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

A standard re-certification survey and focused COVID-19 infection control survey of Tender Loving Care, an Amedisys Company located at 3237 Route 112 Medford N.Y. 11763 was initiated on 03/28/2022 and exited 04/01/2022. Deficient practices were identified within high priority standards in Plan of Care resulting in a partial extended survey. The agency's active patient census as of 03/28/2022 is 598. Nineteen (19) clinical records were reviewed and are identified as Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, and #19. Five (5) Home Visit observations were conducted with patients #1, #2, #3, #4, and #5. Twelve (12) personnel records were reviewed and are identified as Employees #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11 and #12. Policies and procedures for Emergency Preparedness Plan, Health Commerce System, Home Care Registry, Criminal History Record Check, Home Care Covid 19 Infection Control, and Influenza Vaccination policy were reviewed. The agency's Patient Admission Packet and Patient Complaint log for the year 01/10/2021 through 03/07/2022 were reviewed. The agency's Quality Improvement meeting minutes were reviewed for 2021 and 2022. Pre-survey activities consisted of review on 03/23/2022 of the agency’s Health Commerce System account, Home Care Worker Registry, Criminal History Record Check. The Agency's OBQI Adverse Event Outcome Report was reviewed for the period of 01/21 through 12/2021. The agency’s Vice President and Clinical Manager were interviewed. The following Federal deficiencies are cited: G0536 - A Review of all current medications G0544 - Update of the Comprehensive Assessment G0574 - Plan of Care must include the following G0578 - Conformance with Physician Orders G0580 - Only as ordered by a Physician G0710 - Provide services in the Plan of Care G0808 - Onsite supervision every 14 days Criminal History Record Check R1020 - Responsibilities of Providers

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 Home Visit (HV) observation, clinical record review and staff interview, the Agency failed to ensure that the Registered Nurse reviewed all the patient’s current medications as ordered by the Physician. This is evident in one (1) of five (5) home visits conducted. (Patient #2HV). Failure to ensure that the Registered Nurse review all the patient's current medications, has the potential for negative patient outcome. 1) Patient #2 HV has a Start of Care (SOC) date of 02/15/2022 with the following diagnoses "Urinary Tract Infection, Myoclonus, Anoxic Brain Damage, Functional Quadriplegia" documented on the Home Health Certification and Plan of Care dated 02/15/2022 to 04/15/2022. The Home Health Certification and Plan of Care dated 02/15/2022 to 04/15/2022 documents: Divalproex 125 mg (milligram) Capsule, 3 capsules two times daily; Potassium Chloride ER (extended release) 10 mEq (milli Equivalent) Tablet, 2 tablet daily. On 3/30/2022 at 11:30am, a home visit was conducted and Patient's husband was interviewed, stating "These are the medications my wife is currently taking." The following was observed: Divalproex 125 mg capsules, 2 capsules in morning and 4 capsules at night with refill date of 2/27/2022; Potassium Chloride liquid 20mEq/15ml (milliliters), 7.5 ml daily with refill date of 2/9/2022. The Clients Calendar Report documents: SN (Skilled Nurse) visits on 2/19/2022, 2/22/2022, 3/3/2022, 3/8/2022, 3/22/2022, and 3/29/2022. There is no documented evidence that the RN reviewing all medications that the patient is currently using. On 03/31/2022 at 3:20pm, the Director of Patient Services and the Clinical Manager were interviewed and did not provide an explanation for the survey findings.

Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than- This STANDARD is not met as evidenced by: Based on Home Visit (HV) observation, clinical records review and staff interview, Governing Authority failed to ensure that patient's Comprehensive Assessments are updated based on changes in patient's conditions. This was evident in three (3) of nineteen (19) clinical records reviewed. (Patients #5HV, #16, and #17). Failure to update the Comprehensive Assessment, places patients at risk for unmet need. The findings include: 1) Patient #5HV has a Start of Care (SOC) date of 02/02/2022 with the following diagnoses "Type 2 Diabetes Mellitus with Foot Ulcer, Non-Pressure Chronic Ulcer of Right Heel, Low Back Pain, Essential Hypertension" documented on the "Home Health Certification and Plan of Care" dated 02/02/2022 to 04/02/2022. The "Home Health Certification and Plan of Care" dated 02/02/2022 to 04/02/2022 documents an order for “SN (Skilled Nurse) to perform/teach Diabetic Ulcer – Neuropathic care to Right Heel.” The "Visit Note Report" – OASIS (Outcome and Assessment Information Set) Admission dated 2/2/2022, the SN documents: “Wound # / Location / Type: Right Plantar Foot #1 Distal Plantar Right Diabetic Ulcer.” The Visit Note Report documents: Integumentary - Indicate