula by Oxygen Concentrator on home visit and uses Bipap 02 therapy as documented on patient current medication list at the Assisted Living Facility (ALF). The “Visit Note Reports” dated 10/24/23, 10/27/23, 10/31/23, 11/02/23 and 11/07/23, the Licensed Practical Nurse documents “no supplemental oxygen” with vital signs and under Respiratory assessment indicates “no abnormal findings”. The Plan of Care lacks an order for the Oxygen dosage, route/frequency, and patient's Functional Limitation - Hearing Impaiment. The Agency did not establish an individualized POC that includes specific treatments for LPN services. 5) Patient #7 with start of care 10/12/2023 with diagnoses of Malignant Neoplasm of left Female Breast, Abscess of the Breast and Nipple, Urinary Tract Infection, Alzheimer’s Disease, Essential Hypertension, Anemia and Type 2 Diabetes as documented on the "Home Health Certification and Plan of Care" for certification period 10/12/2023-12/10/2023. The Home Health Certification and Plan of Care certification period 10/12/2023 - 12/10/2023 documents an order for "RN (Register Nurse) to observe, assess, evaluate, and develop an individualized plan of care. Registered Nursse to observe and assess, Licensed Practical Nurse to observe for risk for falls and instruct in falls prevention, home safety, medication management infection prevention and nutrition management". The “Home Health Certification and Plan of Care” dated 10/12/23 to 12/10/2023 documents an order for “Skilled Nurse to perform wound care to open wound to left breast twice a week and PRN (as needed) for dislodged and soiled dressing”. The ‘Visit Note Reports’ dated 10/17/23, 10/27/23, 10/31/23, 11/07/23 and 11/14/2023 were conducted by an Licensed Practical Nurse documenting preforming “wound assessment”. Record reviewed noted missed Skilled Nurse visits on 10/20/23, one Skilled Nurse visit for the week of 11/12/23, no Skilled Nurse visits for week of 11/19/23 and one Skilled Nurse visit for the week of 11/26/23. The ‘Visit Note Reports’ dated 10/27/23, 11/03/23, 11/07/23, 11/10/23, 11/29/23 documents open wound to left breast was not measured in “wound assessment”. The Agency Policy “Wound Care-001” last revised 03/08/23documents under measurements “ln accordance with best practice and standard of care, wound will be measured a minimum of one time a week, preferably on the first visit of the week, by the same nurse, utilizing the same tool and measurement terminology. Inconsistencies noted in nursing care during home visit and documentation in record review: interim Medical Doctor order dated 11/21/23 indicated “nursing discharged scheduled week of 11/26/23, patient’s wound closed”. Wound assessment notes dated 11/03/23, 11/07/23 and 11/14/23 noted “Exudate of small amount of serosanguinous drainage”. Wound assessment notes dated 11/07/23 and 11/29/23 documents “none” for any exudate noted. During a Home Visit with the Registered Nurse on 11/29/2023 at 1:00 PM, the Registered Nurse assessed the wound and perform wound care, moderate amount of Serosanguinous drainage noted by Surveyor, but the Registered Nurse documented in her notes “none” for any exudate noted and Registered Nurse did not measure wound. The Agency did not establish an individualized Plan of Care that includes specific treatments for Licensed Practical Nurse services. The Agency failed to ensure that the Skilled Nurse perform the care and services as per the Plan of Care. The survey findings were reviewed with the Administrator and Director of Patient Services on 11/30/2023 at 3:00PM. No explanation was provided. 1) Patient #9 has a start of care date of 08/06/2023 with diagnoses including Hypertension Heart and Chronic Kidney Disease with Heart Failure stage 1, Chronic Diastolic Heart Failure, and Type 2 Diabetes Mellitus as documented on the “Home Health Certification and Plan of Care” for certification period 08/06/2023 to 10/04/2023. The patient has a discharge date of 10/04/2023. The “Home Health Certification and Plan of Care” for certification period 08/06/2023 to 10/04/2023 documents an order for “Skilled Nurse 2wk1, 1wk5, 1 every 2wk2, 1wk1 (two visits a week for one week, one visit a week for five weeks, one visit every two weeks for two weeks), Physical Therapy 1 wk1 (one visit a week for one week), Home Health Aide 1 wk5 (one visit a week for five weeks)”. “Skilled Nurse for instructions of Diabetic Care to include diet, skin care, signs and symptoms of hypo/hyperglycemia, proper administration of diabetic medication, Skilled Nurse to instruct on diabetic foot care and importance HGBA1C (Hemoglobin A1C) monitoring, kidney function test, eye and foot exams”. Blood Sugar testing 4x daily. Medications includes “Insulin Lispro (U-100) 100 units/ml (milliliter) subcutaneous pen sliding scale for blood glucose (BG) 200-250 = 2 units (give two units Insulin), 251 – 300 = 3 units, 301 – 350 = 4 units, 351 – 400 + 5 units. Lantus Solostar (U-100) 100 units/ ml subcutaneous dose 15 units at bedtime”. The “Registered Nurse Oasis Admission” visit note date 08/06/2023, the Registered Nurse documents the patient's and Blood Sugar range of 110 - 175 and the patient's "son checks Blood Sugar 3 x daily and administers Insulin”. There is no documented evidence that the Registered Nurse instructed Diabetic Care to include diet, skin care, signs and symptoms of hypo/hyperglycemia, proper administration of diabetic medication, diabetic foot care and importance HGBA1C (Hemoglobin A1C) monitoring, kidney function test, eye and foot exams”. The “Visit Note Report” dated 08/08/2023, the Registered Nurse documents the patient’s Blood Sugar is 168. The clinical record lacks documented evidence that the Registered Nurse instructed Diabetic Care to include diet, skin care, signs and symptoms of hypo/hyperglycemia, proper administration of diabetic medication, diabetic foot care and importance HGBA1C (Hemoglobin A1C) monitoring, kidney function test, eye and foot exams”. The “Visit Note Report” dated 08/14/2023, the Registered Nurse documents the patient’s Blood Sugar is 156. The clinical record lacks documented evidence that the Registered Nurse instructed Diabetic Care to include diet, skin care, signs and symptoms of hypo/hyperglycemia, proper administration of diabetic medication, diabetic foot care and importance HGBA1C (Hemoglobin A1C) monitoring, kidney function test, eye and foot exams”. The “Visit Note Report” dated 08/22/2023, the Registered Nurse documents the patient’s Blood Sugar is 122. The clinical record lacks documented evidence that the Registered Nurse instructed Diabetic Care to include diet, skin care, signs and symptoms of hypo/hyperglycemia, proper administration of diabetic medication, diabetic foot care and importance HGBA1C (Hemoglobin A1C) monitoring, kidney function test, eye and foot exams”. The “Visit Note Report” dated 08/29/2023, the Registered Nurse lacks documented evidence of the patient’s Blood Sugar level. The clinical record lacks documented evidence that the Registered Nurse instructed Diabetic Care to include diet, skin care, signs and symptoms of hypo/hyperglycemia, proper administration of diabetic medication, diabetic foot care and importance HGBA1C (Hemoglobin A1C) monitoring, kidney function test, eye and foot exams”. The “Visit Note Report” dated 09/07/2023, the Registered Nurse documents the patient’s Blood Sugar is 95. The clinical record lacks documented evidence that the Registered Nurse instructed Diabetic Care to include diet, skin care, signs and symptoms of hypo/hyperglycemia, proper administration of diabetic medication, diabetic foot care and importance HGBA1C (Hemoglobin A1C) monitoring, kidney function test, eye and foot exams”. The “Visit Note Report” dated 09/13/2023, the Licensed Practical Nurse documents the patient’s Blood Sugar is 187. The clinical record lacks documented evidence that the Licesned Practical Nurse nstructed Diabetic Care to include diet, skin care, signs and symptoms of hypo/hyperglycemia, proper administration of diabetic medication, diabetic foot care and importance HGBA1C (Hemoglobin A1C) monitoring, kidney function test, eye and foot exams”. The “Visit Note Report” dated 09/25/2023, the Licensed Practical Nurse lacks documented evidence of the patient’s Blood Sugar. The clinical record lacks documented evidence that the Licensed Practical Nurse instructed Diabetic Care to include diet, skin care, signs and symptoms of hypo/hyperglycemia, proper administration of diabetic medication, diabetic foot care and importance HGBA1C (Hemoglobin A1C) monitoring, kidney function test, eye and foot exams”. The Agency failed to ensure that the Skilled Nurse perform the care and services as per the Plan of Care. The survey findings were reviewed with the Administrator, Director of Patient Services on 11/28/2023 at 03:40PM. No explanation was provided. 2) Patient #14 has a start of care 09/25/23 with diagnoses of Hypertensive Heart and Chronic Kidney Disease, Acute Chronic Systolic Congestive Heart Failure, and Type 2 Diabetes Mellitus as documented on the “Home Health Certification and Plan of Care” for certification period 09/25/2023 to 11/23/2023. The "Home Health Certification and Plan of Care” for certification period 09/25/2023 to 11/23/2023 documents an order for "Skilled Nurse 3 wk 3 (three visits a week for three weeks), Physical Therapy 1 wk1 (one visit a week for one week), Occupational Therapy 1 wk 1, 2 wk 4, 1 wk4 (one visit a week for one week, two visits a week for four weeks, one visit a week for four weeks). Registered Nurse to "observe, assess and evaluate and develop an individualized Plan of Care, Registered Nurse to observe and assess". License Practical Nurse to observe for risk for falls and instruct on fall prevention, home safety, medication management, infection prevention, and nutrition management". "Skilled Nurse to perform wound care to #1 LLE (Left Lower Leg) cleanse with Normal Saline, apply Adaptic, Calcium Alginate and cover with Stratasorb 3w3 (three times a week)". "Skilled Nurse for instructions of Diabetic Care to include diet, skin care, signs and symptoms of hypo/hyperglycemia, proper administration of Diabetic medication". "Blood Glucose testing QID (four times a day), Skilled Nurse to assess patient/caregiver ability to perform and record blood glucose testing and report abnormal findings to Physician. Skilled Nurse to "report to Physician blood glucose readings greater than 350 or less than 70". "Indwelling Urinary Catheter 18 FR (French) with 30 cc (cubic centimeter) balloon. Skilled Nurse to "assess and teach related to altered Genitourinary status to minimize complications and hospitalization". The Skilled Nurse “Visit Note Report” dated 09/27/2023, 09/29/2023, and 10/02/2023 lack documentation of the patient's Blood Glucose levels, Diabetic care instructions including diet, signs and symptoms of hypo/hyperglycemia, and Diabetic medications. There is no documentation of the patient's Indwelling Urinary Catheter urine output. The Skilled Nurse “Visit Note Report” dated 10/05/2023, the License Practical Nurse documents "blood in urine persist, went to Emergency Room yesterday for evaluation, patient seems to be tugging on tubing". The Licensed Practical Nurse documents "Inactive wound - Healed". There is no documentation of the patien'ts blod glucose level. There is no documented evidence that the Licensed Practical Nurse notified the Registered Nurse and the Physician of the change in patient's urinary output, Diabetic care status, and wound healing status. The Skilled Nurse “Visit Note Report” dated 10/09/2023, the License Practical Nurse lack documentation of the patient's Blood Glucose level. The Licensed Practical Nurse documents "Foley draing clear yellow urine". The Skilled Nurse “Visit Note Report” dated 10/16/2023 lack documented evidence of the patient's Blood Glucose level. The Registered Nurse documents "Skilled Nurse was not able to change foley catheter. Patient went to Emergency Room and Foley Catheter was changed". The Registered Nurse documents patient's "Indwelling Foley size 10 cc (cubic centimeter)". There is no documented evidence that the Physician was notified of the Emergency Room visits and change of Indwelling Foley size. The Skilled Nurse “Visit Note Report” dated 10/31/2023, lacks documtation of the patient's Blood Glucose level, Diabetic care instructions including diet, signs and symptoms of hypo/hyperglycemia, and Diabetic medications. The Skilled Nurse “Visit Note Report” date 11/08/2023, the Licensed Practical Nurse lack documentation of the patient's Blood Glucose level, Diabetic care instructions including diet, signs and symptoms of hypo/hyperglycemia, and Diabetic medications. There is no documentation of the patient's Indwelling Urinary Catheter urine output The Agency failed to ensure that the Registered Nurse and Licensed Practical Nurse provide patient care services and treatments in conformance to the Plan of Care. The survey findings and interview were conducted with the Administrator and Director of Patient Services on 11/30/2023 at 04:36 PM. No explanantion was provided.

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on a review of the agency's Quality Assessment Performance Improvement (QAPI) Program, Policy and Procedure, interviews with the Administrator, Director of Patient Services (DPS) it was determined that the scope of the program was inadequate to identify, analyze and track quality indicators necessary to assess the agency processes’ of care, services and operations. This was evident based on review of the Quality Assessment Performance Improvement meeting minutes for the 2022 and 2023. Failure to ensure the QAPI program adequately identify and analyze pquality indicators, has the potential for negative outcome. -The iQIES Potentially Avoidable Events (PAE’s) 10 categories listed indicated the agency observable cases with percentage of negative outcome are close or higher than the National average. The report indicates that in 8/21/ to 8/22, the agency had 46 total PAE's that are possibly preventable. The report attributes the Potentially Avoidable Events: pressure ulcers, urinary tract infections, discharged to community with unhealed stage 2 pressure ulcers were not included in the areas requiring tracking as quality indicators. - The iQIES Potentially Avoidable Event Patient Listing Report (PAEPL) period of 8/1/2022 to 7/31/2023, data for agency documented incidence of pressure ulcer higher than the National Average; National obs: 0.36% to agency’s 0.54%. The Potentially Avoidable Event Patient Listing Report contained the names of 14 patients with increase in pressure ulcer. Patient # 11 also appeared on this report twice for discharged to community needing toileting assistance. The agency quality program did not include quality indicator derived from the iQIES Potentially Avoidable Event Patient Listing and failed to focus on high risk, high volume, or problem- prone areas (G648). - The agency’s Quality Assessment Performance Improvement Quarterly Form” for the 3rd and 4th quarter 2022, and 1st to 3rd Quarter 2023 meeting minutes documented areas of focus are: -Hospitalization. -QI (quality improvement) Events and Potentially Avoidable Events: - Falls -Complaints. The survey identified areas with significant issues that included: - Medical Doctor not notified of changes in patient condition. - Coordination of care between disciplines is limited. - Blood glucose not assessed and undocumented identified in patient # 13. - Weight not being assessed as ordered identified in patient #4. The agency’s “Quality Assessment Performance Improvement Quarterly Forms “does not contain a plan of action for the areas not in compliance and, reflects minimal input from the Professional Advisory Committee. The Patient Care Conference Committee (PCC) Meeting Minutes of 3rd, 4th quarter 2022, and 1st to 3rd quarter 2023 did not include a summary of Comprehensive Clinical Record Audits on hospitalization, avoidable events, falls and complaints. On 11/30/23 at 11am, the Administrator/DPS who is in charge of the Quality Assessment Performance Improvement process was interviewed and did not provide answers to areas of concern. The findings were reviewed with the agency during the exit conference on 12/1/2023 at 4:30PM.

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on staff interviews, the agency failed to provide documented evidence that Performance Improvement Projects (PIP) were conducted. Failure to conduct performance improvement projects that reflect the scope, complexity, past performance of the agency's services, quality improvements with documented measurable progress achieved has the potential for negative patient outcomes. The Findings Are: On 11/30/2023 at 11:00 AM, the Performance Improvement Projects were requested, no information was provided. There is no documented evidence of the agency conducting Performance Improvement Projects. On 11/30/2023 at 04:00 PM, the Chief Operating Officer/ Administrator was interviewed, and said agency did not have performance improvement project at this time.

