Every finding on record at Tri-Borough Certified Health Systems of New York, LLC

The statement of deficiency is as a result of a Federal Recertification Survey conducted on February 24th to February 27th, 2025, to determine agency’s compliance with the applicable Federal, State and local emergency preparedness requirements. The agency's Emergency Preparedness Plan, policies and procedures, the emergency patient roster, and staff call down list were reviewed. Interviews were conducted with the Administrator/Director of Patient Services on 02/26/2025. The following deficiencies are being cited as a result of the survey: E0019-Policies and Procedures of Risk Assessment. E0021-Home Health Agency’s Procedures for Follow-ups. E0024-Policies and Procedures for Volunteers. E0030-Names and Contact Information. E0034-Sharing Information on Occupancy/Needs. E0036-Emergency Prep Training and Testing. E-0039-Emergency Prep Testing Requirements. J-1426-Personnel. J-1156 Governing Authority.

Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment. This STANDARD is not met as evidenced by: Based on policy review and staff interview, the Governing Authority failed to develop a comprehensive Emergency Preparedness Program. This was evident in review of the “Emergency and Disaster Preparedness Plan” and active Patient Roster. Failure to develop a comprehensive Emergency Preparedness Plan, has the potential for negative patient outcomes. 1). The agency’s policy and procedure titled, "Emergency and disaster Preparedness Plan" lacks a procedure to inform State and local emergency preparedness officials about patients in need of evacuation from their homes. 2). The patient classification roster is incomplete and did not include evacuation plans for patients in need of ventilators, oxygen, communication challenges, language barriers and special needs. The findings were reviewed on 02/26/2025 at 3:35 PM with the Director of Patient Services. Interview and findings were conducted on 2/27/2025 at 12:00PM with the Director of Patient Services. No other documents were provided.

HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This STANDARD is not met as evidenced by: Based on policy review and staff interview, the agency failed to develop a comprehensive Emergency Plan that includes procedures necessary to inform State and local officials of patients and staff location. This was evident in review of the Emergency Preparedness Plan. Failure to develop procedures to inform States/local officials of patient/staff location, has the potential for negative patient outcomes. Findings are: Review of the agency's policy entitled "Emergency and Disaster Preparedness Plan" lack documented evidence of how-to follow-up with patients to determine services needed in the event there is service interruption in an emergency. The emergency plan did not include procedures needed to inform State and local officials when on-duty staff or patients could not be located in an actual emergency. The findings were reviewed on 02/26/2025 at 3:40 PM with the Director of Patient Services. Interview and findings were conducted on 2/27/2025 at 12:20PM with the Director of Patient Services. No other documents were provided.

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: Based on policy review and staff interview, the agency failed to develop a comprehensive Emergency policy that includes use of volunteers and other contingencies. This was evident in review of the "Emergency and Disaster Preparedness Plan" and policy. Failure to ensure the development of a comprehensive emergency policy and plan that includes procedures for volunteers, has the potential for negative patient outcomes. The Findings Are: The emergency and disaster preparedness policy lack documented evidence of the role of volunteers or address surge increase in an actual emergency. The agency’s emergency plan failed to include strategies for staff and documentation of staff call-down lists. Interview and findings were conducted on 2/27/2025 at 12:20PM with the Director of Patient Services. No other documents were provided.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based record review and staff interviews, the Agency failed to develop a comprehensive Emergency Preparedness Plan. This was evident in review of the Emergency and Disaster Preparedness Plan revised July 2024. Failure to develop a comprehensive Emergency Preparedness Plan, has the potential for negative patient outcomes. Findings: The agency’s Emergency and Disaster Preparedness Plan revised July 2024 did not include names and contact information of staff, entities providing services under arrangements, patients physicians, and volunteers. The Director of Patient Services was interviewed on 02//26/2025 at 3:30PM and findings were reviewed. No explanation was provided.

Information on Occupancy/Needs CFR(s): 484.102(c)(6) §403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.542(c)(7), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (7) [(5) or (6)] A means of providing information about the [facility's] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice's inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. This STANDARD is not met as evidenced by: Based on policy review and staff interview, the Agency failed to develop an Emergency Communication plan that complies with Federal, State, and local laws. This was evident in review of the "Emergency and Disaster Preparedness Plan", revised July 2024 Failure to develop an Emergency Communication plan, has the potential for negative patient outcomes. Findings: The Emergency and Disaster Preparedness Plan, revised July 2024 did not include: A communication plan that includes means to providing information to the State. A means of providing information about the occupancy, needs, and its ability to aid the authority having jurisdiction, the Incident Command Center, or designee. Interview and findings were conducted on 2/27/2025 at 12:20PM with the Director of Patient Services. No other documents were provided.

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based on record review and staff interview, the agency failed to conduct emergency training and testing program that reflects risks. This was evident in the review of the agency’s Emergency and Disaster Preparedness plan. Failure to conduct testing and training program, has the potential for negative patient outcomes. The findings are: The agency’s “Emergency and Disaster Preparedness Plan revised 7/24 lacked documented evidence of a communication plan, identified risks, analysis, training, testing program and drills. There is no documented evidence that the agency conducted training and testing on how agency will communicate closure, patient tracking and agency-wide risk assessment for the year 2023 and 2024. The findings were reviewed with the Director of Patient Services on 2/27/2024 at 4:00PM. No explanation was provided.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on record review and staff, interview the agency failed to participate in a full-scale community-based exercise to test the emergency plan. This was evident in the review of the “Emergency and Disaster Preparedness Plan.” Failure to ensure exercises were conducted as required has the potential for negative patient outcomes. Findings: The Emergency and Disaster Preparedness Plan, revised July 2024 did not include the following elements: 1). Participation in an annual full-scale exercise that is community based, and agency based. 2). Failed to conduct a second full scale exercise that is community based or agency based. 3). Failed to facilitate a clinically relevant emergency scenario table-top exercise with agency staff. There is no documented evidence of the agency conducted two drills for the year 2023 and 2024. Findings and interview were conducted with the Director of Patient Services on 02/26/2025 at 2:00PM. No additional documents were provided.

The following statement of deficiencies represents the results of a partial extended re-certification survey of Family Care Services, a Certified Home Health Agency located at 50 Clinton Street Hempstead, NY 11550 was conducted on 02/24/2025 through 02/27/2025. A standard re-certification survey was initiated on 02/24/2025. Deficient practices were identified within Level 1 standards in 484.60 Care Planning, Coordination, and Quality Care resulting in a partial extended survey. The survey consisted of a review of 8 clinical records including 2 discharge records, 10 personnel records for professional services, 3 contracts, and 3 observational home visits. The survey included a review of pertinent policies and procedures, Quality Improvement Meeting minutes for the past 12 months, agency’s Admission Packet, the Emergency Preparedness Plan, and Complaint Log. Pre-survey activities consisted of review on 02/20/2025 of the agency’s Health Commerce System account, Home Care Worker Registry, Criminal History Record Check, Certification and Survey Provider Enhanced Reports (CASPER) for the period 12/2023 to 11/2024, and the agency’s compliance with report submissions for the 2022 and 2023 statistical report and the Emergency Drill conducted 06/11/2019 through 06/13/2019. The agency's unduplicated patient count of 171 and active patient census of 25. The Director of Patient Services and Clinical Manager were interviewed. Findings were reviewed at the exit conference on 02/27/2025. The following deficiencies are identified as a result of the survey: Federal Emergency Preparedness regulations: E0019 - Homebound Home Health Agency E0021 - Home Health Agency procedures for follow-up staff/pts E0024 - Policies and Procedures E0030 – Names and Contact E0034 – Information on Occupancy E0036, E0039 – EP Training and Testing Home Health Agency regulations: G0372 - Encoding and Transmitting OASIS G0436 – Receives all services in the Plan of Care G0514 - Registered Nurse Performs Assessments G0572 – Receives services per the Plan of Care G0574 – Plan of Care must include G0580 - Conformance with Physicians Orders G0590 - Promptly Alert Relevant Physician of Changes G0642 - Program Scope G0644 - Program Data G0646 - Program Activities G0660 - Executive Responsibilities G0684 – Infection Control G0728 - Rehabilitation Services supervised by PT, OT G1012 – Required Items in clinical record State regulations: J1426 - Personnel

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on record review and staff interview, the Agency failed to ensure that Outcome and Assessment Information Set (OASIS) data was transmitted to the Centers for Medicare and Medicaid System (CMS) within thirty (30) days. This was evident for one (1) of eight (8) clinical records and the OASIS submittal error report (Patient #8). Failure to ensure transmittal of OASIS data within thirty (30) days, has the potential for negative patient outcomes. 1) Patient #8 has a start of care date of 11/07/2024. The initial "OASIS Nursing Services SOC (Start of Care)" assessment is dated 11/07/2024. The agency's "OASIS Status Report" documents a submittal date/export date of 01/03/2025. The "OASIS Transfer Non-visit" to in-patient facility assessment is dated 11/15/2024. The agency's "OASIS Status Report" documents a submittal date/export date of 01/03/2025. The "OASIS Nursing Services ROC (Resumption of Care) assessment is dated 11/22/2024. The agency's "OASIS Status Report" documents a submittal date/export date of 01/03/2025. The Agency did not submit the OASIS within thirty (30) days of completing the OASIS assessment. 2) The “Home Health Agency Error” report dated 02/18/2025 documents the agency late OASIS submittal rate of 95.9% (235) of records submitted greater than thirty (30) days from the Oasis completion and start of care date. 3) The agency’s “OASIS Status Report” dated 01/01/2025 – 02/25/25 documents six (6) Oasis assessments submitted greater than thirty (30) days. The Agency did not electronically transmit each completed OASIS assessment to the CMS system within thirty (30) days of completing the assessment. An interview was conducted with the Director of Patient Services and Clinical Nurse Manager on 02/26/2025 at 02:45 PM. No explanation was provided. The survey findings were reviewed on 02/27/2025 at 04:30 PM with the Director of Patient Services and Clinical Manager.