Integumentary assessment findings: No problems identified; Wound Assessment - Right Plantar Foot: #1 Distal Plantar Right Diabetic Ulcer, wound assessed and treatment provided on the following dates 2/4/2022, 2/11/2022, 2/14/2022, 2/21/2022, 2/23/2022, 2/25/2022, 3/4/2022, 3/7/2022, 3/9/2022, 3/11/2022, 3/22/2022 to 3/27/2022, 3/29/2022, and 3/30/2022. On 03/31/2022 at 3:20pm, the Director of Patient Services was interviewed and stated, “This is the same site (Right Distal Plantar) and as shown in the picture it is clear that this is the Right Heel.” The comprehensive assessment lacks documented evidence of an accurate health status of the patient. There is no documented evidence that the comprehensive assessment was revised and updated to the patient's condition. On 03/31/2022 at 3:20pm, the Director of Patient Services and the Clinical Manager were interviewed and did not provide an explanation for the survey findings. 2) Patient #16 has a Start of Care date of 05/06/2021 and a discharge date of 12/2/2021 with the following diagnoses "Pressure Ulcer of Left Buttock, Stage 3; Encounter for Fitting and Adjustment of Urinary Device; Retention of Urine; Paraplegia" documented on the Home Health Certification and Plan of Care dated 11/02/2021 to 12/31/2021. The Visit Note Report RN (Registered Nurse) Discharge from Agency dated 12/2/2021 documents: “M1307 The Oldest Stage 2 Pressure Ulcer That is Present at Discharge (Post Edit Answer): 1-Was present at the most recent SOC/ROC (resumption of care). M1311 Current Number of Unhealed Pressure Ulcers/Injuries at Stage 2: 1.” On 03/31/2022 at 3:20pm, the Clinical Manager was interviewed and stated, “This was a wrong entry, Patient does not have a stage II pressure ulcer.” There is no documented evidence that the Patient have a Stage 2 Pressure Ulcer. The comprehensive assessment lacks documented evidence of an accurate health status of the patient, and that it was revised and updated to the patient's condition. On 03/31/2022 at 3:20pm, the Director of Patient Services and the Clinical Manager were interviewed and did not provide an explanation for the survey findings. 3) Patient #17 has a Start of Care date of 10/21/2021 and a discharge date of 11/9/2021 with the following diagnoses "Pressure Ulcer of Right Buttocks, Unstageable; Pressure Ulcer of Sacral Region, Stage 2; Abrasion of Right Forearm; Abrasion Left Forearm" documented on the Home Health Certification and Plan of Care dated 10/21/2021 to 12/19/2021. The Visit Note Report RN OASIS Admission dated 10/21/2022 documents: #5 Sacral Mid Pressure Ulcer Stage II; Granulation Tissue: 75-100%. The OASIS-D Guidance Manual dated 1/1/19 documents: "Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. Stage 2 (partial thickness) pressure ulcers heal through the process of regeneration of the epidermis across a wound surface, known as "re-epithelialization. Stage 3 and 4 (full thickness) pressure ulcers heal through a process of granulation (filling of the wound with connective/scar tissue)." There is no documented evidence of an accurate assessment of patient's status. (Stage II pressure ulcer with granulation). The Wound Record Report for Low Buttock Right Unstageable documents: Is this wound one of the following? SDTI (Suspected Deep Tissue Injury) on 10/26/2021, 10/28/2021, and 11/3/2021; and Other Wound Type on 10/27/2021, 10/29/2021, 11/1/2021, 11/5/2021,11/8/2021. Granulation: 75-100% on 10/27/2021, 11/1/2021, and 11/5/2021; and less than 75 and more than 25% on 10/29/2021 and 11/8/2021. Peripheral Tissue Edema: none on 10/26/2021 to 11/8/2021. Epithelialization: 50 to less than 75% on 10/27/2021, 11/5/2021, and 11/8/2021; 25 to less than 50% on 10/29/2021, and 75 to less than 100% on 11/1/2021. Necrotic Tissue Type and Amount; Undermining; and Tunneling: none from 10/26/2021 to 11/8/2021. Edge / Surrounding Tissue Maceration: Absent from 10/29/2021 to 11/8/2021. The OASIS-D Guidance Manual dated 1/1/19 documents: “Deep tissue injury which is defined as a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue.“ There is no documented evidence of an accurate assessment of the Right buttock as a Deep tissue injury on the patient's status. There is no documented evidence that the comprehensive assessment was revised and updated to the patient's condition. On 03/31/2022 at 3:20pm, the Director of Patient Services and the Clinical Manager were interviewed and did not provide an explanation for the survey findings.