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on record review, review of the agency's Quality Assessment Performance Improvement (QAPI) Program, interviews with the Chief Operating Officer, Director of Patient Services (DPS), and Clinical Manager, it was determined that the scope of the program was inadequate to identify, analyze and track quality indicators necessary to assess the agency processes’ of care, services and operations. This was evident based on review of the Quality Assessment Performance Improvement meeting minutes. Failure to address priorities for improved quality of care, and patient safety has the potential for negative patient outcome. Findings: Agency's Quality Assessment Performance Improvement quarterly forms documented increase in falls both attended and unattended as primary occurrence focus areas. Quarter 1 had 29 falls, Q2- 25, Q3-27, Q4- 43 with 26 unattended. The Quality Assessment Performance Improvement did not include analysis, intervention, and action plan for the areas of focus. The agency quality assessment and improvement program did not include expectations addressing patient safety as priority and failed to evaluate the effectiveness of the program. The Chair-person /Administrator was interviewed on 11/30/2023 at 3: 50.PM, and did not provide an explanation. The survey findings were reviewed with agency leadership at the exit conference on 12/1/2023.

Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This CONDITION is not met as evidenced by: Based on record reviews and staff interviews the agency failed to ensure that Skilled professionals (nursing ) that provide services to Home Health Agency (HHA) patients communicate and are supervised to ensure coordination of care. This was evident for eleven (11) of eleven (11) patients receiving Skilled services from Licensed Practical Nurses (Patients #1, #2, #3, #4, #6, #7, #8, #9, #10, #13, #14). The Home Health Agency failed specifically to: Ensure Skilled Nursing Professionals services are delivered and supervised only by health care professionals who meet the qualifications and practice according to the agency's established policies and procedures, with regards to assessments. (Refer to H-702) Ensure ongoing interdisciplinary assessments and communication between skilled professionals (Refer to H-706) Ensure clinicians prepare and document complete and accurate clinical and progress notes accurately to reflect the current patient's status. (Refer to H-716) Ensure adequate supervision of the Licensed Practical Nurse (LPN) staff. (Refer to H-726) See above.

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on review of clinical records, state regulations, policy/procedure, job description, and staff interviews, the agency failed to ensure Skilled Nursing Professionals services delivery are supervised by qualified health care professionals, in accordance with State regulations; agency's established policy and procedures. This was evident in eleven (11) of eleven (11) patient receiving License Practical Nurse services. (Patients #1, #2, #3, #4, #6, #7, #8, #9, #10, #13 and #14). Failure to ensure skilled professional services are delivered in accordance with agency policies has the potential to result in poor quality of care and possible negative outcome. The findings are: The agency's policy "#AA-007(a) Services Provided/Supervision of Disciplines- RN/LPN" dated "10/05/23" documents: “Interpretive Guidelines §484.75(c)(1) The HHA should identify a registered nurse (RN) to supervise the care provided by licensed practical/vocational nurses (LPN/LVNs). The identified RN must in turn monitor and evaluate LPN/LVN performance in the provision of services, provision of treatments, patient education, communication with the RN, and data collection regarding the patient's status and health needs (as delegated by the RN). Only a registered nurse may perform comprehensive assessment, evaluations, care planning and discharge planning.” 4) Patient #2 with a start of care 10/26/2023 diagnoses of Scoliosis, Raynaud’s Syndrome, Indwelling Catheter, Foot Drop, Atrial Fibrillation Hypertension, Polyneuropathy, Asthma and Spinal Stenosis as documented on the "Home Health Certification and Plan of Care cert period 10/26/2023-12/24/2023. The Home Health Certification and Plan of Care cert period 10/26/2023-12/24/2023 documents an order for “Skilled Nurse 1wk1, 2wk4 (1 time per week for 1 week, 2 times per week for 4weeks); Physical Therapy (PT) effective 10/29/2023 1wk1, 2wk2, 1wk3 (1 times per week for week, 2 time per week for 2 weeks, 1 time per week for 3 weeks; Occupational Therapy (OT) effective 10/29/2023 1wk1 (1 time per week for 1 week). RN (Register Nurse) to observe, assess, evaluate, and develop an individualized plan of care. Register Nurse to observe and assess, License Practical Nurse to observe for risk for falls and instruct in falls prevention, home safety, medication management infection prevention and nutrition management". The “Visit Note Report” Assessment note dated 11/08/23 were conducted by an License Practical Nurse documenting preforming patient assessment. The “Visit Note Report” Assessment note dated 11/08/23 documents “indicate if you communicate with other disciplines involved in the case”. “No”. There is no documented evidence of communication between the Register Nurse and the License Practical Nurse. The License Practical Nurses are completing patient assessments. The record lacks documentation the Register Nurse reviewed the License Practical Nurse visit notes to ensure the supervision of appropriate care. The Agency failed to implement their written policy and procedures. The Director of Patient Services/Administrator was interviewed 12/01/2023 at 2.00 pm, no explanation offered. 5) Patient #3 start of care 10/20/2023 with diagnoses of Laceration to right elbow, Hypertension Heart Disease with Heart Failure, Chronic Obstructive Pulmonary Disease, Acute Respiratory with Hypoxia and Hypercapnia, Anemia, Dependence on Supplemental Oxygen, Anxiety and Major Depression as documented on the "Home Health Certification and Plan of Care" for certification period 10/20/2023-12/18/2023 The Home Health Certification and Plan of Care cert period 10/20/2023-12/18/2023 documents an order for “Skilled Nurse (SN) 1wk1, 2wk4 (1 time per week for 1 week, 2 times per week for 4weeks); Physical Therapy (PT) effective 10/29/2023 1wk1, 2wk2, 1wk3 (1 times per week for week, 2 time per week for 2 weeks, 1 time per week for 3 weeks; Occupational Therapy (OT) effective 10/29/2023 1wk1 (1 time per week for 1 week). RN (Register Nurse) to observe, assess, evaluate, and develop an individualized plan of care. Register Nurse to observe and assess, License Practical Nurse to observe for risk for falls and instruct in falls prevention, home safety, medication management infection prevention and nutrition management". The “Visit Notes Reports” Assessment notes dated 10/24/23, 10/27/23, 10/31/23, 11/02/23, 11/07/23 were conducted by an License Practical Nurse documenting preforming patient assessments. The “Visit Note Reports” dated 10/24/23, 10/27/23, 10/31/23, 11/02/23, 11/07/23 documents “indicate if you communicate with other disciplines involved in the case”. “No”. There is no documented evidence of communication between the Register Nurse and the License Practical Nurse. The License Practical Nurses are completing patient assessments. The clinical record lacks documented evidence of Register Nurse reviewing License Practical Nurse visit note report to ensure the supervision of appropriate care. The Agency failed to implement their written policy and procedures. The Director of Patient Services/Administrator was interviewed 12/01/2023 at 2.00 pm, no explanation offered. 6) Patient #7 with start of care 10/12/2023 with diagnoses of Malignant Neoplasm of left Female Breast, Abscess of the Breast and Nipple, Urinary Tract Infection, Alzheimer’s Disease, Essential Hypertension, Anemia and Type 2 Diabetes as documented on the "Home Health Certification and Plan of Care" for certification period 10/12/2023-09/24/2023. The Home Health Certification and Plan of Care cert period 10/12/2023-09/24/2023 documents an order for "Skilled Nurse (SN) 1WK2, 2WK3 (1 time per week for 2 week, 2 times per week for 3 weeks; Physical Therapy (PT) effective 10/15/2023 2wk3, 1wk1, 2WK3,1WK4 (1 time per week for 1 week, 2 times per week for 3 weeks, 1 time per week for 4 weeks). RN (Register Nurse) to observe, assess, evaluate, and develop an individualized plan of care. Register Nurse to observe and assess, License Practical Nurse to observe for risk for falls and instruct in falls prevention, home safety, medication management infection prevention and nutrition management". The ‘Visit Note Reports’ dated 10/17/23, 10/27/23, 10/31/23, 11/0723 and 11/14/2023 were conducted by an License Practical Nurse documenting preforming patient assessments. The ‘Visit Note Reports’ dated 10/17/23, 10/27/23, 10/31/23, 11/0723 and 11/14/2023 were conducted by License Practical Nurse an documenting preforming “wound assessment”. The License Practical Nurses "Visit Note Reports" dated 10/17/23, 10/27/23, 10/31/23, 11/0723 and 11/14/2023 documents “indicate if you communicate with other disciplines involved in the case”. “No”. There is no documented evidence of communication between the Register Nurse and the License Practical Nurse. The License Practical Nurses are completing patient assessments. The record lacks documentation the Register Nurse reviewed the License Practical Nurse visit notes to ensure the supervision of appropriate care. The Agency failed to implement their written policy and procedures. The Director of Patient Services/Administrator was interviewed 12/01/2023 at 2.00 pm, no explanation offered. 7) Patient #8 with start of care 12/09/22 and discharge date of 01/31/2023 with diagnoses of Surgical Aftercare, Atrioventricular Complete Heart Block, Hypertension Heart, and chronic kidney disease with Heart Failure, Chronic Diastolic Congested Heart Failure, Acute Respiratory with Hypoxia, Dependence on Supplemental Oxygen and History of Fall. The Home Health Certification and Plan of Care cert period 12/9/2022-02/06/2023 documents orders for " SN (Skilled Nurse) 1 wk. 3, Foley change every 6 -7 weeks, 3 PRN (one visits a week for three weeks, the Foley catheter change every six to seven week, three as needed visits)". SN (Skilled Nurse) to assess, evaluate, and develop an individualized plan of care. Register Nurse to observe and assess, License Practical Nurse to observe for risk for falls and instruct in falls prevention, home safety, medication management infection prevention and nutrition management". The “Visit Note Reports” dated 12/14/22, 12/19/22 and 01/25/2023 were conducted by an License Practical Nurse documenting preforming patient assessments. There is no documented evidence of communication between the Register Nurse and the License Practical Nurse. The License Practical Nurse “Visit Note Reports” dated 12/14/22 documents “indicate if you communicate with other disciplines involved in the case”. “No”. There is no documented evidence of communication between the Register Nurse and the License Practical Nurse. The License Practical Nurses are completing patient assessments. The record lacks documentation the Register Nurse reviewed the License Practical Nurses visit notes to ensure the supervision of appropriate care. The Agency failed to implement their written policy and procedures. The Director of Patient Services/Administrator was interviewed 12/01/2023 at 2.00 pm, no explanation offered. 8) Patient #1 has a start of care date of 07/15/2023 with diagnoses of Pressure Ulcer of Right Ankle Stage 2, Type 2 Diabetes Mellitus without complications, Essential Hypertension, Alzheimer’s Disease, and Hypothyroidism as documented on the “Home Health Certification and Plan of Care” dated 11/12/2023 to 01/10/2024. The “Home Health Certification and Plan of Care” dated 11/12/2023 to 01/10/2024 documents orders for “Skilled Nurse (SN) 3wk4, 2every5wk5 (3 times per week for 4 weeks, 2 times per 5 weeks for 5 weeks); Registered nurse (RN) to observe, assess, evaluate, and develop an individualized plan of care. Registered Nurse to observe and assess, Licensed Practical nurse (LPN) to observe for risks for falls and instruct in fall prevention, home safety, medication management, infection preventions, and nutrition management.” The Skilled Nurse “Visit Note Report” dated 11/13/2023, 11/15/2023, 11/17/2023, 11/20/2023, and 11/23/2023 document patient assessments conducted and signed by the Licensed Practical Nurse. There is no documented evidence of communication between the Licensed Practical Nurse and the Registered Nurse. There is no documented evidence the Registered Nurse reviewed the Licensed Practical Nurse visit note to ensure the supervision of appropriate care. The Agency failed to implement their written policy and procedures. On 11/29/2023 at 3:55 PM, the Administrator and Director of Patient Services were interviewed and did not provide an explanation for the findings. 9) Patient #4 has a start of care date of 11/17/2023 with diagnoses of Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Acute on Chronic Congestive Heart Failure, Type 2 Diabetes Mellitus, Atherosclerotic Heart Disease of native Coronary Artery, Hypothyroidism, and Hyperlipidemia as documented on the “Home Health Certification and Plan of Care” dated 11/17/2023 to 01/15/2024. The “Home Health Certification and Plan of Care” dated 11/17/2023 to 01/15/2024 documents orders for “Skilled Nurse (SN) 1wk1, 2wk2, 1wk1 (1 time per week for 1 week, 2 times per week for 2 weeks, 1 time per week for 1 week); Physical Therapy (PT) effective 11/19/2023 2wk3, 1wk3 (2 times per week for 3 weeks, 1 time per week for 3 weeks); Occupational Therapy (OT) effective 11/19/2023 1wk1 (1 time per week for 1 week). Registered nurse (RN) to observe, assess, evaluate, and develop an individualized plan of care. RN to observe and assess, Licensed Practical nurse (LPN) to observe for risks for falls and instruct in fall prevention, home safety, medication management, infection preventions, and nutrition management.” The Skilled Nurse “Visit Note Report” dated 11/24/2023 documents a patient assessment conducted and signed by the Licensed Practical Nurse. There is no documented evidence of communication between the Licensed Practical Nurse and the Registered Nurse. There is no documented evidence the Registered Nurse reviewed the Licensed Practical Nurse visit note to ensure the supervision of appropriate care. The Agency failed to implement their written policy and procedures. On 11/30/2023 at 3:50 PM, the Administrator and Director of Patient Services were interviewed and did not provide an explanation for the findings. 10) Patient #6 has a start of care date of 01/26/2023 with diagnoses of Pressure Ulcer of Left Ankle- Stage 2, Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, Benign Neoplasm of Cerebral Meninges, Essential Hypertension, Epilepsy and Hyperlipidemia as documented on the “Home Health Certification and Plan of Care” dated 11/22/2023 to 01/20/2024. The “Home Health Certification and Plan of Care” dated 11/22/2023 to 01/20/2024 documents an order for “Skilled Nurse (SN) 1wk1 (1 time per week for 1 week), 2wk4 (2 times per week for 4 weeks), 3PRN (as needed). Registered Nurse (RN) to observe and assess, Licensed Practical Nurse (LPN) to observe for risk for falls and instruct in fall prevention, home safety, medication management, infection prevention, and nutrition management”. The Skilled Nurse “Visit Note Report” dated 11/23/2023 and 11/27/2023 document patient assessments conducted and signed by the Licensed Practical Nurse. There is no documented evidence of communication between the Licensed Practical Nurse and the Registered Nurse. There is no documented evidence the Registered Nurse reviewed the Licensed Practical Nurse visit note to ensure the supervision of appropriate care. The Agency failed to implement their written policy and procedures. On 11/30/2023 at 4:30 PM, the Administrator and Director of Patient Services were interviewed and did not provide an explanation for the findings. 11) Patient #13 has a start of care date of 08/08/2023 with diagnoses of Orthopedic Aftercare, Type 2 Diabetes Mellitus with diabetic neuropathy arthropathy, Hypertensive Heart Disease with Heart Failure, Systolic Heart Failure, and Atrial Fibrillation as documented on the “Home Health Certification and Plan of Care” dated 08/08/2023 to 10/06/2023. The “Home Health Certification and Plan of Care” dated 08/08/2023 to 10/06/2023 documents an order for “Skilled Nurse (SN) 1wk4 (1 time per week for 4 weeks), Physical Therapy (PT) 1wk2 (1 time per week for 2 weeks), 2wk3 (2 times per week for 3 weeks), 1wk2 (1 time per week for 2 weeks); Occupational Therapy (OT) 1wk1 (1 time per week for 1 week), 2wk4 (2 times per week for 4 weeks), 3PRN (as needed). Registered nurse (RN) to observe, assess, evaluate, and develop an individualized plan of care. RN to observe and assess, Licensed Practical nurse (LPN) to observe for risks for falls and instruct in fall prevention, home safety, medication management, infection preventions, and nutrition management.” The Skilled Nurse “Visit Note Report” dated 08/16/2023, 09/08/2023, 09/21/2023, and 09/28/2023 document patient assessments conducted and signed by the Licensed Practical Nurse. There is no documented evidence of communication between the Licensed Practical Nurse and the Registered Nurse. There is no documented evidence the Registered Nurse reviewed the Licensed Practical Nurse visit note to ensure the supervision of appropriate care. The Agency failed to implement their written policy and procedures. On 12/01/2023 at 3:45 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings. 1) Patient #9 has a start of care date of 08/06/2023 with diagnoses including Hypertension Heart and Chronic Kidney Disease with Heart Failure stage 1, Chronic Diastolic Heart Failure, and Type 2 Diabetes Mellitus as documented on the “Home Health Certification and Plan of Care” for certification period 08/06/2023 to 10/04/2023. The patient has a discharge date of 10/04/2023. The “Home Health Certification and Plan of Care” for certification period 08/06/2023 to 10/04/2023 documents an order for “SN (Skilled Nurse) 2wk1, 1wk5, 1 every 2wk2, 1wk1 (two visits a week for one week, one visit a week for five weeks, one visits every two weeks for two weeks). Cardiovascular System: Skilled Nurse to assess and teach related to altered cardiovascular status to minimize complications and reduce hospitalization. Heart Failure: Skilled Nurse to assess cardiovascular system to identify signs of decompensation and intervene to minimize the severity of fluid overload, assess patient ability to monitor and recall daily weights and vital signs. Hypertension management: SN to assess/teach warning signs and symptoms to avoid hospitalization. Atrial Fibrillation: Skilled Nurse to assess/teach warning signs and symptoms to avoid hospitalization. Respiratory system: Skilled Nurse to assess and teach related altered respiratory status to minimize complications and reduce hospitalization. Diabetic management: Skilled Nurse for instructions of Diabetic care include diet, skin care, signs and symptoms of hypo/hyperglycemia, proper administration of Diabetic medication". The Skilled Nurse “Visit Note Report” dated 09/13/2023, the LPN (License Practical Nurse) documents assessment of the patient's "Head and Neck, no abnormal findings in head and neck assessment. Integumentary; no abnormal findings in integumentary system. Cardiovascular; no abnormal findings in cardiovascular assessment. Respiratory; no abnormal findings in respiratory assessment. Genitourinary: no abnormal findings in genitourinary assessment. Gastrointestinal: within normal limits. Endocrine/Hematopoietic Systems (Diabetic) ; no abnormal endocrine/hematopoietic findings". The Skilled Nurse “Visit Note Report” dated 09/25/2023, the LPN (License Practical Nurse) documents assessment of the patient's "Head and Neck, no abnormal findings in head and neck assessment. Integumentary; no abnormal findings in integumentary system. Cardiovascular; no abnormal findings in cardiovascular assessment. Respiratory; no abnormal findings in respiratory assessment. Genitourinary: no abnormal findings in genitourinary assessment. Gastrointestinal: within normal limits. Endocrine/Hematopoietic Systems (Diabetic) ; no abnormal endocrine/hematopoietic findings". The Skilled Nurse “Visit Note Report” dated 09/13/2023 and 09/25/2023 document patient assessments conducted and signed by the Licensed Practical Nurse There is no documented evidence of a review or documentation by the Registered Nurse. There is no documented evidence of communication between the Licensed Practical Nurse and the Registered Nurse. There is no documented evidence the Registered Nurse reviewed the Licensed Practical Nurse visit note to ensure the supervision of appropriate care. The Agency failed to implement their written policy and procedures. The survey findings and interview were conducted with the Administrator, Director of Patient Services on 11/28/2023 at 03:40PM. No explanation was provided 2) Patient #10 has a start of care date of 05/30/2023 with diagnoses of Unspecified Open Wound Left Knee, Hypertensive Chronic Kidney Disease stage 1, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease as documented on the "Home Health Certification and Plan of Care" for certification period 05/30/2023 to 07/28/2023. The patient has a discharge date of 07/28/2023. The "Home Health Certification and Plan of Care" for certification period 05/30/2023 to 07/28/2023 documents and order for: Skilled Nurse 2wk1, 1wk3 two visit a week for one week, one visit a week for three weeks), Physical Therapy 2 wk6 (two visit a week for six weeks), and Occupational Therapy 1wk1 (one visit a week for one week). Skilled Nurse to "assess evaluate and develop an individualized Plan of Care". Skilled Nurse for instruction in "Diabetic Care to include diet Low Carb, skin care, and symptoms of hypo/hyperglycemia, proper administration of Diabetic medication". Skilled Nurse to "perfom wound care to Left Knee skin tear: cleanse with wound cleanser , apply Xeroform, cover with Foam dressing. Dressing to be changed 2X (two times) per week and PRN (as needed) for dislodged dressing, wound deterioation". The Skilled Nurse “Visit Note Report” dated 06/02/2023, the License Practical Nurse documents assessment of the patient's "Cardiovascular: no abnormal findings in cardiovascular observation. Respiratory: no abnormal findings in respiratory observation. Genitourinary: no abnormal findings in genitourinary observation. Gastrointestinal: no abnormal findings in gastrointestinal observation. Intergumetary: Incision/wound/skin tear with currentlry included on the patient's Plan of Care. Endocrine/Hematopoietic Systems (Diabetic); no abnormal endocrine/hematopoietic findings". The Skilled Nurse “Visit Note Report” dated 06/05/2023, the License Practical Nurse documents assessment of the patient's "Cardiovascular: no abnormal findings in cardiovascular observation. Respiratory: no abnormal findings in respiratory observation. Genitourinary: no abnormal findings in genitourinary observation. Gastrointestinal: no abnormal findings in gastrointestinal observation. Intergumetary: Incision/wound/skin tear with currentlry included on the patient's Plan of Care. Endocrine/Hematopoietic Systems (Diabetic); no abnormal endocrine/hematopoietic findings". There is no documented evidence of communication between the Licensed Practical Nurse and the Registered Nurse. There is no documented evidence the Registered Nurse reviewed the Licensed Practical Nurse visit note to ensure the supervision of appropriate care. The Agency failed to implement their written policy and procedures. The survey findings and interview were conducted with the Director of Patient Services on 11/29/2023 at 03:57 PM. No explanation was provided. 3) Patient #14 has a start of care 09/25/23 with diagnoses of Hypertensive Heart and Chronic Kidney Disease, Acute Chronic Sytolic Congestive Heart Failure, and Type 2 Diabetes Mellitus as documented on the"Home Health Certification and Plan of Care” for certification period 09/25/2023 to 11/23/2023. The "Home Health Certification and Plan of Care” for certification period 09/25/2023 to 11/23/2023 documents an order for Skilled Nurse 3 wk 3 (three visits a week for three weeks), Physical Therapy 1 wk1 (one visit a week for one week), Occupational Therapy 1 wk 1, 2 wk 4, 1 wk4 (one visit a week for one week, two visits a week for four weeks, one visit a week for four weeks). Registered Nurse to "observe, assess and evaluate and develop an individualized Plan of Care, Registered Nurse to observe and asssess". License Practical Nurse to "observe for risk for falls and instruct on fall prevention, home safety medication management infection prevention and nutrition management". "Skilled Nurse to perform wound care to #1 LLE (Left Lower Leg) cleanse with NS Normal Saline), apply Adaptic, Calcium Alginate and cover with Stratasorb 3w3 (thee times a week for three)". "Skilled Nurse for instructions of Diabetic Care to include diet, skin care, signs and symptoms of hypo/hyperglycemia, proper administration of Diabetic medication". "Blood Glucose (BG) testing QID (four times a day), Skilled Nurse to "assess patient/caregiver ability to perform and record blood glucose testing as ordered and report abnormal findings to Physician". Skilled Nurse to "report to Physician blood glucose readings greater than 350 or less than 70". There is no documented evidence the Registered Nurse reviewed the Licensed Practical Nurse visit note to ensure the supervision of appropriate care. The Agency failed to implement their written policy and procedures. The survey findings and interview were conducted with the Administrator and Director of Patient Services on 11/30/2023 at 04:36 PM. No explanation was provided.