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, the Agency failed to obtain consent that includes all services ordered in the Plan of Care. This was evident in one (1) of eight (8) records reviewed. (Patient #4). Failure to obtain consent for all services ordered in the Plan of Care, has the potential for negative patient outcome. 1) Patient #4 has a start of care date 01/20/2025 with diagnoses of "Covid-19, Generalized Epilepsy, Atrial Fibrillation, Heart Failure, Hypothyroidism, Unspecified Fall, Hyperlipidemia and Transient Ischemic Attack" as documented on the "Home Health Certification and Plan of Care" for certification period 01/20/2025 to 03/20/2025. The "Home Health Certification and Plan of Care" for certification period 01/20/2025 to 03/20/2025 documents "PT/PTD/PTA (Physical Therapy/Physical Therapy Doctor/Physical Therapy Assistance)" for 2x week for 3 weeks, 2x week for 4 weeks, 2 PRN visits (two visits a week for three weeks, two visits a week for four weeks, two as needed visits), and "RN/DNP/LVN (Registered Nurse, Doctor Nurse Practitioner, Licensed Vocational Nurse) 1x week for 1 week, 1x week for 1 week, 2x weeks for 1 week, 2 PRN visits (one visit a week for two weeks, two visits a week for one week, two as needed visits). The "Consent to Provide Care" form dated 01/20/2025 lacks documentation of the Physical Therapy and Skilled Nurse services ordered in the Plan of Care. Interview conducted with the Clinical Manager on 02/27/2025 at 01:00 PM, the Clinical Manager did not give an explanation. The survey findings were reviewed on 02/27/2025 at 04:30 PM with the Director of Patient Services and Clinical Manager.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, the Agency failed to ensure the Registered Nurse perform the initial patient assessment within forty-eight (48) hours of referral and/or return home from facility. This was evident in one (1) of eight (8) records reviewed. (Patient #4). Failure to ensure that the Registered Nurse perform an initial assessment within forty-eight (48) hours of referral and/or return home from facility, has the potential for negative patient outcome. 1) Patient #4 has a start of care date 01/20/2025 with diagnoses of "Covid-19, Generalized Epilepsy, Atrial Fibrillation, Heart Failure, Hypothyroidism, Unspecified Fall, Hyperlipidemia and Transient Ischemic Attack" as documented on the "Home Health Certification and Plan of Care" for certification period 01/20/2025 to 03/20/2025. The referral for services is dated 01/16/2025 for Physical Therapy and Registered Nurse services. The in-patient hospital discharge date is 01/17/2025. The Registered Nurse initial assessment visit to determine the immediate care of the patient is dated 01/20/2025. The "Home Health Certification and Plan of Care" for certification period 01/20/2025 to 03/20/2025 documents "PT/PTD/PTA (Physical Therapy/Physical Therapy Doctor/Physical Therapy Assistance)" for 2x week for 3 weeks, 2x week for 4 weeks, 2 PRN visits (two visits a week for three weeks, two visits a week for four weeks, two as needed visits), and "RN/DNP/LVN (Registered Nurse, Doctor Nurse Practitioner, Licensed Vocational Nurse) 1x week for 1 week, 1x week for 1 week, 2x weeks for 1 week, 2 PRN visits (one visit a week for two weeks, two visits a week for one week, two as needed visits). The Agency did not conduct an initial Registered Nurse assessment within forty-eight (48) hours of referral and return home from hospital. Interview conducted with the Clinical Manager on 02/27/2025 at 01:00 PM, the Clinical Manager did not give an explanation. The survey findings were reviewed on 02/27/2025 at 04:30 PM with the Director of Patient Services and Clinical Manager.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: (1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based of clinical record review and staff interview, the Agency failed to ensure that comprehensive assessments include all pertinent current health status and past medical history. This was evident in two (2) of eight (8) patient records reviewed (Patients #5 and #6). Failure to ensure that comprehensive assessments include all current medical conditions and past medical history, has the potential for negative patient outcomes. 2) Patient #6 has a start of care date of 12/16/2024 with diagnoses of “Pneumonia, Hypertensive Heart, Chronic Kidney Disease with Heart Failure, Stage 1-4 Chronic Kidney Disease, Hyperlipidemia, and Chronic Obstructive Pulmonary Disease” as documented on the “Home Health Certification and Plan of Care” for the certification period of 12/23/2024 to 02/20/2025. The patient has a discharge date of 02/20/2025. The “Home Health Certification and Plan of Care” for certification period of 12/23/2024 to 02/20/2025 documents orders for “RN/DNP/LVN (Registered Nurse/Doctor of Nursing Practice/License Vocational Nurse) 2 PRN visits, 1x week for 1 week, 1x week for 6 weeks (two as needed visits for one week, one visit per week for one week, one visit per week for six weeks)”, and “PT/PTD/PTA (Physical Therapy/Doctor/Physical Therapy Assistant) 2 PRN visit, 1x week for 1 week, 2x week for 4 weeks, 1 x week for 1 week, 2x week for 2 weeks (two visits as needed, one visit per week for one week, two visits per week times four weeks, one visit per week for one week, and two visit for two weeks)”. The “Start of Care Nursing OASIS” dated 12/23/2024 document “patient history of cardiovascular heart disease and chronic obstructive pulmonary disease. Patient instructed on signs and symptoms to report and weigh gain, patient has a scale, and actual weight is 144 pounds at time of visit. Nurse noted 1+ pitting edema noted to lower extremities”. The “Physical Therapy Evaluation and Care Plan” dated 12/23/2024 documents “bilateral lower extremity edema, nursing will monitor. Patient instructed to elevate leg two times for fifteen minutes each, documents patient weight 165 pounds”. The “Physical Therapy Evaluation Reassessment” dated 01/25/2025 documents “patient’s reported weigh as 165 pounds”. The “Skilled Nursing Discharge Summary” dated 02/03/2025 documents “patient actual weigh as 142 pounds”. The comprehensive assessments lack documented evidence of the patient’s accurate and consistent weight. The weights documented range from 142 pounds to 165 pounds. Significant weight gain/loss could cause major health implications related to the patient’s diagnoses of Heart Failure, Chronic Kidney Disease and Chronic Obstructive Pulmonary Disease. Interview conducted with the Director of Patient services and Clinical Manger on 02/26/2025 at 3.30pm and survey findings were reviewed on 02/27/2025 at 04:30 PM with the Director of Patient Services and Clinical Manager. 1) Patient #5 has a start of care date of 01/08/2025 with diagnoses of "Essential Primary Hypertension, Hyperlipidemia, Hypothyroidism, Anxiety Disorder and Gastro-Esophageal Reflux Disease" as documented on the "Home Health Certification and Plan of Care" for certification period 01/08/2025 - 03/08/2025. The "Home Health Certification and Plan of Care" for certification period 01/08/2025 - 03/08/2025 documents an order for "PT/PTD/PTA (Physical Therapy/Physical Therapy Doctor/Physical Therapy Assistance)" for 2x week for 7 weeks, 2 PRN visits (two visits as week for seven weeks, two as needed visits)", and RN/DNP/LVN (Registered Nurse, Doctor Nurse Practitioner, Licensed Vocational Nurse) 1x week for 7 weeks, 2x week for 1 week, 2 PRN visits (one visit a week for seven weeks, two visits a week for one week and two as needed visits)". Skilled Nurse to "assess/instruct/reinstruct on Cardiovascular status". Skilled Nurse to "assess/instruct/reinstruct patient/caregiver on cardiovascular disease management/complications and appropriate interventions". Skilled Nurse to "assess/instruct/reinstruct patient Urinary status and signs/symptoms of infection". Skilled Nurse to "assess Musculoskeletal" status. The Registered Nurse performed the initial patient assessment on 01/08/2025. The "Oasis Nursing Services Start of Care" patient assessment report dated 01/08/2025 lack documented evidence of a Cardiovascular assessment. The "Cardiac History" section is blank - no documentation of the patient's history of Hypertension and Hyperlipidemia. The "Urinary" system assessment section documents "Urinary Tract Infection" past 14 days - yes. There is no documented evidence that Urinary Tract Infection as a pertinent diagnosis on the current Plan of Care. The "Musculoskeletal" system assessment section is blank - no documentation of an assessment of the patient's functional limitations, ambulation and endurance as ordered in the Plan of Care. The comprehensive assessment does not accurately reflect the patient's current health status and functional capacity in accordance with the Plan of Care. Interview was conducted with the Director of Patient Services on 02/25/2025 at 04:35 PM, no explanation was provided. The survey findings were reviewed on 02/27/2025 at 04:30 PM with the Director of Patient Services and Clinical Manager.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on clinical record review and staff interview, the Agency failed to provide Physical Therapy services, Registered Nurse services, and patient care treatments are provided in accordance with the Plan of Care. This was evident in three (3) of eight (8) records reviewed (Patients #4, #6 and #7). Failure to provide Physical Therapy, Registered Nurse services and treatments, has the potential for negative patient outcomes. 2) Patient #6 has a start of care date of 12/16/2024 with diagnoses of “Pneumonia, Hypertensive Heart, Chronic Kidney Disease with Heart Failure, Stage 1-4 Chronic Kidney Disease, Hyperlipidemia, and Chronic Obstructive Pulmonary Disease” as documented on the “Home Health Certification and Plan of Care” for the certification period of 12/23/2024 to 02/20/2025. The patient has a discharge date of 02/20/2025. The “Home Health Certification and Plan of Care” for certification period of 12/23/2024 to 02/20/2025 documents orders for “RN/DNP/LVN (Register nurse/Doctor of Nursing Practice/License Vocational Nurse) 2 PRN visits, 1x week for 1 week, 1x week for 6 weeks (two as needed visits for one week, one visit per week for one week, one visit per week for six weeks)”, and “PT/PTD/PTA (Physical Therapy/Doctor/Physical Therapy Assistant) 2 PRN visit, 1x week for 1 week, 2x week for 4 weeks, 1 x week for 1 week, 2x week for 2 weeks (two visits as needed, one visit per week for one week, two visits per week times four weeks, one visit per week for one week, and two visit for two weeks)”. The clinical record lacks documented evidence of three (3) skilled nursing visits for 12/26/2024, 01/08/2025 and 01/15/2025. The clinical record lacks evidence of four (4) Physical Therapy visit conducted for dates 01/07/2025, 01/11/2025, 01/30/2025 and 02/20/2024. The Agency did not provide Physical Therapy and Skilled Nursing services in accordance with the Plan of Care. Interview conducted with the Director of Patient services 02/26/2025 at 3.30pm and no explanation provided. 3) Patient #7 has a start of care date of 10/10/2024 with diagnoses of “Urinary Tract Infection, Type two Diabetes, Hypertensive, Hyperlipidemia, Malignant neoplasm of prostate and vitamin D deficiency” a documented on the “Home Health Certification and Plan of Care” for the certification period of 12/09/2024 to 02/06/2025. The patient has a discharge date of 02/04/2025 The “Home Health Certification and Plan of Care” for the Certification Period of 10/10/2024 to 12/08/2024 and 12/09/2024 to 02/06/2025 documents orders for "Registered Nurse/Doctor of Nursing Practice/Licensed Vocational Nurse (RN/DNP/LVN) two as needed visits, two times per week for two weeks, one time a week for three weeks starting 10/10/2024 and ended 11/06/2024. Skilled nurse to make prn visits for any changes in clinical/medical status and recertification starting 10/10/2024. Physical therapist evaluation for home exercise program, gait training, balance training, safety, therapeutic exercise and transfer training to start 10/10/2024. Physical therapy to instruct patient/caregiver on diabetic foot care starting 10/10/2024. PT/PTD/PTA (Physical Therapy/Physical Therapy/Doctor/Physical Therapy Assistant) two as needed visits starting, two visit per week for three weeks, two visits per week for three weeks and one visit per week starting 10/17/2024 and ends 12/07/2024. Starting 12/09/2024 two visits per week for six weeks, two visits per week for one week starting 01/19/2025, two visits per week for one week starting 01/26/2025, one visit per week for one week starting 02/02/2025". The clinical record lacks documented evidence of two (2) skilled nursing visits for 10/15/2024 and 10/24/2024. The clinical record lacks evidence of six (6) Physical Therapy visit conducted for dates 11/21/2024, 11/26/2024, 11/28/2024, 12/31/2024, 01/02/2025 and 02/04/2025. The Agency did not provide Physical Therapy and Skilled Nursing services in accordance with the Plan of Care. Interview conducted with the Director of Patient services and Clinical Manger on 02/26/2025 at 3.30pm and survey findings were reviewed on 02/27/2025 at 04:30 PM with the Director of Patient Services and Clinical Manager. 1) Patient #4 has a start of care date 01/20/2025 with diagnoses of "Covid-19, Generalized Epilepsy, Atrial Fibrillation, Heart Failure, Hypothyroidism, Unspecified Fall, Hyperlipidemia and Transient Ischemic Attack" as documented on the "Home Health Certification and Plan of Care" for certification period 01/20/2025 to 03/20/2025. The "Home Health Certification and Plan of Care" for certification period 01/20/2025 to 03/20/2025 documents an order for "PT/PTD/PTA (Physical Therapy/Physical Therapy Doctor/Physical Therapy Assistance)" for 2x week for 3 weeks, 2x week for 4 weeks, 2 PRN visits (two visits a week for three weeks, two visits a week for four weeks, two as needed visits). Phyical Therapy to "assess fall risk and instruct patient/caregiver on fall prevention measures, balance training, bed mobility training, establish home exercise program, gait training, instruct patient/caregiver on fall and safety precaution". The "Physical Therapy Evaluation and Plan of Care" visit report dated 01/22/2025 lacks documentation of an assessment of the patient's muscular strenght to the shoulder, elbow, forearm, wrist, hand, hip, knee, ankle, neck and trunk. The clinical record lacks evidence of two (2) Physical Therapy visit conducted for the week of 02/09/25 - 02/15/25 and 02/16/25 - 02/22/25. The Agency did not provide Physical Therapy services in accordance to the Plan of Care. Interview conducted with the Clinical Manager on 02/27/2025 at 01:00 PM, the Clinical Manager did not give an explanation. The survey findings were reviewed on 02/27/2025 at 04:30 PM with the Director of Patient Services and Clinical Manager.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, the Agency failed to establish individualized Plans of Care. This was evident in four (4) of eight (8) records reviewed (Patients #1, #5, #6 and #7). Failure to establish individualized Plans of Care, has the potential for negative patient outcomes. 2) Patient #1 has a start of care date of 01/30/2025 with diagnoses of "Fracture of left Femur, Collapsed Vertebra, Hypertensive, Hyperlipidemia, Hypothyroidism, Hearing Loss, Fall, Embolism and Thrombosis of superficial veins of left lower extremity" as documented on the “Home Health Certification and Plan of Care” for the certification period of 01/30/2025 to 03/30/2025. The “Home Health Certification and Plan of Care” for certification period of 01/30/2025 to 03/30/2025 documents orders "Registered Nurse/Doctor of Nursing Practice/Licensed Vocational Nurse (RN/DNP/LVN) with two as needed visits for one week 01/30/2025, two visits per week for two weeks starting 02/02/2025, one visit per week for three weeks starting 02/16/2025 and one visit per week for three weeks staring 03/09/2025. Physical Therapist to establish plan of care and home exercise program, Physical Therapy Assistant to conduct home exercise program and as directed by plan of care. A joint visit with the Physical Therapy and the Physical Therapy Assistant will be conducted on the Physical Therapy Assistant initial visit. PT/PTD/PTA (Physical Therapy/Physical Therapy/Doctor/Physical Therapy Assistant) two as needed visits starting 01/30/2025, evaluation one visit per week time one week starting 02/01/2025, evaluation one visit per week time one week starting 02/02/2025, two visits per week for three weeks starting 02/09/2025, one visit per week for three weeks starting 03/02/2025". The Plan of Care lacked documented evidence of specific treatment for the Licensed Vocational Nurse. The agency failed to establish an individualized Plan of Care. Interview conducted with the Director of Patient Services and Clinical Manager on 02/26/2025 at 3.30pm and survey findings were reviewed on 02/27/2025 at 04:30 PM with the Director of Patient Services and Clinical Manager. 3) Patient #6 has a start of care date of 12/16/2024 with diagnoses of “Pneumonia, Hypertensive heart and Chronic Kidney disease with Heart Failure, Stage 1- 4 Chronic Kidney Disease, Hyperlipidemia, Chronic Obstructive Pulmonary Disease” as documented on the “Home Health Certification and Plan of Care” for the certification period of 12/23/2024 to 02/20/2025. The patient has a discharge date of 02/20/2025. The “Home Health Certification and Plan of Care” for certification period of 12/23/2024 to 02/20/2025 documents orders “Skilled Nurse to assess for factors that contribute to the promotion and maintenance of health or that result in alteration in health Provide pertinent information concerning screening for preventative health measures and maintenance that is patient specific to start 12/23/2024. Registered Nurse/Doctor of Nursing Practice/Licensed Vocational Nurse (RN/DNP/LVN) with two as needed visits for one week 12/23/2024, one visit per week for one week, one visit per week for six weeks. Physical Therapist to establish plan of care and home exercise program, Physical Therapy Assistant to conduct home exercise program and directed by plan of care. A joint visit with the physical therapy and the physical therapy assistant will be conducted on the therapy assistant initial visit. PT/PTD/PTA (Physical Therapy/Physical Therapy/Doctor/Physical Therapy Assistant) two as needed visits starting 12/23/2024, one visit per week time one week starting 12/29/2024, two visits per week for four weeks starting 01/05/2025, one visit per week for one week starting 02/02/2025 and two visits for two weeks starting 02/09/2025". The plan of care lacked documented evidence of task and treatment for the Licensed Vocational Nurse. The agency did not establish an individualized Plan of Care. Interview conducted with the Director of Patient Services and Clinical Manager on 02/26/2025 at 3.30pm and survey findings were reviewed on 02/27/2025 at 04:30 PM with the Director of Patient Services and Clinical Manager. 4) Patient #7 has a start of care date of 10/10/2024 and discharge date of 02/04/2025 with diagnoses of "Urinary Tract Infection, Type two Diabetes, Hypertensive, Hyperlipidemia, Malignant neoplasm of prostate and vitamin D deficiency" as documented on the “Home Health Certification and Plan of Care” for the certification period of 12/09/2024 to 02/06/2025. The “Home Health Certification and Plan of Care” for the certification period of 12/09/2024 to 02/06/2025 documents orders “Skilled Nurse to assess patient knowledge in disease process and management of health conditions, symptoms/vital signs complication to start 10/10/2024, two as needed visits, two times per week for two weeks, one time a week for three weeks starting 10/10/2024 and ended 11/06/2024. skilled nurse to make prn visits for any changes in clinical/medical status and recertification starting 10/10/2024. Physical Therapist evaluation for home exercise program, gait training, balance training, safety, therapeutic exercise and transfer training to start 10/10/2024. Physical therapy to instruct patient/caregiver on diabetic foot care starting 10/10/2024. PT/PTD/PTA (Physical Therapy/Physical Therapy/Doctor/Physical Therapy Assistant) two as needed visits starting 12/09/2024, two visits per week for six weeks starting 12/09/2024, two visits per week for one week starting 01/19/2025, two visits per week for one weeks starting 01/26/2025, one visit per week for one week starting 02/02/2025". The plan of care lacked documented evidence of task and treatment for the Physical Therapy Assistant. The agency did not establish an individualized Plan of Care. Interview conducted with the Director of Patient Services and Clinical Manager on 02/26/2025 at 3.30pm and survey findings were reviewed on 02/27/2025 at 04:30 PM with the Director of Patient Services and Clinical Manager. 1) Patient #5 has a start of care date of 01/08/2025 with diagnoses of "Essential Primary Hypertension, Hyperlipidemia, Hypothyroidism, Anxiety Disorder and Gastro-Esophageal Reflux Disease" as documented on the "Home Health Certification and Plan of Care" for certification period 01/08/2025 - 03/08/2025. The "Home Health Certification and Plan of Care" for certification period 01/08/2025 - 03/08/2025 documents an order for “RN/DNP/LVN (Registered Nurse, Doctor Nurse Practitioner, Licensed Vocational Nurse) 1x week for 7 weeks, 2x week for 1 week, 2 PRN visits (one visit a week for seven weeks, two visits a week for one week and two as needed visits)". Skilled Nurse to "assess/instruct/reinstruct patient Urinary status and signs/symptoms of infection". The "Oasis Nursing Services Start of Care" patient assessment report dated 01/08/2025, the Registered Nurse documents the patient had a “Urinary Tract Infection past 14 days - yes". The Plan of Care lacks documentation of pertinent current diagnosis of Urinary Tract Infection. The Agency did not establish an individualized Plan of Care that includes all pertinent diagnoses and related treatments. Interview was conducted with the Director of Patient Services on 02/25/2025 at 04:35 PM, no explanation was provided. The survey findings were reviewed on 02/27/2025 at 04:30 PM with the Director of Patient Services and Clinical Manager.