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record reviews and staff interview, the Agency failed to develop individualized patient Plans of Care for Licensed Practical Nurse services, Physical Therapy Assistant, Occupational Therapy Assistant and Durable Medical Equipment . This was evident in five (5) of nineteen (19) clinical records reviewed. (Patients #8, #9, #11, #13, and #14) Failure to develop individualized Plans of Care has the potential for negative patient outcomes. The findings include: 1) Patient #8 has a start of care date of 02/08/2022 with diagnoses of Hemiplegia following Cerebral Infarct affecting Right Dominant Side, Dysarthria, Dysphagia, Aphasia, Hypertensive Heart disease and Heart Failure as documented in the "Home Health Certification and Plan of Care" dated 02/08/2022. The "Home Health Certification and Plan of Care” from 02/08/2022 to 04/08/2022 documents an order for "SN (Skilled Nurse) 3wk1, 2wk1, 1wk1, 1 every 2 wks. (three visits for one week, two visits for two-week, one visit for one week, every other week for two weeks). "Skilled Nurse (SN) to assess, evaluate and develop individualized Plan of Care". The Home Health Certification and Plan of Care documents an order for PT (Physical Therapy) 1wk1, 2 wk2, 1 wk5 (one visit a week for one week, two visits a week for two weeks and one visit a week for five weeks". The SN "Visit Note Report" dated 02/08/2022 and the "PT Evaluation Report" dated 02/10/2022 documents the patient is using DME (Durable Medical Equipment) includes "wheelchair and walker". The Plan of Care date 02/08/2022 to 04/08/2022 lacks an order for the DME of wheelchair and walker. The agency failed to develop an individualized Plan of Care. The survey findings were reviewed with the agency Director of Patient Services (DPS) and Clinical Manger on (CM) 03/30/2022 at 03:45PM. The DPS and CM acknowledged the findings. . 2) Patient #9 has a start of care date of 02/22/2022 with diagnoses of Hemiplegia following Cerebral Infarct Affecting Right Dominant Side, Pressure Ulcer of Sacral Region, Chronic Kidney Disease as documented on the "Home Health Certification and Plan of Care” dated 02/22/2022. The "Home Health Certification and Plan of Care” from 02/22/2022 to 04/22/2022 documents an order for “SN (Skilled Nurse) 2wk1, 1wk8 (two visit a week for one week, one visits a week for eight weeks). "Skilled Nurse to assess, evaluate and develop individualized Plan of Care". The SN "Visit Note Report" dated 02/22/2022 and "PT Evaluation Report" dated 02/25/2022, documents the patient is using DME (Durable Medical Equipment) to include "wheelchair, bedside commode, shower chair, Hospital Bed and Hoyer Lift ". The Plan of Care lacks an order for the patient's DME of wheelchair, bedside commode, shower chair, Hospital Bed and Hoyer Lift. The agency failed to develop an individualized Plan of Care. The survey findings were reviewed with the agency Director of Patient Services (DPS) and Clinical Manger on (CM) 03/30/2022 at 03:45PM. The DPS and CM acknowledged the findings. . 3) Patient # 13 has a start of care date of 11/11/2021 with diagnoses of Encounter for Orthopedic Aftercare following surgery, Cellulitis of Right Lower Limb and Type 2 Diabetes Mellitus as documented on the "Home Health Certification and Plan of Care” dated 11/11/2021 to 01/09/2022. The "Home Health Certification and Plan of Care” from 11/11/2021 to 01/09/2022 documents an order for "SN (Skilled Nurse) 1wk1, 2wk8 (one visit first week, two visit a week for eight weeks). Skilled Nurse to "instruct Blood Glucose Testing BID (twice daily) and to report abnormal findings to Physician blood glucose readings greater than 400 or less than 60". The medications include "Humulin R U-500 units/ml (milliliter) subcutaneous once daily, and Insulin Lispro U-100 100 units/ml subcutaneous 3x (three times) daily with sliding SS (sliding scale) coverage as per MD order. The Home Health Certification and Plan of Care further documents and order for "Physical Therapy to evaluate for gait and balance". The Home Health Certification and Plan of Care lacks documentation of an order for Humulin R daily dosage, Insulin Lispro 3x day sliding scale dosage, and Blood Glucose parameters for the sliding scale Insulin administration. The agency failed to develop an individualized Plan of Care. The survey findings were reviewed with the agency Director of Patient Services (DPS) and Clinical Manger on (CM) 03/30/2022 at 03:45PM. The DPS and CM acknowledged the findings. 4) Patient #14 has a start of care date of 04/26/2018 with diagnoses of Type 2 Diabetes Mellitus with Foot Ulcer, Non-Pressure Chronic Ulcer of Right Foot and Venous Insufficiency as documented on the "Home Health Certification and Plan of Care" dated 08/08/2021 to 10/06/2021 . The patient was discharged from agency on 08/12/2021. The "Home Health Certification and Plan of Care" dated 08/08/2021 to 10/06/2021 documents an order for "SN (Skilled Nurse) 3wk8, 2wk1 (three visits a week for eight weeks, two visits a week for one week)". SN to "assess patient/caregiver ability to perform and record Blood Glucose Testing as ordered, and to report abnormal findings to Physician". The medications include: "Humalog 100 units/ml (milliliter) subcutaneous administer 5 units 3x daily before meals, Lantus Insulin 100 units/ml subcutaneous administer 30 units every HS (Hours of Sleep)". The Home Health Certification and Plan of Care lacks an order for the Blood Glucose Testing (BGT) frequency and the BGT parameters to report to the Physician. The agency failed to develop an individualized Plan of Care. The survey findings were reviewed with the agency Director of Patient Services (DPS) and Clinical Manger on (CM) 03/30/2022 at 03:45PM. The DPS and CM acknowledged the findings.