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 Clinical Record review and staff interview, the agency failed to ensure an ongoing interdisciplinary assessment between skilled professionals that include periodic discussions among the team regarding the patient's health status and recommendations for the Plan of Care. This was evident in two (2) of seventeen (17) clinical records reviewed (Patients #1 and #9). Failure to ensure of an ongoing interdisciplinary assessments and discussion of the patient's status, has the potential for negative patient outcomes. The findings are: 2) Patient #1 has a start of care date of 07/15/2023 with diagnoses of Pressure Ulcer of Right Ankle Stage 2, Type 2 Diabetes Mellitus without complications, Essential Hypertension, Alzheimer’s Disease, and Hypothyroidism as documented on the “Home Health Certification and Plan of Care” dated 09/13/2023 to 11/11/2023 and 11/12/2023 to 01/10/2024. The “Home Health Certification and Plan of Care” dated 11/12/2023 to 01/10/2024 documents orders for “Skilled Nurse (SN) 3wk4, 2every5wk5 (3 times per week for 4 weeks, 2 times per 5 weeks for 5 weeks); Registered nurse (RN) to observe, assess, evaluate, and develop an individualized plan of care. Registered Nurse to observe and assess, Licensed Practical nurse (LPN) to observe for risks for falls and instruct in fall prevention, home safety, medication management, infection preventions, and nutrition management.” The Skilled Nurse “Visit Note Report” dated 11/10/2023 documents a comprehensive wound assessment conducted and signed by the Licensed Practical Nurse indicating the wound has no scab present. The Skilled Nurse “Visit Note Report” dated 11/13/2023 documents a comprehensive wound assessment conducted and signed by the Licensed Practical Nurse indicating the wound has a scab present. The Skilled Nurse “Visit Note Report” dated 11/15/2023 and 11/17/2023 documents a comprehensive wound assessment conducted and signed by the Licensed Practical Nurse indicating no change in the wound status. The Skilled Nurse “Visit Note Report” dated 11/20/2023 documents a comprehensive wound assessment including wound measurements conducted and signed by the Licensed Practical Nurse. The note documents the wound is “completely epithelized; scab present”. There is no documented evidence that the Licensed Practical Nurse communicated the findings from the visit, including the change in the wound, to the Registered Nurse. The record lacks documented evidence the Registered Nurse and Licensed Practical Nurse communicated to ensure ongoing interdisciplinary assessment of the patient occurs. On 11/29/2023 at 3:55 PM, the Administrator and Director of Patient Services were interviewed and did not provide an explanation for the findings. 1) Patient #9 has a start of care date of 08/06/2023 with diagnoses including Hypertension Heart and Chronic Kidney Disease with Heart Failure stage 1, Chronic Diastolic Heart Failure, and Type 2 Diabetes Mellitus as documented on the “Home Health Certification and Plan of Care” for certification period 08/06/2023 to 10/04/2023. The patient has a discharge date of 10/04/2023. The “Home Health Certification and Plan of Care” for certification period 08/06/2023 to 10/04/2023 documents an order for Skilled Nurse 2wk1, 1wk5, 1 every 2wk2, 1wk1 (two visits a week for one week, one visit a week for five weeks, one visit every two weeks for two weeks, one visit a week for one week). "RN (Registered Nurse) to observe and assess, LPN (License Practical Nurse) observe for risk for falls and instruct in fall prevention, home safety, medication management, infection prevention and nutrition management. The "Visit Note Report" date 09/07/2023, the Registered Nurse documents "Patient had procedure 1 week ago with non-removable dressing on Left chest surgical implants site. Patient states dressing to removed in 2 weeks”. The “Patient Care Coordination” does not include communication with the LPN. The Skilled Nurse “Visit Note Report” dated 09/13/2023, the LPN documents “Surgical incision removable dressing remains clean and intact. Dressing due to be removed next week”. The “Patient Care Coordination” section of the visit report does not include communication with the RN. The Skilled Nurse “Visit Note Report” dated 09/25/2023, the License Practical Nurse does not document the patient’s surgical incision status. The “Patient Care Coordination” does not include communication with the Registered Nurse that the surgical incision was not observed. The record lacks documented evidence the Registered Nurse and Licensed Practical Nurse communicated to ensure ongoing interdisciplinary assessment of the patient occurs. The survey findings were reviewed with the Administrator, Director of Patient Services on 11/28/2023 at 03:40PM. No explanation was provided.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record reviews and staff interview, the agency failed to ensure that clinicians prepare and document complete and accurate clinical and progress notes that reflect the current patients status. This was evident for two (2) of seventeen (17) clinical records reviewed. (Patients #3, and #7). Failure to ensure that clinicians prepare and document complete and accurate clinical and progress notes, has the potential for negative patient outcomes. The Findings are: 1) Patient #3 start of care 10/20/2023 with diagnoses of Laceration to right elbow, Hypertension Heart Disease with Heart Failure, Chronic Obstructive Pulmonary Disease, Acute Respiratory with Hypoxia and Hypercapnia, Anemia, Dependence on Supplemental Oxygen, Anxiety and Major Depression. The Home Health Certification and Plan of Care for certification period 10/20/2023-12/18/2023 documents orders for "Register Nurse 1 wk1, 2wk4 (one visit a week for one week and two visits a week for four weeks) to "observe, assess, evaluate, and develop an individualized plan of care. Register Nurse to observe and assess, License Practical Nurse to observe for risk for falls and instruct in falls prevention, home safety, medication management infection prevention and nutrition management". Medications include “Oxygen 2 Liters continuous”. The License Practical Nurses “Visit Note Reports” dated 10/24/23,10/27/23, 10/31/23,11/02/23 and 11/07/23 documents “no supplemental oxygen” with vital signs and under Respiratory assessment indicates “no abnormal findings”. The clinical record lacks documented that the License Practical Nurse documented the patient's use of oxygen and respiratory status as per the Plan of Care. 2) Patient #7 with start of care 10/12/2023 with diagnoses of Malignant Neoplasm of left Female Breast, Abscess of the Breast and Nipple, Urinary Tract Infection, Alzheimer’s Disease, Essential Hypertension, Anemia and Type 2 Diabetes. The Home Health Certification and Plan of Care for certification period 10/12/23 to 12/10/2023 documents orders for " Skilled Nurse1WK2, 2WK3 (1 time per week for 2 week, 2 times per week for 3 weeks". Skilled Nurse to perform wound Care to open wound to left breast twice a week and PRN for dislodged and soiled dressing”. Register Nurse) to observe, assess, evaluate, and develop an individualized plan of care. RN to observe and assess, License Practical Nurse to observe for risk for falls and instruct in falls prevention, home safety, medication management infection prevention and nutrition management". During home visit on 11/29/23 at 1.00pm with the Register Nurse, the Register Nurse performed wound care and dressing changed to patient's left breast. The Register Nurse documented " no drainage noted" under wound assessment but the Surveyor noted dressing was soiled with moderate amount of drainage. There is no documented evidence of accurate and complete clinical note by the Register Nurse that reflects the patient's wound status. The Director of Patient Services/Administrator was interviewed 12/01/2023 at 2.00 pm, no explanation offered.