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 ans staff interview, the Agency failed to provide Physical Therapy services in accordance with Physican's Orders. This was evident in three (3) of eight (8) records reviewed. (Patient #4, #6 and #7). Failure to provide Physical Therapy services in accordance to the Plan of Care, has the potential for negative patient outcome. 2) Patient #6 has a start of care date of 12/16/2024 and discharge date of 02/20/2025 with diagnoses of "Pneumonia, Hypertensive heart and Chronic Kidney disease with heart failure, stage 1-4 Chronic Kidney Disease, Hyperlipidemia, Chronic Obstructive Pulmonary Disease" as documented on the “Home Health Certification and Plan of Care” for the certification period of 12/23/2024 to 02/20/2025. The “Home Health Certification and Plan of Care” for the Certification Period of 12/23/2024 to 02/20/2025 documents orders “Registered Nurse/Doctor of Nursing Practice/Licensed Vocational Nurse (RN/DNP/LVN) with two as needed visits for one week 12/23/2024, one visit per week for one week starting 12/24/2024, one visit per week for six weeks starting 12/29/2024. Physical Therapist to establish plan of care and home exercise program, Physical Therapy Assistant to conduct home exercise program and directed by plan of care. A joint visit with the Physical Therapy and the Physical Therapy Assistant will be conducted on the therapy assistant initial visit. PT/PTD/PTA (Physical Therapy/Doctor/Physical Therapy Assistant) two visits as needed starting 12/23/2024, one visit per week for one week starting 12/29/2024, two visits per week times four weeks starting 01/05/2025, one visit per week for one week starting 02/02/2025 and two visit for two weeks starting 02/09/2025". The clinical record lacks evidence of four (4) Physical Therapy visit conducted for dates 01/07/2025, 01/11/2025, 01/30/2025 and 02/20/2024. The Agency did not provide Physical Therapy services as ordered by the Physician. Interview conducted with the Director of Patient services 02/26/2025 at 3.30pm and no explanation provided. 3) Patient #7 has a start of care date of 10/10/2024 and discharge date of 02/04/2025 with diagnoses of "Urinary Tract Infection, Type two Diabetes, Hypertensive, Hyperlipidemia, Malignant neoplasm of prostate and vitamin D deficiency" a documented on the “Home Health Certification and Plan of Care” for the Certification Period of 12/09/2024 to 02/06/2025. The “Home Health Certification and Plan of Care” for the Certification Period of 10/10/2024 to 12/08/2024 and 12/09/2024 to 02/06/2025 documents orders “Skilled Nurse to assess patient knowledge in disease process and management of health conditions, symptoms/vital signs complication to start 10/10/2024, skilled nurse to make prn visits for any changes in clinical/medical status and recertification starting 10/10/2024. Physical Therapist evaluation for home exercise program, gait training, balance training, safety, therapeutic exercise and transfer training to start 24. Physical Therapy to instruct patient/caregiver on diabetic foot care starting 10/10/2024. PT/PTD/PTA (Physical Therapy/Physical Therapy/Doctor/Physical Therapy Assistant) two as needed visits starting, two visit per week for three weeks, two visits per week for three weeks and one visit per week starting 10/17/2024 and ends 12/07/2024. Starting 12/09/2024 two visits per week for six weeks, two visits per week for one week starting 01/19/2025, two visits per week for one week starting 01/26/2025, one visit per week for one week starting 02/02/2025". The clinical record lacks evidence of six (6) Physical Therapy visit conducted for dates 11/21/2024, 11/26/2024, 11/28/2024, 12/31/2024, 01/02/2025 and 02/04/2025. The Agency did not provide Physical Therapy services as ordered by the Physician. Interview conducted with the Director of Patient services and Clinical Manger on 02/26/2025 at 3.30pm and survey findings were reviewed on 02/27/2025 at 04:30 PM with the Director of Patient Services and Clinical Manager. 1) Patient #4 has a start of care date 01/20/2025 with diagnoses of "Covid-19, Generalized Epilepsy, Atrial Fibrillation, Heart Failure, Hypothyroidism, Unspecified Fall, Hyperlipidemia and Transient Ischemic Attack" as documented on the "Home Health Certification and Plan of Care" for certification period 01/20/2025 to 03/20/2025. The "Home Health Certification and Plan of Care" for certification period 01/20/2025 to 03/20/2025 documents an order for "PT/PTD/PTA (Physical Therapy/Physical Therapy Doctor/Physical Therapy Assistance)" for 2x week for 3 weeks, 2x week for 4 weeks, 2 PRN visits (two visits a week for three weeks, two visits a week for four weeks, two as needed visits). Physical Therapy to "assess fall risk and instruct patient/caregiver on fall prevention measures, balance training, bed mobility training, establish home exercise program, gait training, instruct patient/caregiver on fall and safety precaution". The "Physical Therapy Evaluation and Plan of Care" visit report dated 01/22/2025 lacks documentation of an assessment of the patient's muscular strength to the shoulder, elbow, forearm, wrist, hand, hip, knee, ankle, neck and trunk. The clinical record lacks evidence of two (2) Physical Therapy visit conducted for the week of 02/09/25 - 02/15/25 and 02/16/25 - 02/22/25. The Agency did not provide Physical Therapy services as ordered by the Physician. Interview conducted with the Clinical Manager on 02/27/2025 at 01:00 PM, the Clinical Manager did not give an explanation. The survey findings were reviewed on 02/27/2025 at 04:30 PM with the Director of Patient Services and Clinical Manager.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, the Agency failed to ensure the coordination of care among all services. This was evident in four (4) of eight (8) records reviewed (Patients #1, #4, #5 and #6). Failure to ensure coordination of services, has the potential for negative patient outcomes. 3) Patient #1 has a start of care date of 01/30/2025 with diagnoses of "Fracture of left femur, collapsed vertebra, Hypertensive, Hyperlipidemia, Hypothyroidism, hearing loss, fall, Embolism and Thrombosis of superficial veins of left lower extremity" as documented on the “Home Health Certification and Plan of Care” for certification period of 01/30/2025 to 03/30/2025. The “Home Health Certification and Plan of Care” for certification period of 01/30/2025 to 03/30/2025 documents orders “Skilled Nurse to assess for factors that contribute to the promotion and maintenance of health or that result in alteration in health Provide pertinent information concerning screening for preventative health measures and maintenance that is patient specific to start 01/30/2025. Registered Nurse/Doctor of Nursing Practice/Licensed Vocational Nurse (RN/DNP/LVN) with two as needed visits for one week 01/30/2025, two visits per week for two weeks starting 02/02/2025, one visit per week for three weeks starting 02/16/2025 and one visit per week for three weeks staring 03/09/2025. Physical Therapist to establish plan of care and home exercise program, Physical Therapy Assistant to conduct home exercise program and as directed by plan of care. A joint visit with the Physical Therapy and the Physical Therapy Assistant will be conducted on the Physical Therapy Assistant initial visit. PT/PTD/PTA (Physical Therapy/Physical Therapy/Doctor/Physical Therapy Assistant) two as needed visits starting 01/30/2025, evaluation one visit per week time one week starting 02/01/2025, evaluation one visit per week time one week starting 02/02/2025, two visits per week for three weeks starting 02/09/2025, one visit per week for three weeks starting 03/02/2025". The Physical Therapy Assistant visit notes dated 02/15/2025, 02/17/2025, 02/22/2025 and 02/24/2025 lack documentation of coordination of care with the Physical Therapy. The Agency did not ensure coordination of patient care among all ordered services. Interview conducted with the Director of Patient Services 02/26/2025 at 3.30pm and no explanation provided. 4) Patient #6 has a start of care date of 12/16/2024 and discharge date of 02/20/2025 with diagnoses of "Pneumonia, Hypertensive heart and Chronic Kidney disease with heart failure, stage 1-4 Chronic Kidney Disease, Hyperlipidemia, Chronic Obstructive Pulmonary Disease" as documented on the “Home Health Certification and Plan of Care” for certification period of 12/23/2024 to 02/20/2025. The “Home Health Certification and Plan of Care” for certification period of 12/23/2024 to 02/20/2025 documents orders “Skilled Nurse to assess for factors that contribute to the promotion and maintenance of health or that result in alteration in health provide pertinent information concerning screening for preventative health measures and maintenance that is patient specific to start 12/23/2024. Registered Nurse/Doctor of Nursing Practice/Licensed Vocational Nurse (RN/DNP/LVN) with two as needed visits for one week 12/23/2024, one visit per week for one week starting 12/24/2024, one visit per week for six weeks starting 12/29/2024. Physical Therapist to establish plan of care and home exercise program, Physical Therapy Assistant to conduct home exercise program and directed by plan of care. A joint visit with the Physical Therapy and the Physical Therapy Assistant will be conducted on the therapy assistant initial visit. PT/PTD/PTA (Physical Therapy/Doctor/Physical Therapy Assistant) two visits as needed starting 12/23/2024, one visit per week for one week starting 12/29/2024, two visits per week times four weeks starting 01/05/2025, one visit per week for one week starting 02/02/2025 and two visit for two weeks starting 02/09/2025". The Physical Therapy Assistant visit notes dated 01/13/2025, 01/17/2025, 01/20/2025, 01/29/2025, 02/02/2025, 02/10/2025, 02/15/2025 and 02/18/2025 lack documented evidence of coordination of care with the Physical Therapy. The Agency did not ensure coordination of patient care among all ordered services. Interview conducted with the Director of Patient Services and Clinical Manager on 02/26/2025 at 3.30pm and survey findings were reviewed on 02/27/2025 at 04:30 PM with the Director of Patient Services and Clinical Manager. 1) Patient #4 has a start of care date 01/20/2025 with diagnoses of "Covid-19, Generalized Epilepsy, Atrial Fibrillation, Heart Failure, Hypothyroidism, Unspecified Fall, Hyperlipidemia and Transient Ischemic Attack" as documented on the "Home Health Certification and Plan of Care" for certification period 01/20/2025 to 03/20/2025. The "Home Health Certification and Plan of Care" for certification period 01/20/2025 to 03/20/2025 documents an order for "PT/PTD/PTA (Physical Therapy/Physical Therapy Doctor/Physical Therapy Assistance)" for 2x week for 3 weeks, 2x week for 4 weeks, 2 PRN visits (two visits a week for three weeks, two visits a week for four weeks, two as needed visits), and "RN/DNP/LVN (Registered Nurse, Doctor Nurse Practitioner, Licensed Vocational Nurse) 1x week for 1 week, 1x week for 1 week, 2x weeks for 1 week, 2 PRN visits (one visit a week for two weeks, two visits a week for one week, two as needed visits). The Physical Therapy visit notes dated 01/22/25, 01/25/25, 01/29/25, 02/01/25, 02/08/25, 02/15/25, 02/19/25 lack documentation of coordination of care with the Registered Nurse. The "Care Coordination" section of the visit notes has no entry and lacks documentation of coordination of care with the Registered Nurse. The Registered Nurse visit notes dated 01/27/25 and 02/03/25 lack documentation of coordination of care with the Physical Therapist. The "Care Coordination" section of the visit notes has no entry and lacks documentation of coordination of care with the Physical Therapist. The Agency did not ensure coordination of patient care among all ordered services. Interview conducted with the Clinical Manager on 02/27/2025 at 01:00 PM, the Clinical Manager did not give an explanation. The survey findings were reviewed on 02/27/2025 at 04:30 PM with the Director of Patient Services and Clinical Manager. 2) Patient #5 has a start of care date of 01/08/2025 with diagnoses of Essential Primary Hypertension, Hyperlipidemia, Hypothyroidism, Anxiety Disorder and Gastro-Esophageal Reflux Disease as documented on the "Home Health Certification and Plan of Care" for certification period 01/08/2025 - 03/08/2025. The "Home Health Certification and Plan of Care" for certification period 01/08/2025 - 03/08/2025 documents an order for "PT/PTD/PTA (Physical Therapy/Physical Therapy Doctor/Physical Therapy Assistance)" for 2x week for 7 weeks, 2 PRN visits (two visits as week for seven weeks, two as needed visits), and “RN/DNP/LVN (Registered Nurse, Doctor Nurse Practitioner, Licensed Vocational Nurse)" 1x week for 7 weeks, 2x week for 1 week, 2 PRN visits (one visit a week for seven weeks, two visits a week for one week and two as needed visits). The Registered Nurse visit notes dated 01/13/25, 01/15/25, 01/21/25, 01/28/25, and 02/12/25 lack documentation of coordination of care with the Physical Therapist. The "Care Coordination" section of the visit notes has no entry and lacks documentation of coordination of care with the Physical Therapist. The Physical Therapy visit notes dated 01/11/25 and 02/01/25 lack documentation of coordination of care with the Registered Nurse. The "Care Coordination" section of the visit notes has no entry and lacks documentation of coordination of care with the Registered Nurse. The Physical Therapist Assistant visit notes dated 01/18/25, 01/25/25, 02/15/25, 02/20/25 and 02/22/25 lack documentation and coordination of care with the Physical Therapist. The Agency did not ensure coordination of patient care among all ordered services. Interview was conducted with the Director of Patient Services on 02/25/2025 at 04:35 PM, no explanation was provided. The survey findings were reviewed on 02/27/2025 at 04:30 PM with the Director of Patient Services and Clinical Manager.