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record reviews and interviews, the agency failed to ensure that Occupational Therapy (OT) and Speech Therapy (ST) are provided in accordance with the Physician's Orders. This was evident in two (2) of nineteen (19) clinical records reviewed. (Patients #8, #10) Failure to ensure that OT and ST services are provided in accordance with the Physician's Orders has the potential for negative patient outcomes. The findings include: . 1) Patient #8 has a start of care date of 02/08/2022 with diagnoses of Hemiplegia following Cerebral Infarct affecting Right Dominant Side, Dysarthria, Dysphagia, Aphasia, Hypertensive Heart disease and Heart Failure as documented in the "Home Health Certification and Plan of Care" dated 02/08/2022 to 04/08/2022. The consent for services dated 02/08/2022 documents the patient consent for proposed services of “OT (Occupational Therapy) 2x wk. (two visits a week). The "Home Health Certification and Plan of Care” period 02/08/2022 to 04/08/2022 documents an order for "Occupational Therapy to evaluate for ADL (Activities of Daily Living), and an order for "OT effective 03/06/2022 1 wk1". The "OT Evaluation” of the patient is dated 03/10/2022. The clinical record lacks documented evidence of the reason for delay in OT services and that the Physician was notified of the delay in OT evaluation. The agency failed to provide OT services in a timely manner in accordance with the Physician's Order. The survey findings were reviewed with the agency Director of Patient Services (DPS) and Clinical Manger on (CM) 03/30/2022 at 03:45PM. The DPS and CM acknowledged the findings. 2) Patient #10 has a start of care date of 02/17/2022 with diagnoses of Essential Hypertension, Traumatic Subdural Hemorrhage, Muscle Weakness and Dysphagia as documented on the "Home Health Certification and Plan of Care" dated 02/17/2022 to 04/17/2022. The "Home Health Certification and Plan of Care" dated 02/17/2022 to 04/17/2022 documents an order for ST (Speech Therapy) services 1 wk. 6 (one visit a week for six weeks). A supplemental "Physician Order" dated 03/02/22 documents "ST effective 02/27/22, 1 every 2wk2, 1 wk3" (one visits every two weeks for two weeks, then one visits a week for three weeks). The ST "Visit Note Reports" are dated 02/21/22, 03/03/22, 03/10/22, and 03/28/22. The clinical record lacks documented evidence of ST 1 every 2wk2, 1 wk3 as ordered by the Physician. The agency failed to provide ST services in accordance with the Physician's Order. The survey findings were reviewed with the agency Director of Patient Services (DPS) and Clinical Manger on (CM) 03/30/2022 at 03:45PM. The DPS and CM acknowledged the findings.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, the Agency failed to ensure that patient care treatments are administered as ordered by the Physician. This was evident in two (2) of nineteen (19) patient record reviewed. Patients #5 and #17. Failure to ensure that patient care treatments are administered as ordered by the Physician, has to potential for negative patient outcome. The findings include: . 1) Patient #5 has a Start of Care (SOC) date of 02/02/2022 with the following diagnoses "Type 2 Diabetes Mellitus with Foot Ulcer, Non-Pressure Chronic Ulcer of Right Heel, Low Back Pain, Essential Hypertension" documented on the Home Health Certification and Plan of Care dated 02/02/2022 to 04/02/2022. The Supplemental Order dated 3/23/2022 documents: “SN to perform/teach Diabetic Ulcer – Neuropathic care to Right Heel Unstageable Irrigate/cleanse with NSS (normal saline solution), pat dry with gauze, apple Hydrogel, cover with abdominal pad, wrap with Kling, secure with tape, follow by ace wrap.” The Wound Record Report documents: #1 Distal Plantar, Right Diabetic Ulcer treatment with Irrigated/cleansed with NSS, patted dry with gauze, Collagen Silver Plus applied, skin barrier applied to peri-wound area as needed to prevent skin maceration and protect peri-wound, gauze applied, covered with abdominal pad, wrapped with Kling, secured with tape, net stretch gauze applied on the following dates: 3/24/2022 to 3/27/2022, 3/29/2022, and 3/30/2022. There is no documented evidence that the treatment Hydrogel to Right Heel was administered as ordered by the physician. There is no documented evidence that treatments are administered as ordered by the physician. On 03/31/2022 at 3:20pm, the Director of Patient Services and the Clinical Manager were interviewed and did not provide an explanation for the survey findings. 