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 reviews and staff interview, the agency failed to ensure that ongoing communication with each patient's Physician was maintained. This was evident for two (2) of seventeen (17) clinical records reviewed (Patients #7 and #13). Failure to ensure that ongoing communication with each patient's Physician, has the potential for negative patient outcomes. The Findings Are: 2) Patient #13 has a start of care date of 08/08/2023 with diagnoses of Type 2 Diabetes Mellitus with foot ulcer, Type 2 Diabetes Mellitus with diabetic neuropathy arthropathy, Hypertensive Heart Disease with Heart Failure, Systolic Heart Failure, and Atrial Fibrillation as documented on the “Home Health Certification and Plan of Care” dated 10/07/2023 to 12/05/2023. The “Home Health Certification and Plan of Care” dated 10/07/2023 to 12/05/2023 documents an order for “Skilled Nurse (SN) effective 10/08/2023 1wk5 (1 time per week for 5 weeks), 3PRN (as needed). Registered Nurse to observe, assess, evaluate, and develop an individualized plan of care. Agency may accept orders from consulting physicians (Podiatrist). Registered Nurse to observe and assess, Licensed Practical Nurse to observe for risk for falls and instruct in fall prevention, home safety, medication management, infection prevention, and nutrition management. The “Client Coordination Note Report” dated 10/19/2023 documents a missed Skilled Nurse visit on 10/19/2023. “Reason visit not made: Patient refused. Missed visit reported to Physician/Physician representative: (Podiatrist). Additional comments: Patient told Skilled Nurse that she will be going to wound care tomorrow 10/20/2023 and that (Podiatrist) didn’t want wound care to be done on Thursday 10/19/2023, since he wanted to see the wound/exudate for himself”. The “Client Coordination Note Report” dated 10/24/2023 documents a missed Skilled Nurse visit on 10/24/2023. “Reason visit not made: Patient refused. Missed visit reported to Physician/Physician representative: (Podiatrist). Additional comments: Patient stated she will be going to wound care to have dressing changed on Tuesday October 24th, 2023 and Thursday October 26th, 2023”. The “Client Coordination Note Report” dated 11/04/2023 documents a missed Skilled Nurse visit on 11/02/2023. “Reason visit not made: Patient had a physician appointment. Missed visit reported to Physician/Physician representative: (Podiatrist).” The “Client Coordination Note Report” dated 11/19/2023 documents a care coordination follow-up note by the Registered Nurse “Patient informed Skilled Nurse that (Podiatrist) does not want anyone doing the wound care as of right now. Patient requested that wound care be stopped for now”. The record lacks documented evidence that the ordering physician was made aware of several missed visits or reported change in care plan by the consulting physician. On 12/01/2023 at 3:45 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings. 1) Patient #7 with start of care 10/12/2023 with diagnoses of Malignant Neoplasm of left Female Breast, Abscess of the Breast and Nipple, Urinary Tract Infection, Alzheimer’s Disease, Essential Hypertension, Anemia and Type 2 Diabetes Mellitus. The Home Health Certification and Plan of Care for certification period 10/12/2023-12/10/2023 documents orders for " Skilled Nurse 1WK2, 2WK3 (1 time per week for 2 week, 2 times per week for 3 weeks). Skilled Nurse to perform wound Care to open wound to left breast twice a week and PRN for dislodged and soiled dressing. Register Nurse to observe, assess, evaluate, and develop an individualized plan of care. Register N to observe and assess, License Practical Nurse to observe for risk for falls and instruct in falls prevention, home safety, medication management infection prevention and nutrition management". Record reviewed noted missed Nurse visits on 10/20/23, one Nurse visit for the week of 11/12/23, no Nurse visits for week of 11/19/23 and one Nurse visit for the week of 11/26/23. There is no documented evidence the physician was notified of missed visits. The survey findings were reviewed with the Administrator and Director of Patient Services on 11/30/2023 at 3:00PM. No explanation was provided.

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on clinical records review, policy review, and staff interview, the agency failed to ensure that Licensed Practical Nurses are working within the services Licensed Practical Nurse State regulations, agency's policy and under the supervision of a Registered Nurse. This was evident for eleven (11) of eleven (11) patients receiving Skilled services from Licensed Practical Nurses (Patients #1, #2, #3, #4, #6, #7, #8, #9, #10, #13, #14). Failure to adequately supervise Licensed Practical Nurse, has the potential to result in negative patient outcomes. The findings are: The agency's policy "#AA-007(a) Services Provided/Supervision of Disciplines- RN/LPN" dated "10/05/23" documents: Interpretive Guidelines §484.75(c)(1) "The HHA should identify a registered nurse (RN) to supervise the care provided by licensed practical/vocational nurses (LPN/LVNs). The identified RN must in turn monitor and evaluate LPN/LVN performance in the provision of services, provision of treatments, patient education, communication with the RN, and data collection regarding the patient's status and health needs (as delegated by the RN)". "Qualified personnel observe and evaluate each direct care personnel performing their job duties prior to providing care independently and at frequencies required by state or federal regulations". "Agencies must adhere to the most stringent regulations (state, federal, accreditation, professional practice, etc.)". 8) Patient #1 has a start of care date of 07/15/2023 with diagnoses of Pressure Ulcer of Right Ankle Stage 2, Type 2 Diabetes Mellitus without complications, Essential Hypertension, Alzheimer’s Disease, and Hypothyroidism as documented on the “Home Health Certification and Plan of Care” dated 11/12/2023 to 01/10/2024. The “Home Health Certification and Plan of Care” dated 11/12/2023 to 01/10/2024 documents orders for “Skilled Nurse 3wk4, 2every5wk5 (3 times per week for 4 weeks, 2 times per 5 weeks for 5 weeks); Registered Nurse to "observe, assess, evaluate, and develop an individualized plan of care. Registered Nurse to observe and assess", Licensed Practical Nurse to "observe for risks for falls and instruct in fall prevention, home safety, medication management, infection preventions, and nutrition management.” The Skilled Nurse “Visit Note Report” dated 11/13/2023, 11/15/2023, 11/17/2023, 11/20/20, and 11/23/2023 document patient assessments conducted and signed by the Licensed Practical Nurse. The clinical record lacks documented evidence that the Registered Nurse communicated, reviewed visit notes, supervised and evaluated the Licensed Practical Nurse performance in the provision of patient care and services. On 11/29/2023 at 3:55 PM, the Administrator and Director of Patient Services were interviewed and did not provide an explanation for the findings. 9) Patient #4 has a start of care date of 11/17/2023 with diagnoses of Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Acute on Chronic Congestive Heart Failure, Type 2 Diabetes Mellitus, Atherosclerotic Heart Disease of native Coronary Artery, Hypothyroidism, and Hyperlipidemia as documented on the “Home Health Certification and Plan of Care” dated 11/17/2023 to 01/15/2024. The “Home Health Certification and Plan of Care” dated 11/17/2023 to 01/15/2024 documents orders for Skilled Nurse 1wk1, 2wk2, 1wk1 (1 time per week for 1 week, 2 times per week for 2 weeks, 1 time per week for 1 week); Physical Therapy effective 11/19/2023 2wk3, 1wk3 (2 times per week for 3 weeks, 1 time per week for 3 weeks; Occupational Therapy effective 11/19/2023 1wk1 (1 time per week for 1 week). Registered Nurse to "observe, assess, evaluate, and develop an individualized plan of care. Registered Nurse to observe and assess", Licensed Practical Nurse to "observe for risks for falls and instruct in fall prevention, home safety, medication management, infection preventions, and nutrition management.” The Skilled Nurse “Visit Note Report” dated 11/24/2023 documents a patient assessment conducted and signed by the Licensed Practical Nurse. The clinical record lacks documented evidence that the Registered Nurse communicated, reviewed visit notes, supervised and evaluated the Licensed Practical Nurse performance in the provision of patient care and services. On 11/30/2023 at 3:50 PM, the Administrator and Director of Patient Services were interviewed and did not provide an explanation for the findings. 10) Patient #6 has a start of care date of 01/26/2023 with diagnoses of Pressure Ulcer of Left Ankle- Stage 2, Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, Benign Neoplasm of Cerebral Meninges, Essential Hypertension, Epilepsy and Hyperlipidemia as documented on the “Home Health Certification and Plan of Care” dated 11/22/2023 to 01/20/2024. The “Home Health Certification and Plan of Care” dated 11/22/2023 to 01/20/2024 documents an order for “Skilled Nurse 1wk1 (1 time per week for 1 week), 2wk4 (2 times per week for 4 weeks), 3PRN (as needed). Registered Nurse to "observe and assess", Licensed Practical Nurse to "observe for risk for falls and instruct in fall prevention, home safety, medication management, infection prevention, and nutrition management”. The Skilled Nurse “Visit Note Report” dated 11/23/2023 and 11/27/2023 document patient assessments conducted and signed by the Licensed Practical Nurse. The clinical record lacks documented evidence that the Registered Nurse communicated, reviewed visit notes, supervised and evaluated the Licensed Practical Nurse performance in the provision of patient care and services. On 11/30/2023 at 4:30 PM, the Administrator and Director of Patient Services were interviewed and did not provide an explanation for the findings. 11) Patient #13 has a start of care date of 08/08/2023 with diagnoses of Orthopedic Aftercare, Type 2 Diabetes Mellitus with diabetic neuropathy arthropathy, Hypertensive Heart Disease with Heart Failure, Systolic Heart Failure, and Atrial Fibrillation as documented on the “Home Health Certification and Plan of Care” dated 08/08/2023 to 10/06/2023. The “Home Health Certification and Plan of Care” dated 08/08/2023 to 10/06/2023 documents an order for “Skilled Nurse 1wk4 (1 time per week for 4 weeks), Physical Therapy 1wk2 (1 time per week for 2 weeks), 2wk3 (2 times per week for 3 weeks), 1wk2 (1 time per week for 2 weeks); Occupational Therapy 1wk1 (1 time per week for 1 week), 2wk4 (2 times per week for 4 weeks), 3PRN (as needed). Registered Nurse to "observe, assess, evaluate, and develop an individualized plan of care". Registered Nurse to "observe and assess". Licensed Practical Nurse to "observe for risks for falls and instruct in fall prevention, home safety, medication management, infection preventions, and nutrition management.” The Skilled Nurse “Visit Note Report” dated 08/16/2023, 09/08/2023, 09/21/2023, and 09/28/2023 document comprehensive assessments conducted and signed by the Licensed Practical Nurse. The clinical record lacks documented evidence that the Registered Nurse communicated, reviewed visit notes, supervised and evaluated the Licensed Practical Nurse performance in the provision of patient care and services. On 12/01/2023 at 3:45 PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings. 4) Patient #2 with a start of care 10/26/2023 diagnoses of Scoliosis, Raynaud’s Syndrome, Indwelling Catheter, Foot drop, ATRIAL Fibrillation, Hypertension, Polyneuropathy, Asthma and Spinal Stenosis, admitted to the home care agency on 10/26/2023. The Home Health Certification and Plan of Care certification period 10/26/2023-12/24/2023 documents orders for "Registered Nurse to observe, assess, evaluate, and develop an individualized plan of care. Registered Nurse to observe and assess, Licensed Practical Nurse to observe for risk for falls and instruct in falls prevention, home safety, medication management infection prevention and nutrition management". The “Visit Note Report” Assessment note dated 11/08/23 were conducted by an Licesne Practical Nurse documenting preforming patient assessments. The Licensed Practical Nurse documents “indicate if you communicate with other disciplines involved in the case”. “No”. The clinical record lacks documented evidence that the Registered Nurse communicated, reviewed visit notes, supervised, and evaluated the Licensed Practical Nurse performance in the provision of patient care and services. 5) Patient #3 start of care 10/20/2023 with diagnoses of Laceration to right elbow, Hypertension Heart Disease with Heart Failure, Chronic Obstructive Pulmonary Disease, Acute Respiratory with Hypoxia and Hypercapnia, Anemia, Dependence on Supplemental Oxygen, Anxiety and Major Depression. The Home Health Certification and Plan of Care for certication period 10/20/2023-12/18/2023 documents an oders for Registered Nurse to "observe, assess, evaluate, and develop an individualized plan of care. Registered Nurse to observe and assess, Licensed Practical Nurse to observe for risk for falls and instruct in falls prevention, home safety, medication management infection prevention and nutrition management". The “Visit Notes Reports” Assessment notes dated 10/24/23, 10/27/23, 10/31/23, 11/02/23, and 11/07/23 were conducted by an Licensed Practical Nurse documenting performing patient assessments. The Licensed Practical Nurse documents “indicate if you communicate with other disciplines involved in the case”. “No”. The clinical record lacks documented evidence that the Registered Nurse communicated, reviewed visit notes, supervised and evaluated the License Practical Nurse performance in the provision of patient care and services. 6) Patient #7 with start of care 10/12/2023 with diagnoses of Malignant Neoplasm of left Female Breast, Abscess of the Breast and Nipple, Urinary Tract Infection, Alzheimer’s Disease, Essential Hypertension, Anemia and Type 2 Diabetes. The Home Health Certification and Plan of Care for certification period 10/12/2023-12/10/2023 documents orders for " Skilled Nurse 1wk2, 2wk3 (1 time per week for 2 week, 2 times per week for 3 weeks). Skilled Nurse to "observe, assess, evaluate, and develop an individualized plan of care. Registered Nurse to observe and assess, Licensed Practical Nurse to observe for risk for falls and instruct in falls prevention, home safety, medication management infection prevention and nutrition management". The ‘Visit Note Reports’ dated 10/17/23, 10/27/23, 10/31/23, 11/0723 and 11/14/2023 were conducted by an Licensed Practical Nurse documenting performing patient assessments. The Licensed Practical Nurse documents “indicate if you communicate with other disciplines involved in the case”. “No”. The clinical record lacks documented evidence that the Registered Nurse communicated, reviewed visit notes, supervised, and evaluated the Licensed Practical Nurse performance in the provision of patient care and services. 7) Patient #8 with start of care 12/09/22 and discharge date of 01/31/2023 with diagnoses of Surgical Aftercare, Atrioventricular Complete Heart Block, Hypertension Heart, and chronic kidney disease with Heart Failure, Chronic Diastolic Congested Heart Failure, Acute Respiratory with Hypoxia, Dependence on Supplemental Oxygen and History of Fall. The Home Health Certification and Plan of Care for certification period 12/9/2022-02/06/2023 documents orders "Skilled Nurse to "assess, evaluate, and develop an individualized plan of care. Registered Nurse to observe and assess, License Practical Nurse to "observe for risk for falls and instruct in falls prevention, home safety, medication management infection prevention and nutrition management". The “Visit Note Reports” dated 12/14/22,12/19/22 and 01/25/2023 were conducted by an Licensed Practical Nurse documenting preforming comprehensive assessments. The “Visit Note Reports” dated 12/14/22 documents “indicate if you communicate with other disciplines involved in the case”. “No”. The record lacks documented evidence that the Registered Nurse communicated, reviewed visit notes, supervised, and evaluated the Licensed Practical Nurse performance in the provision of patient care and services. The Director of Patient Services/Administrator was interviewed 12/01/2023 at 2.00 pm and findings reviewed, no explanation was provided. 1) Patient #9 has a start of care date of 08/06/2023 with diagnoses including Hypertension Heart and Chronic Kidney Disease with Heart Failure stage 1, Chronic Diastolic Heart Failure, and Type 2 Diabetes Mellitus as documented on the “Home Health Certification and Plan of Care” for certification period 08/06/2023 to 10/04/2023. The patient has a discharge date of 10/04/2023. The “Home Health Certification and Plan of Care” for certification period 08/06/2023 to 10/04/2023 documents an order for “Skilled Nurse 2wk1, 1wk5, 1 every 2wk2, 1wk1 (two visits a week for one week, one visit a week for five weeks, one visits every two weeks for two weeks). Registered Nurse to "observe and assess". Licensed Practical Nurse "observe for risk for falls and instruct in fall prevention, home safety, medication management, infection prevention and nutrition management". The Skilled Nurse “Visit Note Report” dated 09/13/2023 and 09/25/2023 document patient assessments conducted and signed by the Licensed Practical Nurse. The clinical record lacks documented evidence that the Registered Nurse communicated, reviewed visit notes, supervised and evaluated the Licensed Practical Nurse performance in the provision of patient care and services. The survey findings were reviewed with the Administrator, Director of Patient Services on 11/28/2023 at 03:40 PM. No explanation was provided. 2) Patient #10 has a start of care date of 05/30/2023 with diagnoses of Unspecified Open Wound Left Knee, Hypertensive Chronic Kidney Disease stage 1, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease as documented on the "Home Health Certification and Plan of Care" for certification period 05/30/2023 to 07/28/2023. The patient has a discharge date of 07/28/2023. The "Home Health Certification and Plan of Care" for certification period 05/30/2023 to 07/28/2023 documents and order for Skilled Nurse 2wk1, 1wk3 two visit a week for one week, one visit a week for three weeks). Skilled Nurse "assess evaluate and develop an individualized Plan of Care". Skilled Nurse for instruction in "Diabetic Care to include diet Low Carb, skin care, and symptoms of hypo/hyperglycemia, proper administration of Diabetic medication". Skilled Nurse to "perform wound care to Left Knee skin tear: cleanse with wound cleanser, apply Xeroform, cover with Foam dressing. Dressing to be changed 2X (two times) per week and PRN (as needed) for dislodged dressing, wound deterioration". The Skilled Nurse “Visit Note Report” dated 06/02/2023 and 06/05/2013 document patient assessments conducted and signed by the Licensed Practical Nurse. The clinical record lacks documented evidence that the Registered Nurse communicated, reviewed visit notes, supervised and evaluated the Licensed Practical Nurse performance in the provision of patient care and services. The survey findings and interview were conducted with the Director of Patient Services on 11/29/2023 at 03:57 PM. No explanation was provided. 3) Patient #14 has a start of care 09/25/23 with diagnoses of Hypertensive Heart and Chronic Kidney Disease, Acute Chronic Systolic Congestive Heart Failure, and Type 2 Diabetes Mellitus as documented on the “Home Health Certification and Plan of Care” for certification period 09/25/2023 to 11/23/2023. The "Home Health Certification and Plan of Care” for certification period 09/25/2023 to 11/23/2023 documents an order for Skilled Nurse 3 wk 3, Physical Therapy 1 wk1 (one visit a week for one week), Occupational Therapy 1 wk 1, 2 wk 4, 1 wk4 (one visit a week for one week, two visits a week for four weeks, one visit a week for four weeks). Registered Nurse to "observe, assess and evaluate and develop an individualized Plan of Care, Registed Nurse to observe and assess. License Practical Nurse to "observe for risk for falls and instruct on fall prevention, home safety, medication management, infection prevention, and nutrition management". "Skilled Nurse to perform wound care to #1 LLE (Left Lower Leg) cleanse with Normal Saline, apply Adaptic, Calcium Alginate and cover with Stratasorb 3w3 (three times a week)". "Skilled Nurse for instructions of Diabetic Care to include diet, skin care, signs and symptoms of hypo/hyperglycemia, proper administration of Diabetic medication". "Blood Glucose testing QID (four times a day), Skilled Nurse to assess patient/caregiver ability to perform and record blood glucose testing and report abnormal findings to Physician. SN to "report to Physician blood glucose readings greater than 350 or less than 70". "Indwelling Urinary Catheter 18 FR (French) with 30 cc (cubic centimeter) balloon. SN to "assess and teach related to altered Genitourinary status to minimize complications and hospitalization". The Skilled Nurse “Visit Note Report” dated 09/27/2023, 09/29/2023, 10/02/2023, 10/05/2023, 10/09/2023, and 11/08/2023, documents patient assessments conducted and signed by the Licensed Practical Nurse. The clinical record lacks documented evidence that the Registered Nurse communicated, reviewed visit notes, and evaluated the Licensed Practical Nurse performance in the provision of patient care and services. The survey findings and interview were conducted with the Administrator and Director of Patient Services on 11/30/2023 at 04:36 PM. No explanation was provided.