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 review of the agency’s Quality Assessment and Performance Improvement program and staff interview, the Governing Authority failed to ensure that the Quality Assessment and Performance Improvement program identify quality indicators, establish data measures related to patient care, services and outcomes. This was evident in review of the Quality Assessment and Performance Improvement meeting minutes dated 04/2024 – 01/2025. Failure to develop a comprehensive Quality Assessment and Performance Improvement program, has the potential for negative patient outcomes. The Quality Assessment and Performance Improvement meeting minutes dated 04/19/2024 (1st Quarter 2024), 07/12/2024 (2nd Quarter 2024), 10/10/2024 (3rd Quarter 2024), and 01/10/2025 (4th Quarter 2024) lack documented evidence of how the agency measured, analyzed, and track quality indicators related to patient care and services. There is no documented evidence that the agency is monitoring the quality-of-care indicators that impacts the care and services the agency is providing. An interview was conducted with the Director of Patient Services and Clinical Nurse Manager on 02/26/2025 at 02:45 PM. The Quality Assessment and Performance Improvement program and meeting minutes 04/19/24 -01/10/25 were reviewed. The Director of Patient Services was unable to show evidence of quality indicators, the frequency of data collection/measure, and the agency's analysis of quality indicators. The Agency did not measure, analyze, and track quality indicators that impacts patient care and services. The Agency did not ensure Quality Assessment and Performance Improvement program that enable the Agency to assess processes of patient care, services, and operations. The survey findings were reviewed on 02/27/2025 at 04:30 PM with the Director of Patient Services and Clinical Manager.