2) Patient #17 has a Start of Care date of 10/21/2021 and a discharge date of 11/9/2021 with the following diagnoses "Pressure Ulcer of Right Buttocks, Unstageable; Pressure Ulcer of Sacral Region, Stage 2; Abrasion of Right Forearm; Abrasion Left Forearm" documented on the Home Health Certification and Plan of Care dated 10/21/2021 to 12/19/2021. The Home Health Certification and Plan of Care dated 10/21/2021 to 12/19/2021 documents: “Skilled Nurse to perform/teach patient/caregiver pressure ulcer care to Sacral region healing wound: Cleanse with Normal Saline, pat dry with gauze, apply Silver Alginate, cover with 4 x 4 and DCD (dry clean dressing) 2 times a week; Skilled Nurse to perform/teach patient/caregiver ulcer care to bilateral Forearm skin tear: Cleanse with Normal Saline, pat dry with gauze, apply Silver Alginate, cover with 4 x 4 and DCD (dry clean dressing) 2 times a week.” The Visit Note Report documents: 10/25/2021 Mid Forearm Right - Skin Tear and Sacral Mid Pressure Ulcer Stage II with Change in status: Inactivate Wound- Healed. 10/29/2021 Left Forearm Mid – Skin Tear with Change in status: Inactivate Wound- Healed. There is documented evidence that treatment for the Sacral pressure ulcer and the bilateral Forearm were discontinued from the plan of care when the wounds healed. The Supplemental Order documents: 10/22/2021: Cleanse reopen Unstageable Pressure Ulcer wound with Normal Saline, pat dry with gauze, apply Silver Alginate cut to the size of the wound. Cover with 4x4, Abdominal and dry clean dressing three times a week. 10/25/2021: Cleanse reopen Unstageable Pressure Ulcer wound with Normal Saline, pat dry with gauze, apply Silver Alginate cut to the size of the wound. Cover with 4x4, Abdominal and dry clean dressing daily times two weeks then three times a week. 10/29/2021: Cleanse reopen Unstageable Pressure Ulcer wound with Normal Saline, pat dry with gauze, loosely pack wound with Iodoform followed by Xeroform cover with 4x4, Abdominal and dry clean dressing three times a week. The Supplemental Order lacks documented evidence of the site of wounds. On 03/31/2022 at 3:20pm, the Director of Patient Services and the Clinical Manager were interviewed and did not provide an explanation for the survey findings.

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 Skilled Nursing services as ordered in the Plan of Care. This was evident in fourteen (14) of nineteen (19) clinical records reviewed. Patients #2, #4 #5, #6, #7, #8, #9, #11, #12, #13, #16, #17, #18 and #19. Failure to provide Skilled Nursing services as ordered in the Plan of Care, has the potential for negative patient outcome. The findings include: 9) Patient #2 has a Start of Care (SOC) date of 02/15/2022 with the following diagnoses "Urinary Tract Infection, Myoclonus, Anoxic Brain Damage, Functional Quadriplegia" documented on the Home Health Certification and Plan of Care dated 02/15/2022 to 04/15/2022. The Home Health Certification and Plan of Care dated 02/15/2022 to 04/15/2022 documents: SN (Skilled Nurse) 2WK1 (twice a week for one week), 1WK8 (once a week for eight weeks); Cardiovascular system: SN to assess and teach related to altered cardiovascular status to minimize complications and reduce hospitalization; Heart Failure: SN to assess cardiopulmonary system. The Clients Calendar Report documents: LPN (Licensed Practical Nurse) visits on 2/19/2022, 2/22/2022, 3/3/2022, 3/8/2022, 3/22/2022, and 3/29/2022. There is no documented evidence that the patient was assessed for cardiovascular on 2/19/2022, 2/22/2022, 3/3/2022, 3/8/2022, 3/22/2022, and 3/29/2022, assessment is outside the scope of practice for LPN. On 03/31/2022 at 3:20pm, the Director of Patient Services and the Clinical Manager were interviewed and did not provide an explanation for the survey findings. 10) Patient #5 has a Start of Care date of 02/02/2022 with the following diagnoses "Type 2 Diabetes Mellitus with Foot Ulcer, Non-Pressure Chronic Ulcer of Right Heel, Low Back Pain, Essential Hypertension" documented on the Home Health Certification and Plan of Care dated 02/02/2022 to 04/02/2022. The Home Health Certification and Plan of Care dated 02/02/2022 to 04/02/2022 documents: SN 2WK1 (twice a week for one week), 3WK4 (three times a week for four weeks); Cardiovascular system: SN to assess and teach related to altered cardiovascular status to minimize complications and reduce hospitalization. The Clients Calendar Report documents: LPN visits on 2/4/2022, 2/9/2022, 2/11/2022, 2/14/2022, 2/21/2022, 2/23/2022, 2/25/2022, 3/2/2022, 3/4/2022, 3/7/2022, 3/9/2022, 3/11/2022, 3/24/2022 to 3/27/2022, and 3/30/2022. There is no documented evidence that the patient was assessed for cardiovascular on 2/4/2022, 2/9/2022, 2/11/2022, 2/14/2022, 2/21/2022, 2/23/2022, 2/25/2022, 3/2/2022, 3/4/2022, 3/7/2022, 3/9/2022, 3/11/2022, 3/24/2022 to 3/27/2022, and 3/30/2022, assessment is outside the scope of practice for LPN. On 03/31/2022 at 3:20pm, the Director of Patient Services and the Clinical Manager were interviewed and did not provide an explanation for the survey findings. 