An onsite complaint # 96003 survey was conducted on 03/08/2023 – 03/09/2023 at Tender Loving Care - An Amedisys Co, located at 100 Garden City Plaza, Garden City NY 11530. The survey consists of review of four (4) clinical records, three (3) personnel records, patient Complaint Log for 07/01/22 – 01/31/2023, patient Discharge Policy and the agency’s On-Call Policy. Interviews were conducted with the Agency's Occupational Therapist, Registered Nurse, and On-Call Nurse on 03/09/2023. Complaint #96003 is substantiated. The following deficiencies are cited as a result on the survey: G0574 - Plan of Care must include the following G0704 - Responsibilities of Skilled Professionals

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical chart review and staff interview, the Agency failed to ensure that individualized Plan of Care are established for each patient. This was evident in one (1) of four (4) patient record reviewed. Patient #1. Failure to ensure an individualized Plan of Care, has the potential for negative patient outcome. The findings include: 1) Patient has a start of care date of 12/09/2022 with diagnoses of Encounter for surgical aftercare following surgery of circulatory system, Atrial ventricular block, Hypertensive Heart, Encounter for Fitting of Urinary Device, and Acute Respiratory Failure with Hypoxia as documented on the "Home Health Certification and Plan of Care" dated 12/09/2022 - 02/06/2023. The "Home Health Certification and Plan of Care" dated 12/09/2022 - 02/06/2023 documents an order for "SN (Skilled Nurse) 1 wk. 3, Foley change every 6 -7 weeks, 3 PRN (one visit a week for three weeks, the Foley catheter change every six to seven week, three as needed visits)". SN to "assess, evaluate and develop an individualized Plan of Care". SN to "perform O2 (Oxygen) saturation level on admission and PRN (as needed) to assess patient , with notification to the Physician if saturation is The SOC (Start of Care) assessment “Narrative" note dated 12/09/2022, the SN documents "patient had pacemaker placement in hospital and was discharge home on Oxygen". The Plan of Care lacks documented evidence of an order for the Pacemaker and the Oxygen rate, route and frequency of usage. The survey findings were reviewed with the Assistant Vice President (AVP), Director of Operations (DOO) and Director of Patient Services (DPS) on 03/08/2023 at 04:15 PM. Interview of the DOO and DPS on 03/09/2023 at 01:20 PM, no explanation was provided.

Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This STANDARD is not met as evidenced by: Based on clinical record review and staff interview, the Agency failed to ensure Skilled Professional Nurse assessment of the patient's clinical status. This was evident in one (1) of four (4) patient record reviewed. Patient #1. Failure to ensure the Skilled Professional clinical assessment of the patient, has the potential for negative patient outcome. The findings include: 1) Patient #1 has a start of care date of 12/09/2022 with diagnoses of Encounter for surgical aftercare following surgery of circulatory system, Atrial Ventricular block, Hypertensive Heart, Encounter for Fitting of Urinary Device, and Acute Respiratory Failure with Hypoxia as documented on the "Home Health Certification and Plan of Care" dated 12/09/2022 - 02/06/2023. The patient has a discharge date of 01/31/2023 form the Agency. The "Home Health Certification and Plan of Care" dated 12/09/2022 - 02/06/2023 documents an order for "SN (Skilled Nurse) 1 wk. 3, Foley change every 6 -7 weeks, 3 PRN (one visit a week for three weeks. “SN to "perform O2 (Oxygen) saturation level on admission and PRN (as needed) to assess patient , with notification to the Physician if saturation is The “Clinical Coordination Notes Report” dated 12/10/2022 and 12/11/2022, the On – Call RN documents the patient’s daughter called the agency inquiring about the patient’s clinical status, respiratory status, heart rate, oxygen saturation, and oxygen administration. The On – Call RN documents on 12/10/2022 at 09:09 AM, patient's daughter called to report that the “Patient just woke up from sleep and his lips were white. Patient is not wearing his Oxygen at this time and his Oxygen saturation is down to 88%. Advised for her to place his Oxygen back on and have him take slow, deep breaths. The On – Call RN documents on 12/10/2022 at 09:22 AM, “Daughter was unsure which number on the Pulse Oximeter was the Oxygen saturation and which number was the Heart Rate. She also was unsure about what the numbers should be. Educated her on how to read pulse and normal values”. The On – Call RN documents on 12/10/2022 at 20:44 (08:44 PM) – “daughter called wanting to know if he could get too much Oxygen. She stated that he just coughed up a lot of mucus and started breathing hard. She wanted to send a video of his breathing. Daughter sent video to RN’s phone”. The On – Call RN documents on 12/10/2022 at 20:51 (08:51 PM) Daughter called to “inquire about oxygen saturation and heart rate again. She stated that was reading 78% and 95 for Heart rate. Advised to have him take slow deep breaths. She sated that his fingers were cold advised that this would affect the reading. She completed a recheck and stated that his breathing changed. Advised her to call EMS and have him transported to hospital for evaluation”. The On – Call RN documents on 12/10/2022 at 20:58 (08:58 PM) “Daughter called again stating that his oxygen was back up to 95% and that he was using portable oxygen concentrator on battery. She plugged in the concentrator and his oxygen went right back up. Advised for her to make sure he was plugged in the concentrator and his oxygen was working properly”. The On – Call RN documents on 12/11/2022 at 12:10 AM, the On-Call RN documents “daughter called stating that the patient was still coughing and couldn’t stop. He is also constantly blowing his nose and pulling his oxygen out. She stated that she is giving him several things today for his runny nose and coughing without relief. Even though she was advised several times today by this nurse to notify his PCP (Primary Care Physician) and discuss with them about what to give him. His breathing is still heavy and she wants to take him to the ER for evaluation. Advised that if she wanted him to be evaluated then she should take him. The On – Call RN documents on 12/11/2022 at 10:08 AM, the patient's “daughter worried that the patient was getting too much oxygen, so she took his oxygen off to see what his oxygen saturation was, which was 93% on room air. Advised that she needed to follow the orders for oxygen from the Physician at the hospital and discuss with PCP tomorrow”. The clinical record lacks documented evidence that the On-Call RN arranged for a Skilled Professional Nurse visit the patient for assessment of the patient’s respiratory status, oxygen saturation rate, oxygen adminitration, and notify the Physician of the changes in the patient’s clinical status on 12/10/2022 and 12/11/2022. The clinical record lacks documented evidence of a SN visit 12/10/2022 – 12/13/2022 to evaluate the patient’s clinical status, respiratory status, educate the patient/caregiver on oxygen usage and oxygen precautions, oxygen saturation parameters, signs/symptoms to notify the Physician. The Agency failed to ensure that the Skilled Professional Nurse perform a clinical assessment of the patient after reported changes in the clinical status. The survey findings were reviewed with the Assistant Vice President (AVP), Director of Operations (DOO) and Director of Patient Services (DPS) on 03/08/2023 at 04:15 PM. Interview of the DOO and DPS on 03/09/2023 at 01:20 PM, no explanation was provided.

An on-site complaint investigation survey for Complaint 61462 was conducted on 01/04/2022 at Tender Loving Care, 100 Garden City Plaza, Garden City, NY 11530. The investigation consisted of a review of three (3) Clinical Records (Patients #1, #2 and #3), three (3) Personnel Records (Employee's #1, #2 and #3), the Complaint Log from October 01, 2021 to January 04, 2022, and The Provision of Wound and Skin Care policy and procedure. The current patient census as of 01/04/2022 at 10:00 AM is three hundred fifty-five (355). The allegations in complaint 61462 are determined to be substantiated. Deficiencies are being cited as a result of the complaint investigation. G 0578 Conformance with physician orders G 0710 Provide services in the plan of care G 0718 Communication with physicians

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on Clinical Record review and staff interview, the Agency failed to ensure that services and/or treatments were provided in conformance with physician orders documented on the Plan of Care. This is evident in one (1) of three (3) Clinical Records reviewed (Patient #1). Failure to ensure that patient services and/or treatments are provided in conformance with physician order as documented on the Plan of Care has the potential for unmet patient needs and negative patient outcomes. The finding is: Patient #1 has a start of care date of 10/01/2021 with diagnoses Hypertensive Heart Disease with heart failure, heart failure, unspecified and Pressure Ulcer of Sacral Region, Stage 2 on the "Home Health Certification and Plan of Care" from 10/01/2021 to 11/29/2021 and diagnoses Pressure Ulcer of Sacral Region, Stage 4 , Hypertensive Heart Disease with Heart Failure and Heart Failure, unspecified as documented on the "Home Health Certification and Plan of Care" from 11/30/2021 to 01/28/2022. The "Home Health Certification and Plan of Care" from 10/01/2021 to 11/29/2021 documents SN 1Wk1 (one visit first week), 2Wk2 (two visits per week for 2 weeks), 1Wk3 (one visit per week for three weeks), 3 PRN for complications related to wound status and for the Skilled Nurse to "Observe and assess integumentary status related to pressure ulcer injury management to identify changes and intervene to minimize complications. Provide skilled teaching related to altered skin integrity to include offloading, frequent position changes, keep skin clean and dry to prevent skin breakdown and minimize friction and shearing. Report significant changes in status to physician for early intervention" and " Skilled nurse to assess each visit and prn (as needed) for complications related to wound status". The "Nurse Visit Report" dated 10/07/2021, 10/08/2021 and 10/12/2021 documents "#1 Coccyx, PU (pressure ulcer) Stage II (2) Change in Status: None, Wound Assessed: No, Caregiver completed care and Wound Care Provided: Wound care not provided Caregiver completed care". The "Wound Record Report" documents #1 Coccyx measurements 1.5 x 0.5 x 0.2, Surface Area (Square centimeters) 0.75, Partial Thickness on 10/05/2021 and 2.5 x 2 x 0.5, Surface Area (Square centimeters) 5, Full Thickness on 10/22/2021. The Skilled Nurse failed to assess the wound to the coccyx area on 10/07/2021, 10/08/2021 and 10/12/2021 in conformance with physician order. The Clinical Record includes "Visit Note Report(s)" dated 11/01/2021, 11/05/2021, 11/08/2021, 11/10/2021, 11/16/2021 and, 11/18/2021 and three (3) "Client Coordination Note Reports" documenting Skilled Nurse missed visits on 11/04/2021, 11/13/2021 and 11/20/2021. The prescribed Skilled Nurse frequency is 3wk3 (three visits per week for three weeks). The Skilled Nurse failed to provide visits of three times per week in conformance with physician order. The Skilled Nurse "Visit Note Report(s)" dated 10/05/2021, 10/07/2021, 10/08/2021, 10/12/2021, 10/22/2021, 10/25/2021, 10/27/2021, 10/29/2021, 11/01/2021, 11/05/2021, 11/08/2021, 11/10/2021, 11/16/2021, 11/18/2021, and 11/24/2021 lack documented evidence the Skilled Nurse provided education related to altered skin integrity to include offloading, frequent position changes, keeping skin clean and dry to prevent skin breakdown and minimize friction and shearing. The Skilled Nurse failed to provide education and teaching related to pressure ulcer prevention and mitigation in conformance with physician order. In an interview with the Agency's Area Vice President and Director of Operations on 01/04/2022 at 3:30PM regarding these areas of concern the findings were acknowledged.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on Clinical Record review and staff interview, the Agency failed to provide services as ordered by the physician as indicated on the plan of care. This is evident in one (1) of three (3) Clinical Records reviewed (Patient #1). Failure to ensure that patient services are provided as ordered by the physician as indicated on the plan of care has the potential for unmet patient needs and negative patient outcomes. The finding is: Patient #1 has a start of care date of 10/01/2021 with diagnoses Hypertensive Heart Disease with heart failure, heart failure, unspecified and Pressure Ulcer of Sacral Region, Stage 2 on the "Home Health Certification and Plan of Care" from 10/01/2021 to 11/29/2021 and diagnoses Pressure Ulcer of Sacral Region, Stage 4 , Hypertensive Heart Disease with Heart Failure and Heart Failure, unspecified as documented on the "Home Health Certification and Plan of Care" from 11/30/2021 to 01/28/2022. The "Home Health Certification and Plan of Care" from 10/01/2021 to 11/29/2021 documents SN 1Wk1 (one visit first week), 2Wk2 (two visits per week for 2 weeks), 1Wk3 (one visit per week for three weeks), 3 PRN for complications related to wound status and for the Skilled Nurse to "Observe and assess integumentary status related to pressure ulcer injury management to identify changes and intervene to minimize complications. Provide skilled teaching related to altered skin integrity to include offloading, frequent position changes, keep skin clean and dry to prevent skin breakdown and minimize friction and shearing. Report significant changes in status to physician for early intervention" and " Skilled nurse to assess each visit and prn (as needed) for complications related to wound status". The Clinical Record includes "Visit Note Report(s)" dated 11/01/2021, 11/05/2021, 11/08/2021, 11/10/2021, 11/16/2021 and, 11/18/2021 and three (3) "Client Coordination Note Reports" documenting Skilled Nurse missed visits on 11/04/2021, 11/13/2021 and 11/20/2021. The prescribed Skilled Nurse frequency is 3wk3 (three visits per week for three weeks). The Skilled Nurse failed to provide visits of three times per week as ordered by the physician and documented on the plan of care. The "Nurse Visit Report" dated 10/07/2021, 10/08/2021 and 10/12/2021 documents "#1 Coccyx, PU (pressure ulcer) Stage II (2) Change in Status: None, Wound Assessed: No, Caregiver completed care and Wound Care Provided: Wound care not provided Caregiver completed care". The "Wound Record Report" documents #1 Coccyx measurements 1.5 x 0.5 x 0.2, Surface Area (Square centimeters) 0.75, Partial Thickness on 10/05/2021 and 2.5 x 2 x 0.5, Surface Area (Square centimeters) 5, Full Thickness on 10/22/2021. The Skilled Nurse failed to assess the wound to the coccyx area on 10/07/2021, 10/08/2021 and 10/12/2021 as ordered by the physician and documented on the plan of care. The Skilled Nurse "Visit Note Report(s)" dated 10/05/2021, 10/07/2021, 10/08/2021, 10/12/2021, 10/22/2021, 10/25/2021, 10/27/2021, 10/29/2021, 11/01/2021, 11/05/2021, 11/08/2021, 11/10/2021, 11/16/2021, 11/18/2021, and 11/24/2021 lack documented evidence the Skilled Nurse provided education related to altered skin integrity to include offloading, frequent position changes, keeping skin clean and dry to prevent skin breakdown and minimize friction and shearing. The Skilled Nurse failed to provide education and teaching related to pressure ulcer prevention and mitigation as ordered by the physician and documented on the plan of care. In an interview with the Agency's Area Vice President and Director of Operations on 01/04/2022 at 3:30PM regarding these areas of concern the findings were acknowledged.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on Clinical Record review and staff interview, the Agency failed to ensure communication with the patient's Physician related to the current Plan of Care. This was evident in one (1) of three (3) Clinical Records reviewed (Patient #1). Failure to ensure ongoing communication is maintained with the patient's Physician has the potential for negative patient outcomes. The finding is: Patient #1 has a start of care date of 10/01/2021 with diagnoses Hypertensive Heart Disease with heart failure, heart failure, unspecified and Pressure Ulcer of Sacral Region, Stage 2 on the "Home Health Certification and Plan of Care" from 10/01/2021 to 11/29/2021 and diagnoses Pressure Ulcer of Sacral Region, Stage 4 , Hypertensive Heart Disease with Heart Failure and Heart Failure, unspecified as documented on the "Home Health Certification and Plan of Care" from 11/30/2021 to 01/28/2022. The "Home Health Certification and Plan of Care" from 10/01/2021 to 11/29/2021 documents SN 1Wk1 (one visit first week), 2Wk2 (two visits per week for two weeks), 1Wk3 (one visit per week for three weeks), 3 PRN for complications related to wound status and for the Skilled Nurse to "Observe and assess integumentary status related to pressure ulcer injury management to identify changes and intervene to minimize complications. Provide skilled teaching related to altered skin integrity to include offloading, frequent position changes, keep skin clean and dry to prevent skin breakdown and minimize friction and shearing. Report significant changes in status to physician for early intervention" The "Nurse Visit Report" dated 10/27/2021 documents in the narrative "Wound care administered per MD orders. Area around wound is hard, aide states wound has an odor. SN notified MD [name]. Waiting for MD to contact SN back. No redness or heat to area surrounding wound. No fever. Patient denies pain. Patient has some swelling in the lower back above the sacrum". The Clinical Record lacks documented evidence that the SN followed up and actually communicated the changes in patient condition to the patients physician regarding the wound and swelling which may have necessitated a change in the patients Plan of Care . In an interview with the Agency's Area Vice President and Director of Operations on 01/04/2022 at 3:30PM regarding these areas of concern the findings were acknowledged.