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on review of the agency’s Quality Assessment and Performance Improvement program and staff interview, the Governing Authority failed to ensure quality indicators data measurement. This was evident in review of the Quality Assessment and Performance Improvement meeting minutes for the year 2024. Failure to ensure quality indicator data measurement, has the potential for negative patient outcomes. The Quality Assessment and Performance Improvement meeting minutes dated 04/19/2024 (1st Quarter 2024), 07/12/2024 (2nd Quarter 2024), 10/10/2024 (3rd Quarter 2024), and 01/10/2025 (4th Quarter 2024) lack documented evidence of quality indicators data, how the agency measure, analyze, and track quality indicators related to patient care and services. There is no documented evidence of quality indicators collected by the Agency for the year 2024. There is no documented evidence indicators data collection that monitors the effectiveness and safety of services and quality care. An interview was conducted with the Director of Patient Services and Clinical Nurse Manager on 02/26/2025 at 02:45 PM. The Quality Assessment and Performance Improvement program and meeting minutes 04/19/24 -01/10/25 were reviewed. The Director of Patient Services was unable to show evidence of data collection, the frequency of data collection, data measurement, and the Agency's analysis of data. The survey findings were reviewed on 02/27/2025 at 04:30 PM with the Director of Patient Services and Clinical Manager.