11) Patient #6 has a Start of Care date of 02/12/2022 with the following diagnoses "Parkinson’s Disease, Repeated Falls, Pressure Ulcer of Right Heel" documented on the Home Health Certification and Plan of Care dated 02/12/2022 to 04/12/2022. The Home Health Certification and Plan of Care dated 02/12/2022 to 04/12/2022 documents: SN 1WK4 (once a week for four weeks); Cardiovascular system: SN to assess and teach related to altered cardiovascular status to minimize complications and reduce hospitalization. The Supplemental Order dated 3/7/2022 documents: SN effective 3/6/2022 1WK1 (once a week for one week). The Clients Calendar Report documents: LPN visits on 2/17/2022 and 3/11/2022. There is no documented evidence that the patient was assessed for cardiovascular 2/17/2022 and 3/11/2022, assessment is outside the scope of practice for LPN. On 03/30/2022 at 3:20pm, the Director of Patient Services and the Clinical Manager were interviewed and did not provide an explanation for the survey findings. 12) Patient #16 has a Start of Care date of 05/06/2021 and a discharge date of 12/2/2021 with the following diagnoses "Pressure Ulcer of Left Buttock, Stage 3; Encounter for Fitting and Adjustment of Urinary Device; Retention of Urine; Paraplegia" documented on the Home Health Certification and Plan of Care dated 11/02/2021 to 12/31/2021. The Home Health Certification and Plan of Care dated 11/02/2021 to 12/31/2021 documents: SN 1WK9 (once a week for nine weeks); Cardiovascular system: SN to assess and teach related to altered cardiovascular status to minimize complications and reduce hospitalization. The Clients Calendar Report documents: LPN visits on 11/4/2021, 11/8/2021, and 11/15/2021. There is no documented evidence that the patient was assessed for cardiovascular on 11/4/2021, 11/8/2021, and 11/15/2021, assessment is outside the scope of practice. On 03/30/2022 at 3:20pm, the Director of Patient Services and the Clinical Manager were interviewed and did not provide an explanation for the survey findings. 13) Patient #17 has a Start of Care date of 10/21/2021 and a discharge date of 11/9/2021 with the following diagnoses "Pressure Ulcer of Right Buttocks, Unstageable; Pressure Ulcer of Sacral Region, Stage 2; Abrasion of Right Forearm; Abrasion Left Forearm" documented on the Home Health Certification and Plan of Care dated 10/21/2021 to 12/19/2021. The Home Health Certification and Plan of Care dated 10/21/2021 to 12/19/2021 documents: SN 2WK1 (twice a week for one week), 7WK1 (seven times a week for one week), 2WK2 (twice a week for two weeks); Cardiovascular system: SN to assess and teach related to altered cardiovascular status to minimize complications and reduce hospitalization. The Clients Calendar Report documents: LPN visits on 10/24/2021, 10/26/2021, 10/27/2021, 10/28/2021, and 11/03/2021. There is no documented evidence that the patient was assessed for cardiovascular on 10/24/2021, 10/26/2021, 10/27/2021, 10/28/2021, and 11/03/2021, assessment is outside the scope of practice for LPN. On 03/30/2022 at 3:20pm, the Director of Patient Services and the Clinical Manager were interviewed and did not provide an explanation for the survey findings. 5) Patient #4 has a start of care date of 02/03/2022 with diagnoses of Parkinson’s Disease, Dementia, Congestive Heart Failure as documented on the Home Health Certification and Plan of Care for the Certification Period from 02/03/2022 to 04/03/2022. The Home Health Certification and Plan of Care for the Certification Period from 02/03/2022 to 04/03/2022 documents: “SN (Skilled Nurse) 1wk1, 2 wk4, 1wk4 (one visit a week for one week, two visits a week for four weeks, one visit a week for four weeks); Heart Failure: Skilled Nurse to assess Cardiopulmonary system to identify signs of decompensation and intervene to minimize the severity of fluid overload.” The clinical record documents LPN (Licensed Practical Nurse) visits on following dates: 02/08/2022, 02/11/2022, 02/15/2022, 02/18/2022, 02/23/2022, 02/25/2022, 02/28/2022, 03/04/2022, 03/08/2022, 03/17/2022, and 03/23/2022. The clinical record documents Registered Nurse visits on 02/03/2022, and 03/30/2022. Patient assessment is outside of service for LPN. There is no documented evidence of assessment of Cardiopulmonary System by Registered Nurse as ordered in Plan of Care. On 03/31/2022 at 3:30 pm, the Director of Patient Services, and the Clinical Manager were interviewed and did not provide an explanation for the survey findings. 6) Patient #7 has a start of care date of 08/04/2021 with diagnoses of Other Complications of Procedures, Congestive Heart Failure, Paroxysmal Atrial Fibrillation as documented on the Home Health Certification and Plan of Care for the Certification Period from 01/31/2022 to 03/31/2022. The Home Health Certification and Plan of Care for the Certification Period from 01/31/2022 to 03/31/2022 documents: “SN (Skilled Nursing) 3wk2, 1wk1 (three visits a week for two weeks, one visit a week for one week). Heart Failure: Skilled Nurse to assess Cardiopulmonary system to identify signs of decompensation and intervene to minimize the severity of fluid overload. Atrial fibrillation management: Skilled Nurse to assess/teach warning signs and symptoms to avoid hospitalization” The