A Standard Re-certification survey of Tender Loving Care, An Amedisys Co. Certified Home Health Agency located at 100 Garden City Plaza, Garden City, NY 11530 was initiated on 01/19/2021 and exited 01/25/2021. Deficient practices were identified within high priority standards in Care Planning, Coordination, Quality of Care; Skilled Professional Services; and Organization and administration of services; resulting in a Partial Extended Survey. The survey consisted of review of seventeen (17) Clinical Records including five (5) discharge records were reviewed and identified as Patients: #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, and #17. Seven (7) observable home visits (HV) were conducted and identified as Patients: #1, #2, #3, #4, #5, #8, and #12. Thirteen (13) personnel records were reviewed and identified as Employees: #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, and #13. The survey included a review of pertinent policies and procedures including COVID-19 Infection control, the agency's Quality Improvement/Quality Assurance/Performance Group (PAG) meetings minutes were reviewed for 2019 and 2020, agency's Admission Packet and Complaint Log for 2020 to present. Pre-survey activities consisted of a review on 1/13/21, 1/14/21 and 1/15/21 of the agency's Health Commerce System account, Home Care Worker Registry, Criminal History Record Check, QIES (Quality Improvement and Evaluation System) Reports for the period 11/2019 to 10/2020, the agency's compliance with report submissions for the 2018 statistical report and the Emergency Drill conducted 06/11/2019 through 06/13/2019. The Director of Operations were interviewed throughout the survey and findings were reviewed at the Exit Conference on 01/25/2021 at 3:45 PM. The following deficiencies are cited as a result of survey: G - 574 - Plan Of Care Must Include The Following G - 578 - Conformance With Physician Orders G - 606 - Integrate All Services G - 706 - Interdisciplinary Assessment Of The Patient G - 718 - Communication With Physicians G - 984 - In Accordance With Current Clinical Practice J - 1132 and 1172 - Governing Authority; J - 1412, 1416, 1420, 1424, 1426, 1428, 1440, 1444, 1456, 1460 - Personnel. J - 1512 - Records and Reports 0606, and 0610 Responsibilities of Home Care Svcs Entities (Home Care Worker Registry) 0702 Criminal History Record Check Process (CHRC)