Program activities CFR(s): 484.65(c) (1) The HHA's performance improvement activities must— (i) Focus on high risk, high volume, or problem-prone areas; (ii) Consider incidence, prevalence, and severity of problems in those areas; and (iii) Lead to an immediate correction of any identified problem that directly or potentially threaten the health and safety of patients. This STANDARD is not met as evidenced by: Based on review of the agency’s Quality Assessment and Performance Improvement program and staff interview, the Governing Authority failed to ensure data collection during the Quality Assessment and Performance Improvement activities was used to identify areas for improvement. This was evident in review of the Quality Assessment and Performance Improvement meeting minutes for the year 2024. Failure to use data to monitor the effectiveness of services, quality of care and performance improvement, has the potential for negative patient outcomes. The Quality Assessment and Performance Improvement meeting minutes dated 04/19/2024 (1st Quarter 2024), 07/12/2024 (2nd Quarter 2024), 10/10/2024 (3rd Quarter 2024), and 01/10/2025 (4th Quarter 2024) lack documented evidence of performance improvement actives focusing on the Agency's high-risk, high volume and problem prone patient areas. The meeting minutes lack documented evidence that the Agency collected data to identify a need for improvement in patient care and service area of Skilled Nurse, Physical Therapy, Occupational Therapy, Speech language Pathology and Home Health Aide. An interview was conducted with the Director of Patient Services and Clinical Nurse Manager on 02/26/2025 at 02:45 PM. The Director of Patient Services was unable to show evidence of peromance improvement activities. The survey findings were reviewed on 02/27/2025 at 04:30 PM with the Director of Patient Services and Clinical Manager.

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 review of the agency’s Quality Assessment and Performance Improvement program and staff interview, the Governing Authority failed to ensure ongoing QAPI activities. This was evident in review of the Quality Assessment and Performance Improvement meeting minutes for the year 2024. Failure to ensure ongoing Quality Assessment and Performance Improvement activities, has the potential for negative patient outcomes. · There is no documented evidence of quality indicators collected by the Agency for the year 2024. There is no documented evidence indicators data collection that monitors the effectiveness and safety of services and quality care. · The Agency did not measure, analyze, and track quality indicators that impacts patient care and services. The Agency did not ensure Quality Assessment and Performance Improvement program that enable the Agency to assess processes of patient care, services, and operations. · The Quality Assessment and Performance Improvement meeting minutes dated 04/19/2024 (1st Quarter 2024), 07/12/2024 (2nd Quarter 2024), 10/10/2024 (3rd Quarter 2024), and 01/10/2025 (4th Quarter 2024) lack documented evidence of performance improvement actives focusing on the Agency's high-risk, high volume and problem prone patient areas. The meeting minutes lack documented evidence that the Agency collected data to identify a need for improvement in patient care and service area of Skilled Nurse, Physical Therapy, Occupational Therapy, Speech language Pathology and Home Health Aide. The survey findings were reviewed on 02/27/2025 at 04:30 PM with the Director of Patient Services and Clinical Manager.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on policy review, Quality Assessment and Performance Improvement program review, and staff interview, the Governing Authority failed to maintain a coordinated agency-wide Infection Control program. This was evident in review of the Quality Assessment Performance Improvement and Infection Control programs for year 2024. Failure to maintain an agency- wide Quality Assessment Performance Improvement (QAPI) and Infection Control programs, has the potential for negative patient outcome. The Quality Assessment and Performance Improvement meeting minutes dated 04/19/2024 (1st Quarter 2024), 07/12/2024 (2nd Quarter 2024), 10/10/2024 (3rd Quarter 2024), and 01/10/2025 (4th Quarter 2024) lack documented evidence of how the agency identified, investigate, monitored and measured infections An interview was conducted with the Director of Patient Services and Clinical Nurse Manager on 02/26/2025 at 02:45 AM. The Quality Assessment and Performance Improvement program and meeting minutes 04/19/24 -01/10/25 were reviewed. The Director of Patient Services was unable to show evidence of infection control surveillance, chart audits and monitoring of agency wide infections The survey findings were reviewed on 02/27/2025 at 04:30 PM with the Director of Patient Services and Clinical Manager.