Supplemental Orders dated 02/04/2022 documents: “SN Effective 02/06/2022 4wk1 (four visits a week for one week), 3wk1 (three visits a week for one week), 4wk1, 3wk1, 4wk1, 3wk1, 4wk1, 2wk1 (two visit a week for one week)” The clinical record documents LPN (Licensed Practical Nurse) visits on following dates: 01/31/2022, 02/02/2022, 02/04/2022, 02/06/2022, 02/08/2022, 02/10/2022, 02/14/2022, 02/16/2022, 02/18/2022, 02/20/2022, 02/21/2022, 02/24/2022, 02/26/2022, 02/28/2022, 03/03/2022, 03/04/2022, 03/07/2022, 03/08/2022, 03/10/2022, 03/12/2022, 03/14/2022, 03/16/2022, 03/18/2022, 03/20/2022, 03/22/2022, 03/24/2022, and 03/26/2022. The clinical record documents Registered Nurse visits on 01/26/2022, and 03/28/2022. Patient assessment is outside of service for LPN. There is no documented evidence of assessment of Cardiopulmonary System by Registered Nurse as ordered in Plan of Care. On 03/31/2022 at 3:30 pm, the Director of Patient Services, and the Clinical Manager were interviewed and did not provide an explanation for the survey findings. 7) Patient #11 has a start of care date of 06/29/2021 with diagnoses of Diabetes Mellitus, Blister Left Foot, Congestive Heart Failure on the Home Health Certification and Plan of Care for the Certification Period from 02/24/2022 to 04/24/2022. The Home Health Certification and Plan of Care for the Certification Period from 02/24/2022 to 04/24/2022 documents: “SN (Skilled Nursing) 2wk1, 3wk4 (two visits a week for one week, three visits a week for four weeks). Heart Failure: Skilled Nurse to assess Cardiopulmonary system to identify signs of decompensation and intervene to minimize the severity of fluid overload.” The clinical record documents LPN (Licensed Practical Nurse) visits on following dates: 02/24/2022, 02/27/2022, 03/02/2022, 03/07/2022, 03/09/2022, 03/11/2022, 03/15/2022, 03/18/2022, and 03/21/2022. The clinical record documents Registered Nurse visits on 02/22/2022, and 03/04/2022. Patient assessment is outside of service for LPN. There is no documented evidence of assessment of Cardiopulmonary System by Registered Nurse as ordered in Plan of Care. On 03/30/2022 at 3:15 pm, the Director of Patient Services, and the Clinical Manager were interviewed and did not provide an explanation for the survey findings. 8) Patient #19 has a start of care date of 02/07/2022 with diagnoses of Orthostatic Hypotension, Chronic Atrial Fibrillation, Congestive Heart Failure on the Home Health Certification and Plan of Care for the Certification Period from 02/07/2022 to 04/07/2022. The Home Health Certification and Plan of Care for the Certification Period from 02/24/2022 to 04/24/2022 documents: “SN (Skilled Nursing) 2wk3, 1every2wk4 (two visits a week for three weeks, one visit every two weeks for four weeks); PT (Physical Therapy) 1wk6, 1every2wk2 (one visit a week for six weeks, one visit every two weeks for 2 weeks). Heart Failure: Skilled Nurse to assess Cardiopulmonary system to identify signs of decompensation and intervene to minimize the severity of fluid overload. ” The clinical record documents LPN (Licensed Practical Nurse) visits on following dates: 02/11/2022, 02/15/2022, and 02/20/2022. The clinical record documents Registered Nurse visits on 02/22/2022, and 03/04/2022. Patient assessment is outside of service for LPN. There is no documented evidence of assessment of Cardiopulmonary System by Registered Nurse as ordered in Plan of Care. On 04/01/2022 at 3:00 pm, the Director of Patient Services, and the Clinical Manager were interviewed and did not provide an explanation for the survey findings. . 1) Patient #8 has a start of care date of 02/08/2022 with diagnoses of Hemiplegia following Cerebral Infarct affecting Right Dominant Side, Dysarthria, Dysphagia, Aphasia, Hypertensive Heart disease and Heart Failure as documented in the "Home Health Certification and Plan of Care" dated 02/08/2022. The "Home Health Certification and Plan of Care” period 02/08/2022 to 04/08/2022 documents an order for "SN (Skilled Nurse) 3wk1, 2wk1, 1wk1, 1 every 2 wks. (three visits for one week, two visits for two-week, one visit for -one week, every other week for two weeks). Skilled Nurse (SN) to "assess, teach and monitor effectiveness of Anticoagulant therapy, SN to "assess Cardiopulmonary system to identify signs of decompensation and intervene to minimize severity of fluid overload". Hypertension management, SN to "assess/teach warning signs/symptoms to avoid hospitalization". Neurological system management, SN to assess and teach related altered neurological status to minimize complications and reduce hospitalization". The clinical record documents Skilled Nurse (SN)/Registered Nurse (RN) visits on the following dates : 02/08/22, 02/09/22 and 02/17/22 for patient assessment. The clinical record documents LPN (Licensed Practical Nurse) visits on the following dates: 02/11/22, 02/15/22, 02/24/22, 03/11/22, and 03/24/22 for patient assessment. Patient assessment is outside of nursing practice for LPN. The clinical record lacks document evidence that the agency provided a Registered Nurse service at the ordered frequency of 3wk1, 2wk1, 1wk1 to assess the patient's Anticoagulant therapy, Cardiopulmonary system, Neurological system as ordered in the Plan of Care. The agency failed to provide RN services as ordered in the Plan of Care. The survey findings were reviewed with the agency Director of Patient Services (DPS) and Clinical Manger on (CM) 03/30/2022 at 03:45PM. The DPS and CM acknowledged the findings. . 