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 may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to ensure Plan of Care (POC) was developed to meet the individualized needs of the patient. This was evident in six (6) of (17) clinical records reviewed. (Patient's #1HV, #2HV, #3, #5HV #14 and #17). Failure to develop complete and comprehensive Plans of Care places patients at risk for not having needs met and negative patient outcomes. The findings are: 1) Patient #14 has a start of care date of 11/05/2019 with diagnoses Hemiplegia following cerebral infarction affecting left nondominant side, Type 2 diabetes mellitus without complications, Essential (primary) Hypertension, Malignant neoplasm of unspecified site of left female breast, and Long term use of Insulin as documented in the "Home Health Certification and Plan of Care" from 11/5/2019 to 1/3/2020". The "Home Health Certification and Plan of Care" from 11/5/2019 to 1/3/2020 is incomple as it fails to a include risk assessment for hospitalization and a description of the patient's risk for emergency department visits and necessary interventions to address underlying risk factors. Survey findings were reviewed with the Director of Operations (DOO) on 01/22/21 at 4:30 PM. On 1/25/21 at 11:45 AM, the DOO acknowledged the findings. 2) Patient #1HV has a start of care date of 11/03/2020 with diagnoses Pressure Ulcer of Right Ankle, Stage 2, Encephalopathy, Unspecified, Alzheimer's Disease, Unspecified, and Anxiety Disorder, Unspecified as documented on the "Home Health Certification and Plan of Care" from 01/02/2021 to 03/02/2021. The "Home Health Certification and Plan of Care" from 01/02/2021 to 03/02/2021 documents the medications Escitalopram 5 mg Tablet Daily, Divalproex 125 mg Tablet, Delayed Release Daily, Docusate Sodium 100 mg Capsule Daily, and Risperidone 0.25 mg Tablet Daily. The Clinical Record includes a "Physician Order" effective 01/14/2021 for Speech Language Therapy 1WK4 (one visit per week for four weeks). A home visit was conducted on 01/19/2021 to observe a Speech Language Therapy visit. A medication reconciliation was conducted with the Speech Therapist and the patients son via facetime. The patients son states: Divalproex, Escitalopram and Risperidone were stopped "one month ago". Escitalopram 0.25 MG Tablet Daily was resumed one (1) week ago related to increased agitation. Docusate Sodium 50 MG Soft Gel in the AM and PM, Methenamine 1 gram PO BID (twice per day) for Chronic Urinary Tract Infection (most recent fill date 09/24/2020), and Trazadone 50 MG 1 Tablet at Bedtime (most recent fill date 12/20/2020). The "Home Health Certification and Plan of Care" from 01/02/2021 to 03/02/2021 lacks documented evidence of the medications Trazadone and Methenamine; the correct dosage, frequency and formation of Docusate Sodium and the discontinuance of Divalproex, Escitalopram and Risperidone, and subsequent resumption of Escitalopram. The survey findings were reviewed with the Agency's DOO on 01/22/2021 at 3:15 PM. On 01/25/2021 at 10:40 AM, the DOO acknowledged the findings. 3) Patient #2HV has a start of care date of 11/11/2020 with diagnoses Pressure Ulcer of Sacral Region, Stage 2, Pressure Ulcer of Left Ankle, Unstageable, and Hemiplegia following nontraumatic subarachnoid hemorrhage affecting left nondominant side as documented on the "Home Health Certification and Plan of Care" from 01/10/2021 to 03/10/2021. The "Home Health Certification and Plan of Care" from 01/10/2021 to 03/10/2021 documents "SN 3WK8 (three visits per week for eight weeks), 2WK1 (two visits per week for one week), 3 PRN (three visits as needed)" and medications "Baclofen 10 mg Tablet daily, Lisinopril 20 mg Tablet daily and Xarelto 10 mg Tablet daily". A home visit was conducted on 01/20/2021 to observe a Skilled Nursing visit. A medication reconciliation was conducted with the patients wife. The patient takes Baclofen 5 mg in the morning and 10 mg at bedtime since "the end of December", Lisinopril 20 mg Tablet "as needed if his systolic is greater than 110", Ritalin (generic Methylphenidate) 5 mg by mouth in the morning "as of 11/11/2020", Xarelto 5 mg once a day "all along", iron sulfate 65 mg in the "AM and PM all along", Centrum multivitamin once a day "all along", chewable 81 mg Aspirin "in the morning all along", Magnesium 250 mg "in the morning since 12/09/2020, and Senokot 8.6 mg Tablet once a day. The "Home Health Certification and Plan of Care" from 01/10/2021 to 03/10/2021 lacks documentation of the current dosage and frequency of Baclofen, the qualifier for the medication Lisinopril, the medication Ritalin, the correct dosage of Xarelto, and the medications/supplements iron sulfate, Centrum multivitamin, Aspirin, Magnesium, and Senokot. The survey findings were reviewed with the Agency's DOO on 01/22/2021 at 3:15 PM. On 01/25/2021 at 10:54 AM, the DOO acknowledged the findings. 4) Patient #5HV has a start of care date of 01/11/2021 with diagnoses Covid-19, Pneumonia due to Coronavirus disease 2019 and Type 2 Diabetes Mellitus without complications as documented on the "Home Health Certification and Plan of Care" from 01/11/2021 to 03/11/2021. The "Home Health Certification and Plan of Care" from 01/11/2021 to 03/11/2021 documents medications "Omeprazole 20 mg capsule, delayed release 1 capsule daily and Metformin 500 mg 1 tablet 2 times daily". A home visit was conducted on 01/20/2021 to observe a Occupational Therapy visit. A medication reconciliation was conducted with the patient and Occupational Therapist. The patients medication list documents the patient takes Omeprazole 20 mg two times a day and Metformin 500 mg once a day. The Occupational Therapist verified the frequency with the patient. The patient states taking a "senior multivitamin every day for a longtime", Tylenol 500 mg in the morning and 500 mg 2 tablets at bedtime "it helps me sleep, I've been doing it forever", and Miralax "a level teaspoon once a day forever". The "Home Health Certification and Plan of Care" from 01/11/2021 to 03/11/2021 lacks documentation of the correct frequency of Metformin and Omeprazole and the over the counter medications/supplements Tylenol, Multivitamin, and Miralax. The survey findings were reviewed with the Agency's Director of Operations (DOO) on 01/22/2021 at 3:15 PM. On 01/25/2021 at 11:06 AM, the DOO acknowledged the findings. 5) Patient #17 has a start of care date of 11/15/2019 with diagnoses Type 2 Diabetes Mellitus with Hyperglycemia, Unspecified Dementia without behavioral disturbance and Essential (Primary) Hypertension as documented on the "Home Health Certification and Plan of Care" from 11/15/2019 to 01/13/2019. The patient was discharged from the Agency on 01/04/2020. The "Home Health Certification and Plan of Care" from 11/15/2019 to 01/13/2019 documents "ST (Speech Therapy) Effective 11/17/2019 1WK1 (one visit week one)" and "Nutritional Requirements: Diabetic, Low Sodium" and "Safety Measures: Anticoagulant Precautions, Fall Precautions, Safety Precautions". A "Client Coordination Note Report" dated 11/22/2019 entered by the Speech Language Therapist documents "Patient currently on chopped foods and thin liquids via straw. Patient is tolerating safest and least restrictive diet. No signs and symptoms aspiration noted. Compensatory swallowing strategies given to patients wife and caregiver. No further treatment warranted at this time." The "Home Health Certification and Plan of Care" from 11/15/2019 to 01/13/2019 lacks documented evidence of the patients nutritional requirements of "chopped foods and thin liquids via straw" and the safety measure of Aspiration Precautions. The survey findings were reviewed with the Agency's DOO on 01/22/2021 at 3:15 PM. On 01/25/2021 at 11:05 AM, the DOO acknowledged the findings. 6) Patient #3 has a start of care date of 01/06/21 with diagnoses of Type 2 Diabetes Mellitus with Chronic Kidney Disease as documented on the "Home Health Certification and Plan of Care for certification period 01/06/21 to 03/06/21". The "Home Health Certification and Plan of Care" for certification period 01/06/21 to 03/06/21 documents an order for "SN 2 wk 4, 1 wk 2, 1 OW 2" (Skilled Nurse two visits a week for four weeks, one visit a week for two weeks and one visit every other week for two weeks). Skilled Nurse to assess patient/caregiver ability to perform and record Blood Glucose test as needed. Skilled Nurse to report to Physician Blood Glucose readings out of range parameters established by the MD (Medical Doctor)". Medications includes "Novolog mix 70/30 Flexpen U-100 Insulin 100 units/ml subcutaneous give 23 units before breakfast, 25 units before dinner". The "Home Health Certification and Plan of Care" lacks an order for the frequency of Blood Glucose (BG) testing and the BG parameters to notify the MD. The survey findings were reviewed with the agency's Director of Operations (DOO) on 01/22/21 at 4:00 PM. On 01/25/21 at 1:00 PM, the DOO acknowledged the findings.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician orders. This STANDARD is not met as evidenced by: Based on Home Visit Observations, Clinical Record reviews, and staff interviews, the agency failed to ensure that services and treatments are provided in accordance with the Plan of Care (POC). This was evident in nine (9) of seventeen (17) clinical records reviewed. (Patient's #2, #4, #7, #9, #10, #11, #12HV, #16, and #17). Failure to promptly alert the Physician regarding the patient's status and the inability to conform to the Physicians Orders by The findings are: The Agency's policy and procedure "Vital Signs", Policy: MSC-004, revised 04/20 documents "All field staff providing direct patient care (with the exception of MSW/LBSW/BSW/Chaplain) is required to perform vital signs to assess the patient's medical condition." 1) Patient #7 has a start of care date of 12/31/2020 with diagnoses Unspecified Dementia without behavioral disturbance, Atherosclerosis Heart Disease of Native Coronary Artery without Angina Pectoris, Essential (primary) Hypertension, Bradycardia, Difficulty in walking, and History of falling as documented in the "Home Health Certification and Plan of Care" from 12/31/2020 to 2/28/2021. The "Home Health Certification and Plan of Care" from 12/31/2020 to 2/28/2021 documents an Orders for "PT (Physical Therapy) effective 01/03/2021 1wk1 (1 x week for 1 week)"; "OT (Occupational Therapy) effective 01/03/2021 2wk4 (2 x week for 4 weeks)". The POC documents under the Orders of Disciplines and Treatments on page 2 to report physician: "Licensed Professional to report vital signs falling outside the following established parameters. Temp 100, Pulse100, Resp20, SystolicBP180 DiastolicBP100." The Initial OT evaluation conducted on 01/04/21 lacks baseline blood pressure reading. The OT visit note dated 01/07/21 lacks documented evidence of Temperature, Respiratory rate and pulse monitored by the OT. The OT visit notes dated 01/11/21 and 1/13/21 lack documented evidence of blood pressure monitored by the OT. 2) Patient #9 has a start of care date of 12/29/2020 with diagnoses Unspecified Fracture of humerus, left arm, Subsequent encounter for FX with routine heating, Atherosclerosis Heart Disease of Native Coronary Artery without Angina Pectoris, Essential (primary) Hypertension, Unspecified Atrial Fibrillation, and History of falling as documented in the "Home Health Certification and Plan of Care" fr the certification period 12/29/2020 to 2/26/2021". The "Home Health Certification and Plan of Care" for the certification period 12/29/2020 to 2/26/2021 documents an Orders for "PT 1wk1, 2wk3 (1 x week x 1 week, 2 x week for 3 weeks)", 1 every 2 weeks for 4 weeks; and OT 1 x week x 6 weeks. The POC documents under the Orders of Disciplines and Treatments on page 2 to report physician: "Licensed Professional to report vital signs falling outside the following established parameters. Temp 100, Pulse100, Resp20, SystolicBP180 DiastolicBP100." The Initial PT evaluation conducted on 12/30/20 lacks baseline Blood Pressure (BP) reading and temperature. The PT visit note dated 01/08/21 lacks documented evidence of blood pressure monitored by the PT. 3) Patient #11 has a start of care date of 12/19/2020 with diagnoses Atherosclerosis Heart Disease of Native Coronary Artery without Angina Pectoris, Hypertensive heart disease with heart failure, Unspecified systolic (Congestive) heart failure, and History of falling as documented in the "Home Health Certification and Plan of Care" from 12/19/2020 to 2/16/2021. The "Home Health Certification and Plan of Care" from the certification period 12/19/2020 to 2/16/2021 documents an Orders for PT 1wk1 (1 x week x 1), and OT 1wk1. The POC documents under the Orders of Disciplines and Treatments on page 2 to report physician: "Licensed Professional to report vital signs falling outside the following established parameters. Temp 100, Pulse100, Resp20, SystolicBP180 DiastolicBP100." An Interim order dated 12/21/20 orders: OT 1 x week x 5 weeks. An Interim order dated 12/22/20 orders: PT 2 week x 2 weeks, 1 x week x 2 weeks, 1 every 2 weeks x 2 weeks. The Initial OT evaluation conducted on 12/21/20 lacks baseline blood pressure, temperature, and pulse being monitored by the OT. The PT visit notes dated 12/28/20, 12/30/20, 1/04/21, and 1/14/21 lack documented evidence of blood pressure monitored by the PT. Survey findings were reviewed with the Director of Operations (DOO) on 01/22/21 at 4:30 PM. On 1/25/21 at 11:15 AM, the DOO acknowledged the findings. 4) Patient #12 HV has a start of care date of 01/03/21 with diagnoses of Essential Hypertension, Diabetes Mellitus and Osteoarthritis as documented in the "Home Health Certification and Plan of Care" from 01/03/2021 to 03/03/2021. The "Home Health Certification and Plan of Care" from 01/03/2021 to 03/03/2021 documents an order for "SN 2 wk 1, 1 wk 3 ( Skilled Nurse two visits a week for one week, one visit a week for three weeks)". SN for instructions of "Diabetic care to include administration of Diabetic Medication, Blood Glucose testing daily, Skilled Nurse to assess patient/caregiver ability to performed record Blood Glucose testing as ordered and report abnormal findings to the Physician, Skilled Nurse to report to Physician Blood Glucose readings greater than 285 and less than 85". The "Home Health Certification and Plan of Care" from 01/03/2021 to 03/03/2021 documents an order for "Insulin Degludec (U-100) 100 units/ml subcutaneous give 26 units daily". A Home Visit (HV) was conducted on 01/21/21 with the agency's Clinical Manager. During the HIV, the patient and caregiver stated: "I don't check Blood Glucose daily, I check every couple of months". The Clinical Manager reviewed the patient's Glucometer reading which reports a Blood Glucose of "87 tested 14 days ago". The patient and caregiver reports that Blood Glucose log is not maintained. The patient's Insulin vial documents "Insulin Degludec (U-100) 200 units/ml subcutaneous give 40 units daily". The Insulin filed date is "11/16/20". The "Visit Note" report dated 01/07/21, the Skilled Nurse (SN) documents the patients Blood Glucose range "100 - 300". The clinical record lacks documented evidence that the SN notified the Physician of the Blood Glucose reading greater than 285 as ordered by the Physician. The clinical record lacks documented evidence that the Skilled Nurse conformed with the Physician's Orders to instruct: Diabetic Medication, Insulin dosage, Blood Glucose testing daily, Blood Glucose parameters to notify the Physician. Survey findings were reviewed with the Director of Operations (DOO) on 01/22/21 at 10:00 AM and 04:00 PM. On 1/25/21 at 12:00 PM, the DOO acknowledged the findings. 5) Patient #16 has a start of care date of 01/04/21 with diagnoses of Pressure Ulcer of Sacral Region - Stage 2, Laceration of right lower leg, Laceration of left lower leg as documented in the "Home Health Certification and Plan of Care" from 04/28/2020 to 06/26/2020. The "Home Health Certification and Plan of Care" from 04/28/2020 to 06/26/2020 documents an order for "SN (Skilled Nurse) 2wk4" (two visits a week for four weeks. SN to perform wound care. The clinical record lacks documented evidence that the SN conducted 2 (two) visits a week for the week of 5/24/20 to 5/30/20 to perform wound care in accordance to the "Home Health Certification and Plan of Care". The survey findings were reviewed with the agency's DOO on 01/22/21 at 4:00 PM. On 01/25/21 at 1:00 PM, the DOO acknowledged the findings. 6) Patient #4 has a start of care date of 12/31/20 with diagnoses of Laceration without foreign body of right forearm, Laceration without foreign body of right lower leg, Parkinson's Disease, Diabetes Mellitus with Diabetic Neuropathy as documented in the "Home Health Certification and Plan of Care" from 12/31/2020 to 02/28/2021. The "Home Health Certification and Plan of Care" from 12/31/2020 to 02/28/2021 documents orders for "PT (Physical Therapy) 2wk3, 1wk1" (two visits a week for three weeks, one visit a week for one week). Licensed professionals to report vital signs falling outside the following established parameters Temp less 100, Pulse 100, Respiration 20, Systolic BP (Blood Pressure) 180, Diastolic BP 100". The Physical Therapy (PT) visit note dated 01/05/21 lacks documented evidence that the PT performed assessment of the patient's Blood Pressure as ordered by the Physician. The PT performed therapeutic exercise prior to assessment of the patient's Blood Pressure. Survey findings were reviewed with the Agency's DOO on 01/22/21 at 04:00 PM. On 1/25/21 at 12:00 PM, the DOO acknowledged the findings. 7) Patient #2 has a start of care date of 11/11/2020 with diagnoses Pressure-Induced Deep Tissue Damage of Left Heel, Pressure Ulcer of Left Ankle, Unstageable, and Hemiplegia following nontraumatic subarachnoid hemorrhage affecting left nondominant side as documented on the "Home Health Certification and Plan of Care" from 11/11/2020 to 01/09/2021. The "Home Health Certification and Plan of Care" from 11/11/2020 to 01/09/2021 documents "PT (Physical Therapy) effective 11/15/2020 1WK1 (one visit week one), 2WK2 (two visits per week for two weeks), 1EVERY2WK4 (one visit every two weeks for four weeks)" and "Licensed Professional to Report Vital Signs Falling Outside the Following Established Parameters. Temp 100 Pulse 100 Resp 20 Systolic 180 DiastolicBP 100 Pain >6". The Physical Therapy "Visit Note Report" dated 12/22/2020 and 01/08/2021 lacks documented evidence of the patients blood pressure. The survey findings were reviewed with the Agency's Director of Operations (DOO) on 01/22/2021 at 3:15 PM. On 01/25/2021 at 10:54 AM, the DOO acknowledged the findings. 8) Patient #10 has a start of care date of 12/09/2020 with diagnoses Pressure Ulcer of Right Heel, Stage 2, Fracture of Unspecified Park of Neck of Right Femur subsequent encounter for closed fracture with routine healing and Essential (Primary) Hypertension as documented on the "Home Health Certification and Plan of Care" from 12/09/2020 to 02/02/2021. The "Home Health Certification and Plan of Care" from 12/09/2020 to 02/02/2021 documents "PT (Physical Therapy) 1WK1 (one visit week one), 2WK4 (two visits per week for four weeks), 1WK3 (1 visit per week for three weeks)", "OT (Occupational Therapy) 1WK1 (one visit week one) 2WK3 (two visits per week for three weeks)" and "Licensed Professional to Report Vital Signs Falling Outside the Following Established Parameters. Temp 100 Pulse 100 Resp 20 Systolic 180 DiastolicBP 100". The OT "Visit Note Report" dated 12/21/2020, 12/23/2020, 01/02/2021, and 01/14/2021 lacks documented evidence of the patients blood pressure. The OT "Visit Note Report" dated 12/29/2020 lacks documented evidence of the patients respiratory rate, pulse and temperature. The OT "Visit Note Report" dated 12/30/2020 and 01/12/2021 lacks documented evidence of the patients blood pressure, respiratory rate, pulse, and temperature. The OT "Visit Note Report" dated 01/09/2021 lacks documented evidence of the patients blood pressure and temperature. The PT "Visit Note Report" dated 01/04/2021 lacks documented evidence of the patients patients blood pressure, respiratory rate, pulse, and temperature. The survey findings were reviewed with the Agency's Director of Operations (DOO) on 01/22/2021 at 3:15 PM. On 01/25/2021 at 10:57 AM, the DOO acknowledged the findings. 9) Patient #17 has a start of care date of 11/15/2019 with diagnoses Type 2 Diabetes Mellitus with Hyperglycemia, Unspecified Dementia without behavioral disturbance and Essential (Primary) Hypertension as documented on the "Home Health Certification and Plan of Care" from 11/15/2019 to 01/13/2019. The patient was discharged from the Agency on 01/04/2020. The "Home Health Certification and Plan of Care" from 11/15/2019 to 01/13/2019 documents "PT (Physical Therapy) Effective 11/17/2019 2Wk3 (two visits per week for three weeks), 1WK1 (one visit per week for one week)", "SN (Skilled Nurse) 1WK1, 2WK1, 1WK1", "Licensed Professional to Report Vital Signs Falling Outside the Following Established Parameters. Temp 100 Pulse 100 Resp 20 Systolic 180 DiastolicBP 100", and "Skilled Nurse to report to Physician blood glucose readings greater than 285 or less than 85". The LPN (Licensed Practical Nurse) "Visit Note Report" dated 11/19/2019 lacks documented evidence of the patients blood glucose value. The PT "Visit Note Report" dated 11/20/2019, 11/27/2019 and 12/02/2019 lacks documented evidence of the patients blood pressure. The PT "Visit Note Report" dated 11/18/2019 lacks documented evidence of the patients blood pressure, respiratory rate, pulse, and temperature. The survey findings were reviewed with the Agency's DOO on 01/22/2021 at 3:15 PM. On 01/25/2021 at 11:05 AM, the DOO acknowledged the findings.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on Clinical Record review and staff interview the Agency failed to ensure the coordination of care provided by the disciplines to ensure the integration of services, identification of patient needs and treatment continuity and effectiveness. This was evident in three (3) of seventeen (17) Clinical Records reviewed (Patient's #1, #7, and #14). Failure to integrate services to assure the identification of patient needs has the potential to affect treatment effectiveness and the coordination of care provided by all disciplines. The findings are: 1) Patient #14 has a start of care date of 11/05/2019 with diagnoses Hemiplegia following cerebral infarction affecting left nondominant side, Type 2 diabetes mellitus without complications, Essential (primary) Hypertension, Malignant neoplasm of unspecified site of left female breast, and Long term use of Insulin as documented in the "Home Health Certification and Plan of Care" from 11/5/2019 to 1/3/2020. The "Home Health Certification and Plan of Care" from 11/5/2019 to 1/3/2020 documents an Orders for "PT 1wk1 (Physical Therapy 1 x week for 1 week)", "2wk4 (2 x week for 4 weeks)", 1wk1. "SN 1wk1 (Skilled Nursing 1 x week for 1 week)". The Physical Theray visit note dated 11/12/19 documenting: Patient has pain on her toe, she hit it in the bathroom. The therapist assessed the wound as 'quite infected'. The patient has diabetes. The therapist will add nurse visit. The note further documents therapist communicated with the physician and the RN. The Clinical Record includes a "Client Coordination Note Report" order dated 11/14/2019 documenting discussion with the nurse from physician's office regarding the patient's Big Toe which looked infected and the addition of the nurse evaluation. The PT mentioned to the nurse at the physician's office that the patient is diabetic and she mentioned that she will set an appointment with the physician. The patient's wound was photographed and sent to the doctor with the consent from the patient and the POA. The Clinical Record includes a Skilled Nursing visit dated 11/18/2019 six (6) days after the PT communicated with the RN. RN documents in the narrative note: Patient has a reddened swolen right great toe. patient denies having any pain. RN instructed patient on the use of antibiotics, patient and private home health aide both verbalized understanding. The Agency failed to integrate services to assure the identification of patient needs by not conducting SN visit in a timely. Survey findings were reviewed with the Director of Operations (DOO) on 01/22/21 at 4:30 PM. On 1/25/21 at 11:45 AM, the DOO could not provide an explanation for delay in SN services for evaluation of big toe but stated: "the PT did his part". 2) Patient #7 has a start of care date of 12/31/2020 with diagnoses Unspecified Dementia without behavioral disturbance, AtherosclerosisHeart Disease of Native Coronary Artery without Angina Pectoris, Essential (primary) Hypertension, Bradycardia, Difficulty in walking, and History of falling as documented in the "Home Health Certification and Plan of Care" from 12/31/2020 to 2/28/2021. The RN OASIS (Outcome and Assessment Information Set) Admission on 12/31/20 documents: Patient noted with hematuria physician ordered to change Xarelto to 15 mg every other day and continue rest of the medications as ordered. Follow-up with physician on 1/5/21. The SN visit note 1/6/21 documents: spouse verbalized patient was seen by primary care physician on 1/5/21 and ordered to continue Xarelto 15 mg daily hematuria has subsided. On 1/9/21 the LPN (Licensed Practical Nurse) documents spouse reports no hematuria since patient has been home from hospital, which is inconsistent with the SN visit from initial 12/31/20. The SN failed to coordinate care with the LPN to ensure that the patient continued to maintain bleeding precautions with Xarelto. Survey findings were reviewed with the DOO on 01/22/21 at 4:30 PM. On 1/25/21 at 11:40 AM, the DOO acknowled the findings. 3) Patient #1 has a start of care date of 11/03/2020 with diagnoses Pressure Ulcer of Right Ankle, Stage 2, Encephalopathy, Unspecified, Alzheimer's Disease, Unspecified, and Anxiety Disorder, Unspecified as documented on the "Home Health Certification and Plan of Care" from 01/02/2021 to 03/02/2021. The "Home Health Certification and Plan of Care" from 11/03/2020 to 01/01/2021 documents "PT1WK1 (one visit week one), 2WK4 (two visits per week for four weeks), 1WK2 (one visit per week for two weeks); SN 3WK9 (three visits per week for nine weeks); OT 1WK1 (one visit week one)". The Physical Therapy "Visit Note Report" dated 11/20/2020 documents "Change to medication. Is on Docusate Sodium 100 MG BID (twice per day), Methenamine 1 G (gram) BID, Trazadone 50 MG Daily, ASA (Aspirin) 81 MG Daily" and "Not Applicable" in response to the "Care Coordination" query "Indicate if you communicated with Physician or other disciplines involved in this case:". The Physical Therapist failed to coordinate the care and integrate the change in medication across the disciplines. The survey findings were reviewed with the Agency's Director of Operations (DOO) on 01/22/2021 at 3:15 PM. On 01/25/2021 at 10:40 AM, the DOO acknowledged the findings.