Rehab services supervised by PT, OT CFR(s): 484.75(c)(2) Rehabilitative therapy services are provided under the supervision of an occupational therapist or physical therapist that meets the requirements of §484.115(f) or (h), respectively. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, the Agency failed to ensure the Physical Therapist Assistant supervision as per the Plan of Care. This was evident in three (3) of eight (8) records reviewed (Patients #1, #5 and #6). Failure to ensure the supervision of Physical Therapist Assistant, has the potential for negative patient outcomes. The findings include: 2) Patient #1 has a start of care date of 01/30/2025 with diagnoses of "Fracture of left femur, collapsed vertebra, Hypertensive, Hyperlipidemia, Hypothyroidism, hearing loss, fall, Embolism and Thrombosis of superficial veins of left lower extremity" as documented on the “Home Health Certification and Plan of Care” for the Certification Period of 01/30/2025 to 03/30/2025. The “Home Health Certification and Plan of Care” for the Certification Period of 01/30/2025 to 03/30/2025 documents orders “Skilled Nurse to assess for factors that contribute to the promotion and maintenance of health or that result in alteration in health provide pertinent information concerning screening for preventative health measures and maintenance that is patient specific to start 01/30/2025. Registered Nurse/Doctor of Nursing Practice/Licensed Vocational Nurse (RN/DNP/LVN) with two as needed visits for one week 01/30/2025, two visits per week for two weeks starting 02/02/2025, one visit per week for three weeks starting 02/16/2025 and one visit per week for three weeks staring 03/09/2025. Physical Therapist to establish plan of care and home exercise program, physical therapy assistant to conduct home exercise program and as directed by plan of care. A joint visit with the physical therapy and the Physical Therapy Assistant will be conducted on the Physical Therapy assistant initial visit. PT/PTD/PTA (Physical Therapy/Physical Therapy/Doctor/Physical Therapy Assistant) two as needed visits starting 01/30/2025, evaluation one visit per week time one week starting 02/01/2025, evaluation one visit per week time one week starting 02/02/2025, two visits per week for three weeks starting 02/09/2025, one visit per week for three weeks starting 03/02/2025". The Physical Therapist joint visit with the Physical Therapist Assistant dated 02/14/2025. The visit note section for “Supervisory visit” was incomplete and lacked documented evidence of the physical therapist documentation providing supervision and documentation. The Physical Therapy Assistant visit notes dated 02/14/2025, 02/15/2025, 02/17/2025, 02/22/2025 and 02/24/2025 lack documentation of supervision of the Physical Therapy Assistant in the provision of patient care and treatment. Interview conducted with the Director of Patient Services on 02/25/2025 at 3.00pm regarding the incomplete supervisory visit section, as per Director of Patient Services “the Physical Therapist do not like to use the form, he feels it’s more geared for the aides and prefers to use another form for supervision documentation”. Evidence of supervision was not provided. 3) Patient #6 has a start of care date of 12/16/2024 and discharge date of 02/20/2025 with diagnoses of "Pneumonia, Hypertensive Heart and Chronic Kidney Disease with Heart Failure, stage 1-4 Chronic Kidney Disease, Hyperlipidemia, Chronic Obstructive Pulmonary Disease" as documented on the “Home Health Certification and Plan of Care” for certification period of 12/23/2024 to 02/20/2025. The “Home Health Certification and Plan of Care” for certification period of 12/23/2024 to 02/20/2025 documents orders “Skilled Nurse to assess for factors that contribute to the promotion and maintenance of health or that result in alteration in health provide pertinent information concerning screening for preventative health measures and maintenance that is patient specific to start 12/23/2024. Register nurse/Doctor of Nursing Practice/Licensed Vocational Nurse (RN/DNP/LVN) with two as needed visits for one week 12/23/2024, one visit per week for one week starting 12/24/2024, one visit per week for six weeks starting 12/29/2024. Physical Therapist to establish plan of care and home exercise program, Physical Therapy Assistant to conduct home exercise program and directed by plan of care. A joint visit with the Physical Therapy and the Physical Therapy Assistant will be conducted on the therapy assistant initial visit. PT/PTD/PTA (Physical Therapy/Doctor/Physical Therapy Assistant) two visits as needed starting 12/23/2024, one visit per week for one week starting 12/29/2024, two visits per week times four weeks starting 01/05/2025, one visit per week for one week starting 02/02/2025 and two visit for two weeks starting 02/09/2025". The clinical record lacked documented evidence of the Physical Therapist conducting a joint visit with the Physical Therapist Assistant on the initial visit dated 01/13/2024. The Physical Therapy Assistant visit notes dated 01/13/2025, 01/17/2025, 01/20/2025, 01/29/2025, 02/02/2025, 02/10/2025, 02/15/2025 and 02/18/2025 lack documentation of supervision of the Physical Therapy Assistant in the provision of patient care and treatment. Interview conducted with the Director of Patient Services and Clinical Manager on 02/26/2025 at 3.42 PM and surveyor was provided with a blank form title “Physical Therapy Assistant (PTA) supervisory visit assessment”. Survey findings were reviewed on 02/27/2025 at 04:30 PM with the Director of Patient Services and Clinical Manager, no further explanation provided. 1) Patient #5 has a start of care date of 01/08/2025 with diagnoses of Essential Primary Hypertension, Hyperlipidemia, Hypothyroidism, Anxiety Disorder and Gastro-Esophageal Reflux Disease as documented on the "Home Health Certification and Plan of Care" for certification period 01/08/2025 - 03/08/2025. The "Home Health Certification and Plan of Care" for certification period 01/08/2025 - 03/08/2025 documents an order for "PT/PTD/PTA (Physical Therapy/Physical Therapy Doctor/Physical Therapy Assistance)" for 2x week for 7 weeks, 2 PRN visits (two visits as week for seven weeks, two as needed visits)". Physical Therapy Assistant "joint initial visit with Physical Therapist and the Physical Therapy Assistant will be conducted on the initial visit for the patient". The Physical Therapist joint visit with the Physical Therapist Assistant is dated 01/11/2025. The Physical Therapist Assistant visit reports are dated 01/18/25, 01/25/25, and 02/15/25. There is no documented evidence of supervision of the Physical Therapist Assistant in the provision of patient care and treatment. Interview was conducted with the Director of Patient Services on 02/25/2025 at 04:35 PM, no explanation was provided. The survey findings were reviewed on 02/27/2025 at 04:30 PM with the Director of Patient Services and Clinical Manager.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on clinical records review and staff interview, the Agency failed to ensure that the clinical record includes all pertinent patient assessments, clinical notes and discharge summaries. This was evident in two (2) of eight (8) records reviewed (Patient # 6 and #7). Failure to ensure that the clinical record includes all pertinent assessments and clinical notes, has the potential for negative patient outcomes. 1) Patient #6 has a start of care date of 12/16/2024 and discharge date of 02/20/2025 with diagnoses of "Pneumonia, Hypertensive heart and Chronic Kidney disease with heart failure, stage 1-4 Chronic Kidney Disease, Hyperlipidemia, Chronic Obstructive Pulmonary Disease" as documented on the “Home Health Certification and Plan of Care” for the certification period of 12/23/2024 to 02/20/2025. The “Home Health Certification and Plan of Care” for the certification period of 12/23/2024 to 02/20/2025 documents orders: “Skilled Nurse to assess for factors that contribute to the promotion and maintenance of health or that result in alteration in health provide pertinent information concerning screening for preventative health measures and maintenance that is patient specific to start 12/23/2024. Registered Nurse/Doctor of Nursing Practice/Licensed Vocational Nurse (RN/DNP/LVN) with two as needed visits for one week 12/23/2024, one visit per week for one week starting 12/24/2024, one visit per week for six weeks starting 12/29/2024. Physical Therapist to establish plan of care and home exercise program, Physical Therapy Assistant to conduct home exercise program and directed by plan of care. A joint visit with the Physical Therapy and the Physical Therapy Assistant will be conducted on the therapy assistant initial visit. PT/PTD/PTA (Physical Therapy/Doctor/Physical Therapy Assistant) two visits as needed starting 12/23/2024, one visit per week for one week starting 12/29/2024, two visits per week times four weeks starting 01/05/2025, one visit per week for one week starting 02/02/2025 and two visit for two weeks starting 02/09/2025". The Skilled Nurse discharge summary dated 02/03/2025 documents “goals met, patient and caregiving given teaching and discharge instructions. To continue with home exercise program, all medications, treatments and doctor with next appointment”. Interim physician order dated 02/20/2025 documents “patient refused physical therapy visit on 02/20/2025, patient discharge start effective date: 02/20/2025 met discharged date: 02/20/2025”. The document lacked evidence of signatures by caregiver and physician. The Physical Therapy Assistant visit notes dated 02/10/2025, 02/15/2025 and 02/18/2025 lacked documentation of pending patient discharge plans. The clinical record lacked documented evidence of a Physical Therapist discharge summary to include assessment of patient health status, goals being met, caregiver and patient teach/instruction and referrals for ongoing treatment and community resources. Interview conducted with the Director of Patient Services on 02/26/2025 at 3.30pm regarding the lack of a discharge summary and no explanation was provided. 2) Patient #7 has a start of care date of 10/10/2024 with diagnoses of "Urinary Tract Infection, Type two Diabetes, Hypertensive, Hyperlipidemia, Malignant neoplasm of prostate and vitamin D deficiency" a documented on the “Home Health Certification and Plan of Care” for the Certification Period of 12/09/2024 to 02/06/2025. The patient has a discharge date of 02/04/2025. The “Home Health Certification and Plan of Care” for the certification period of 10/10/2024 to 12/08/2024 and 12/09/2024 to 02/06/2025 documents orders “Skilled Nurse to assess patient knowledge in disease process and management of health conditions, symptoms/vital signs complication to start 10/10/2024, skilled nurse to make prn visits for any changes in clinical/medical status and recertification starting 10/10/2024. Physical Therapist evaluation for home exercise program, gait training, balance training, safety, therapeutic exercise and transfer training to start 24. Physical Therapy to instruct patient/caregiver on diabetic foot care starting 10/10/2024. PT/PTD/PTA (Physical Therapy/Physical Therapy/Doctor/Physical Therapy Assistant) two as needed visits starting 12/09/2024, two visits per week for six weeks starting 12/09/2024, two visits per week for one week starting 01/19/2025, two visits per week for one week starting 01/26/2025, one visit per week for one week starting 02/02/2025". The Skilled Nurse discharge summary dated 11/04/2024 documents “patient and caregiving given teaching and discharge instructions. Skilled nursing goals met and to continue with Physical Therapy”. The “Oasis transfer non-visit” dated 02/04/2025 documents: “Medical Doctor (MD) made aware of hospitalization. Discharge summary is available upon request from doctor”. The transfer summary was incomplete, lacked documentation of the reason for patient’s “admission/diagnosis, skill service provided and patient and caregiver transfer/discharge instructions and follow care”. The clinical record lacked documented evidence of a comprehensive transfer and discharge summary. The clinical record lacked documented evidence of clinical coordination notes. Interview conducted with Director of Patient Services on 02/27/2025 at 2.00pm regarding the lacked a discharge summary. The Director of Patient services stated, “the oasis transfer is also the discharge summary”. Surveyor highlighted the blank areas on transfer summary and the missing pertinent patient information as to reason for patient hospitalization and transfer. Surveyor requested all clinical coordination notes for certification period of 12/09/2024 to 02/06/2025. No further explanation or information provided. Survey findings were reviewed on 02/27/2025 at 04:30 PM with the Director of Patient Services and Clinical Manager.