2) Patient #9 has a start of care date of 02/22/2022 with diagnoses of Hemiplegia following Cerebral Infarct Affecting Right Dominant Side, Pressure Ulcer of Sacral Region, Chronic Kidney Disease as documented on the "Home Health Certification and Plan of Care” dated 02/22/2022. The "Home Health Certification and Plan of Care” from 02/22/2022 to 04/22/2022 documents an order for “SN (Skilled Nurse) 2wk1, 1wk8 (two visit a week for one week, one visits a week for eight weeks). SN to "assess Hypertension management; assess/teach warning signs/symptoms to avoid hospitalization". SN to "assess Integumentary status to identify changes and intervene to minimize complications”, SN to "assess Integumentary status related to Pressure Injury”, SN to "assess and provide education on Pain management techniques". The clinical record documents Skilled Nurse (SN)/Registered Nurse (RN) visits on the following on 02/22/22 for patient assessment. The clinical record documents LPN visits on the following dates: 02/24/22, 03/01/22, 03/08/22, 03/17/22, and 03/24/22 for patient assessment. Patient assessment is outside of nursing practice for LPN. The clinical record lacks document evidence of RN service at the ordered frequency of 2wk1, 1wk8 to assess the patient's Hypertension management, Integumentary status, and Pain management. The agency failed to provide RN services as ordered in the Plan of Care. . 3) Patient # 13 has a start of care date of 11/11/2021 with diagnoses of Encounter for Orthopedic Aftercare following surgery, Cellulitis of Right Lower Limb and Type 2 Diabetes Mellitus as documented on the "Home Health Certification and Plan of Care” dated 11/11/2021. The "Home Health Certification and Plan of Care” period 11/11/2021 to 01/09/2022 documents an order for "SN (Skilled Nurse) 1wk1, 2wk8 (one visit first week, two visit a week for eight weeks). Skilled Nurse (SN) to "assess and teach related to altered Cardiovascular status to minimize complications and reduce hospitalization; Hypertension management: SN to" assess/teach warning signs and symptoms to avoid hospitalization"; SN to "assess and instruct patient/caregiver on interventions to improve Nutritional Intake". The clinical record documents Skilled Nurse (SN)/Registered Nurse (RN) visits on the following dates: 11/11/21, 11/16/21, 11/24/21, and 12/07/21 for patient assessment. The clinical record documents LPN visits on the following dates: 11/24/21, 11/26/21, 12/02/21, 12/04/21, 12/10/21, 12/14/21, and 12/24/22 for patient assessment. Patient assessment is outside of nursing practice for LPN. The clinical record lacks documented evidence that Registered Nurse services are provided 2wk8 to assess the patient's Cardiovascular status, Hypertension management, and Nutritional intake as ordered in the Home Health Certification and Plan of Care. The agency failed to provide RN services as ordered in the Plan of Care. The survey findings were reviewed with the agency Director of Patient Services (DPS) and Clinical Manger on (CM) 03/30/2022 at 03:45PM. The DPS and CM acknowledged the findings. . 4) Patient #12 has a start of care date of 02/23/2022 with diagnoses of Permanent Atrial Fibrillation, Encounter for Surgical Aftercare following Circulatory systems, Presence of Cardiac Pacemaker as documented on "Home Health Certification and Plan of Care” dated 02/23/2022 to 04/23/2022. The "Home Health Certification and Plan of Care” dated 02/23/2022 to 04/23/2022 documents an order for SN (Skilled Nurse) 1wk1, 2wk1, 1wk3, 1every2wk4 (one visit first week, two visits a week second week, one visit a week for three weeks, one visit every other week for four weeks). SN to "assess and teach related to altered Cardiovascular status to minimize complications and reduce hospitalization; Hypertension management: SN to" assess/teach warning signs and symptoms to avoid hospitalization"; Atrial Fibrillation management: SN to "assess /teach warning signs and symptoms to avoid hospitalization". The clinical record documents LPN (Licensed Practical Nurse) visits on the following dates: 03/06/22, 03/13/22, and 03/20/22 for patient assessment. The clinical record lacks documented evidence that Registered Nurse services are provided to assess the patient's Cardiovascular status, Hypertension and Atrial Fibrillation management. The agency failed to provide RN services as ordered in the Plan of Care. The survey findings were reviewed with the agency Director of Patient Services (DPS) and Clinical Manger on (CM) 03/30/2022 at 03:45PM. The DPS and CM acknowledged the findings.