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 Clinical Record review and staff interview, the agency failed to ensure an ongoing interdisciplinary assessment between skilled professionals that include periodic discussions among the team regarding the patient's health status and recommendations for the Plan of Care. This was evident for two (2) of seventeen (17) clinical records reviewed (Patient's #13 and #17 ). Failure to ensure of an ongoing interdisciplinary assessments and discussion of the patient's status, has the potential for negative patient outcomes. The findings are: 1) Patient #13 has a start of care date of 08/05/2019 with diagnoses Type 2 diabetes mellitus with foot ulcer, Non-Pressure Chronic ulcer of left heel and midfoot with fat layer exposed, acute embolism due to vascular thrombosis unspecified veins of right upper extremity, Type 2 Diabetes mellitus with diabetic chronic kidney disease, End stage renal disease, and dependence on renal dialysis as documented on the "Home Health Certification and Plan of Care" from 10/4/2019 to 12/2/2019. Pre-survey review of the agency's Potentially avoidable Event Patient Listing Report submission from 11/2019 to 10/2020 as reflected on the QIES (Quality Improvement and Evaluation System) Report revealed the patient was listed as having a Potentially Avoidable Event from 11/05/2019 to 12/25/2019 under the category of Emergent Care for Hypoglycemia/Hyperglycemia. The Skilled Nursing (SN) Visit Note dated 11/08/19 the LPN (Licensed Practical Nurse) documents under the Endocrine: "No problems identified". On 11/12/19, the agency was notified by the patient's x-wife "patient hospitalized". Transfer to an Inpatient facility dated 11/15/2019 documents: "Hypo/Hyperglycemia, Diabetic out of control". The patient has Resumption of Care episode with the agency on 12/2/19 and the Skilled Nurse documents: patient hospitalized due to Hypoglycemia, patient was refusing to eat. There is a lack of documented evidence the SN communicated with the interdisciplinary team regarding the patient's need for nutritional consultant. During interview on 1/19/2021 at 3:30 PM, the Director of Operations (DOO) were informed of the record review findings. On 1/25/21 at 12:30 PM the DOO provided no explanation except that the clinician will be coming into the office for counseling. 2) Patient #17 has a start of care date of 11/15/2019 with diagnoses Type 2 Diabetes Mellitus with Hyperglycemia, Unspecified Dementia without behavioral disturbance and Essential (Primary) Hypertension as documented on the "Home Health Certification and Plan of Care" from 11/15/2019 to 01/13/2019. The patient was discharged from the Agency on 01/04/2020. The "Home Health Certification and Plan of Care" from 11/15/2019 to 01/13/2019 documents "SN (Skilled Nurse) 1WK1, 2WK1, 1WK1", "ST (Speech Therapy) Effective 11/17/2019 1WK1 (one visit week one)", and "Nutritional Requirements: Diabetic, Low Sodium". A "Client Coordination Note Report" dated 11/22/2019 entered by the Speech Language Therapist documents "Patient currently on chopped foods and thin liquids via straw. Patient is tolerating safest and least restrictive diet." The LPN (Licensed Practical Nurse) "Visit Note Report" dated 12/10/19 documents the patient is on a "Regular Diet". The LPN failed to document the patients nutritional requirements based on ongoing interdisciplinary assessments. The survey findings were reviewed with the Agency's Director of Operations (DOO) on 01/22/2021 at 3:15 PM. On 01/25/2021 at 11:05 AM, the DOO acknowledged the findings.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on Clinical Record reviews and staff interview, the agency failed to ensure that ongoing communication with each patient's physician is maintained. This was evident for four (4) of seventeen (17) clinical records reviewed. (Patient's #1HV, #6, #15, and #17). Failure to ensure ongoing communication is maintained with each patient's physician has the potential for negative patient outcomes. The Findings are: 1) Patient #15 has a start of care date of 05/29/2020 with diagnoses Pressure Ulcer of sacral region, stage 2, Pressure Ulcer of left heel and right heel, unstageable, Hypertension heart disease with heart failure, unspecified dementia without behavioral disturbance, and unspecified Atrial Fibrillation as documented in the "Home Health Certification and Plan of Care" from 05/29/2020 to 07/27/2020. Pre-survey review of the agency's Potentially avoidable Event Report submission from 11/2019 to 10/2020 as reflected on the QIES (Quality Improvement and Evaluation System) Report revealed the patient was listed as having a Potentially Avoidable Event from 05/29/2020 to 08/01/2020 under the category of Increase in Number of Pressure Ulcers and Discharged to the Community with an Unhealed Stage II Pressure Ulcer. The SN Visit Note Report dated 07/17/20 the LPN (Licensed Practical Nurse) documents "Wound noted with purulent drainage and strong odor. Writer contacted and spoke to" agent of physician's office. "As per our conversation she will be sending over abt (antibiotics) for patient. Spouse and caregiver was given update." The SN Visit Note Report dated 7/20/20 documents "during wound care, patient's wounds noted with strong odor". The agent of physician's office ordered Doxycycline every 12 hours and is scheduled tomorrow to see patient. "Spouse administered first dose with writer present." There is no documented evidence of need to update/revision to the plan of care. Survey findings were reviewed with the Director of Operations (DOO) on 01/22/21 at 4:30 PM. On 01/25/21 at 11:45 AM the DOO acknowledged the findings and no further explanation was provided. 2) Patient #6 has a start of care date of 01/12/2021 with diagnoses Pressure Ulcer of left buttock, stage 2, age-related osteoporosis with current path fracture, vertebrae 7th, Essential (primary) hypertension, Chronic Obstructive Pulmonary Disease, and history of falling as documented in the "Home Health Certification and Plan of Care" from 01/12/2021 to 3/12/2021. The "Home Health Certification and Plan of Care" from 01/12/2021 to 3/12/2021 documents an order for "Skilled Nurse (SN) 2WK1, 1WK4 (2 x week x 1 week, 1 x week x 4 weeks) to assess evaluate and develop an individualized POC. "SN to observe and assess integumentary status to identify changes and intervene to minimize complications. Provide skilled teaching related to general wound care and skin care and prevention related to potential for actual altered skin integrity... Report significant changes in status to physician for early intervention." The "RN OASIS (Outcome and Assessment Information Set) Admission" dated 01/12/21 documents in the narrative note "rash like redness noted to left groin. SN placed call PCP (primary care physician)", "no answer and SN was unable to leave voice message , SN to F/U (follow-up)". The clinical record lacks documented evidence even thought the SN placed a call with the physician's office, the SN failed to follow-up with the physician's office and update the Plan of Care with interventions if any. On 01/22/21 at 4:30 PM the record was reviewed with the Agency's DOO. On 01/25/21 at 11:30 the DOO acknowledged the findings and provided no additional information. 3) Patient #1HV has a start of care date of 11/03/2020 with diagnoses Pressure Ulcer of Right Ankle, Stage 2, Encephalopathy, Unspecified, Alzheimer's Disease, Unspecified, and Anxiety Disorder, Unspecified as documented on the "Home Health Certification and Plan of Care" from 01/02/2021 to 03/02/2021. The "Home Health Certification and Plan of Care" from 11/03/2020 to 01/01/2021 documents "PT1WK1 (one visit week one), 2WK4 (two visits per week for four weeks), 1WK2 (one visit per week for two weeks)." The "Home Health Certification and Plan of Care" from 01/02/2021 to 03/02/2021 documents "Nutritional Requirements: 2G Sodium". The Clinical Record includes a "Physician Order" effective 01/14/2021 for Speech Language Therapy 1WK4 (one visit per week for four weeks). The Physical Therapy "Visit Note Report" dated 11/20/2020 documents "Change to medication. Is on Docusate Sodium 100 MG BID (twice per day), Methenamine 1 G (gram) BID, Trazadone 50 MG Daily, ASA (Aspirin) 81 MG Daily" and "Not Applicable" in response to the "Care Coordination" query "Indicate if you communicated with Physician or other disciplines involved in this case:". A Speech Language "Client Coordination Note Report" dated 01/15/2021 documents "Patient has been pocketing food during meals. Patient requires to be fed all meals. Recommend puree foods and thin liquids and use compensatory swallowing and feeding strategies including alternating between liquids and solids." A home visit was conducted on 01/19/2021 to observe the second Speech Language Therapy visit. The Speech Therapist explained to the Surveyor the need for the patient to intake pureed food related to pocketing. The Surveyor observed the patient being fed yogurt from the private hire aide. A medication reconciliation was conducted with the Speech Therapist and the patients son via facetime. The patients son states: Divalproex, Escitalopram and Risperidone were stopped "one month ago". Escitalopram 0.25 mg Tablet Daily was resumed one (1) week ago related to increased agitation. Docusate Sodium 50 mg Soft Gel in the AM and PM, Methenamine 1 gram PO BID (twice per day) for Chronic Urinary Tract Infection (most recent fill date 09/24/2020), and Trazadone 50 mg 1 Tablet at Bedtime (most recent fill date 12/20/2020). The Clinical Record lacks documented evidence the Speech Language Therapist communicated the recommendation for change in the patient's nutritional requirements to the patients physician. The Clinical Record lacks documented evidence the Physical Therapist communicated the change in medications to the patients physician. The survey findings were reviewed with the Agency's Director of Operations (DOO) on 01/22/2021 at 3:15 PM. On 01/25/2021 at 10:40 AM, the DOO acknowledged the findings. 4) Patient #17 has a start of care date of 11/15/2019 with diagnoses Type 2 Diabetes Mellitus with Hyperglycemia, Unspecified Dementia without behavioral disturbance and Essential (Primary) Hypertension as documented on the "Home Health Certification and Plan of Care" from 11/15/2019 to 01/13/2019. The patient was discharged from the Agency on 01/04/2020. The "Home Health Certification and Plan of Care" from 11/15/2019 to 01/13/2019 documents "SN (Skilled Nurse) 1WK1, 2WK1, 1WK1" and "Skilled Nurse to report to Physician blood glucose readings greater than 285 or less than 85". The SN "Visit Note Report" dated 12/18/2019 documents a "fasting blood sugar" value of 308. The SN documents in the narrative "Blood Sugar was 308 wife is aware. She administered insulin." The patient was discharged from Skilled Nursing services as of this visit, 12/18/2019. The Clinical Record lacks documented evidence the Skilled Nurse reported the blood glucose of 308 to the physician per the Plan of Care. The survey findings were reviewed with the Agency's DOO on 01/22/2021 at 3:15 PM. On 01/25/2021 at 11:05 AM, the DOO acknowledged the findings.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on Clinical Record review, policy and procedure review, current practice guidelines, and staff interview, the Agency failed to ensure services are provided in accordance with current clinical practice guidelines, accepted professional standards of practice and the Agency's policy and procedure. This was evident in two (2) of seventeen (17) Clinical Records reviewed (Patient's #2 and #16). Failure to ensure that the Agency follows accepted professional standards of practice has the potential for negative patient outcomes through delayed wound healing. The findings are: The Agency's policy and procedure "The Provision of Wound and Skin Care", WC-001, revised 09/2018 documents "In accordance with best practice and standard of care, wounds will be measured a minimum of one time a week, preferably on the first visit of the week, by the same nurse, utilizing the same tool and measurement terminology." 1) Patient #2 has a start of care date of 11/11/2020 with diagnoses Pressure-Induced Deep Tissue Damage of Left Heel, Pressure Ulcer of Left Ankle, Unstageable, and Hemiplegia following nontraumatic subarachnoid hemorrhage affecting left nondominant side as documented on the "Home Health Certification and Plan of Care" from 11/11/2020 to 01/09/2021. The "Home Health Certification and Plan of Care" from 11/11/2020 to 01/09/2021 documents "SN 2WK1 (2 visits week one), 3WK2 (3 visits a week for 2 weeks), 2WK6 (two visits a week for six weeks), 3 PRN (3 visits as needed) SN to perform/teach patient/caregiver pressure ulcer to left heel and left ankle irrigate/cleanse with normal saline, apply santyl to left ankle and medihoney to left heel may apply skin barrier to periwound prn to prevent maceration and protect periwound cover with dry sterile gauze secure with tape and kerlix change dressing 3 days a week and prn for 3 weeks. Patients wife will provide wound care on days nurse does not come." The "Home Health Certification and Plan of Care" from 01/10/2021 to 03/10/2021 documents "SN 3WK8 (three times a week for eight weeks), 2WK1 (two times a week for one week), 3PRN (3 visits as needed) SN to perform/teach wound care as follows: Cleanse pressure ulcer to ankle and ischium/buttocks with normal saline. Apply hydrogel, cover with dsg (dressing), followed by optifoam, secure with paper tape change dressing 3X (three times) weekly and prn (as needed) for dislodged dressing." The Clinical Record includes a physician order, dated 01/08/2021 to "cleanse bilateral heels with NS (normal saline) apply hydrogel cover with tegaderm heel dressings three times a week 1 PRN for soiled or dislodged dressing". The Clinical Record documents Wound #1 as Left proximal ankle, Wound #2 as Left proximal heel and Wound #3 as Right Ischium stage 2. The Clinical Record documents wound measurements for Wound #3 on 11/16/2020, 11/23/2020, 12/11/2020, 12/21/2020, 01/06/2021, and 01/11/2021. The Agency failed to ensure weekly measurements for Wound #3 between 11/23/2020 to 12/11/2020, 12/11/2020 to 12/21/2020, 12/21/2020 to 01/06/2021, and 01/11/2021 to 01/18/2021. The Clinical Record documents wound measurements for Wound #1 on 11/16/2020, 11/23/2020, 11/30/2020, 12/21/2020, 12/29/2020, 01/11/2021, and 01/18/2021. The Agency failed to ensure weekly measurements for Wound #1 between 11/30/2020 to 12/21/2020 and 12/29/2020 to 01/11/2021. The survey findings were reviewed with the Agency's Director of Operations (DOO) on 01/22/2021 at 3:15 PM. On 01/25/2021 at 10:54 AM, the DOO acknowledged the findings. 2) Patient #16 has a start of care date of 01/04/19 with diagnoses of Pressure Ulcer of Sacral Region - Stage 2, Laceration of right lower leg, Laceration of left lower leg as documented in the "Home Health Certification and Plan of Care from "04/28/20 to 06/26/20". The "Home Health Certification and Plan of Care" from 04/28/2020 to 06/26/2020 documents an order for "SN (Skilled Nurse) 2wk4" (two visits a week for four weeks. SN to perform wound care to the Coccyx, Right and Left Lower Extremity, Right and Left Heels. Change all wound care dressings 2x (two times) weekly". The Skilled Nurse (SN) visit notes dated 05/04/20, 05/18/20, 06/01/20 and 06/25/20 documents wound measurements. The SN visit reports dated 05/12/20, 05/14/20, 06/08/20, 06/11/20, 06/15/20, 06/18/20, 06/22/20 lacks documented evidence of wound care measurements. The Clinical Record lacks documented evidence that the SN performed weekly measurements of the patient's wounds in accordance to clinical practice guidelines and Agency's policy and procedures. The survey findings were reviewed with the agency's Director of Operations (DOO) on 01/22/21 at 4:00 PM. On 01/25/21 at 1:00 PM, the DOO acknowledged the findings.