A standard re-certification survey and focused COVID-19 infection control survey of Family Care Certified Services at 50 Clinton Street Hempstead, NY 11550 was initiated on 3/14/22 and exited 3/17/22. Deficient practices were identified within high priority standards in Plan of Care resulting in a partial extended survey. The agency's active census as of 3/14/22 is 31. Seven (7) clinical records were reviewed and are identified as Patients #1, #2, #3, #4, #5, #6, and #7. Three (3) Home Visits (HV) were conducted with Patients #4, #6, and #7. Eight (8) personnel records were reviewed and are identified as Employees #1, #2, #3, #4, #5, #6, #7, and #8. Policies and procedures for Emergency Preparedness Plan, Health Commerce System, Home Care Registry, Criminal History Record Check, Infection Control and Influenza Vaccination policy were reviewed. OBQI Adverse Event Outcome Report was reviewed for the period of 1/21 through 12/2021. The agency's Complaint log was reviewed for the years 3/1/2021 through 3/1/2022. Administrative and clinical staff were interviewed. The agency's Quality Improvement meeting minutes were reviewed for 2021 and 2022. The following federal deficiencies are cited: G - 514 - Registered Nurse Performs Assessments; G - 574 - Plan of Care Must include the Following; G - 578 - Conformance with Physicians Orders; G - 590 - Promptly Alert Relevant Physician of Changes; G - 606 - Integrate All Services; G - 726 - Nursing Services Provided By Registered Nurse; J - 1164, and 1260 - Governing Authority; J - 1420, J1426 and 1456 - Personnel; L - 000 - Initial Comments; L - 0002 - Acceptable Infection Control Procedures

Transmittal of OASIS data CFR(s): 484.45(c) Standard: Transmittal of OASIS data. An HHA must- This STANDARD is not met as evidenced by: Based on record review and staff interview, the agency failed to ensure that OASIS data was transmitted to Centers for Medicare and Medicaid System (CMS). This was evident for four (4) of four (4) clinical records requiring OASIS submissions. ( Patients #1, #2, #3, and #6). Failure to ensure transmittal of OASIS data has the potential for negative patient outcomes. The findings are: 1. Patient #1 has a start of care date of 4/13/19. The record lacks documented evidence of an OASIS assessment was submitted to CMS. A re-certification OASIS assessment was completed on 1/26/22. 2. Patient #2 has a start of care date of 10/14/21 and a discharge date of 11/24/21. A re-certification OASIS assessment was completed on 10/14/21 and a discharge OASIS on 11/24/21. 3. Patient #3 has a start of care date of 10/28/21 and a discharge date of 11/24/21. A re-certification OASIS assessment was completed on 10/28/21 and a discharge OASIS on 11/24/21. 4. Patient #6 has a start of care date of 2/3/22. An initial OASIS assessment was completed on There is no documented the OASIS data is being transmitted to CMS. A request was made for documented evidence the OASIS data was being transmitted to CMS. The agency did not provide the documentation. During an interview with the Administrator on 3/14/22 at 2:00 PM, the Administrator did not provide an explanation for the above.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on clinical record reviews, home visit observations, and staff interview, the Governing Authority failed to ensure that the Registered Nurse conduct the initial patient assessment within 48 hours of referral, or the Patient's return home to determine the immediate care and support needs of the patient. This was evident for two (2) of seven (7) clinical records reviewed. ( Patients # 4 and #7). Failure to ensure that a Registered Nurse conducts the initial patient assessment within 48 hours of referral, or the Patient's return home has the potential for negative patient outcomes. The findings include:. 1. Patient #4 has a start of care date of 2/15/2022 with diagnosis that include Arthrodesis, Wedge Compression Fracture T 11, T 12 Vertebra, Essential Hypertension, Gastro Esophageal Reflux Disease GERD) with Esophagitis without Bleeding, Unspecified Abnormalities Of Gait and Mobility, Unspecified Fall as documented on the " Plan Of Care" for the Certification Period of 2/15/22 to 4/15/22. The agency " Patient Profile" document:" Referral Date: 2/11/22. Projected Start of Care Date: 2/14/22. Referral Facility: Fulton Commons Care Center. The record document :" Fulton Commons Care Center Discharge & Instructions: Date of discharge: 2/12/22." The Social Worker Note document: Resident will be discharged 2/12/22.Home Care Referral made through Family Care Services". The " OASIS Nursing Services Start Of Care is dated 2/15/22. There is no documented evidence the Initial assessment was performed within 48 hours of the referral or the patient's return home. On 3/16/22 at 2: 45 PM, the Administrator was interviewed and did not have an explanation. 2. Patient # 7 has a start of care date of 02/11/2022 with diagnoses of Fx (Fracture) Shaft of Right Fibula, Fx unspecified Metatarsal Bone Left Foot, Hypertensive Heart Disease, Heart Failure, Unspecified Atrial Fibrillation, Atherosclerosis Heart Disease, Unspecified Urethral Stricture as documented on the "Plan of Care" dated 02/11/2022 to 04/11/2022,. The "Plan of Care" for certification period from 02/11/2022 to 04/11/2022 documents an order for " PT/PTA (Physical Therapy/Physical Therapy Assistant) 1x week for 2 weeks, 2x week for 3 weeks ( one visit a week for two weeks, two visits a week for three weeks), RN 1x week for 1 week, 1x week for two weeks ( one visit a week for one week, one visit a week for two weeks). The "Referral" for services dated 02/08/2022 documents the patient's "Discharge Instructions" from the in-patient facility documents the patient has "wound upon discharge". The Initial assessment visit dated 02/11/2022, was conducted by the Physical Therapist. The initial assessment lacks documentation of the patient's wound status. The RN initial patient assessment is dated 03/07/2022. The RN documents "No" wounds identified. The RN patient "missed visit" notes are dated 02/16/2022 and 02/26/2022. A Home Visit (HV) observation was conducted on 03/15/2022 with the agency's PT and PT Director. The Patient was seen ambulating in the home. During an interview with the patient, the patient reported having a "wound" to the heel of the Right foot and wound care treatment is done by the Podiatrist. The agency failed to ensure that Registered Nurse conduct the initial assessment visit to determine the immediate care and support needs of the patient with diagnoses of Heart Failure, Atrial Fibrillation and discharged from an in-patient facility with a wound. The survey findings were reviewed on 03/16/2022 at 02:25 P.M with the agency’s Director of Patient Services, Clinical Manager, Physical Therapist Director, and Quality Improvement Manager. On 03/17/2022 at 01:15 P.M, the Clinical Manager was interviewed and acknowledged the findings.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record reviews and interview, the agency failed to develop complete and comprehensive Plans of Care. This was evident for three (3) of seven (7) clinical records reviewed. (Patients #4, #6, and #7) Failure to develop complete and comprehensive Plans of Care has the potential for negative patient outcomes. The findings are:. 1. Patient #4 has a start of care date of 2/15/2022 with diagnosis that include Arthrodesis, Wedge Compression Fracture T 11, T 12 Vertebra, Essential Hypertension, Gastro Esophageal Reflux Disease with Esophagitis without Bleeding, Unspecified Abnormalities Of Gait and Mobility, Unspecified Fall as documented on the " Plan Of Care" for the Certification Period of 2/15/22 to 4/15/22. The " Plan Of Care" for the Certification Period of 2/15/22 to 4/15/22 document: " Medications: Cilostazol 50 mg oral one tablet three times a day, Omeprazole 40 mg oral one capsule daily, Famotidine 20 mg tablet oral one tablet every night, Ezetimibe 10 mg tablet oral one tablet twice a day, Acetaminophen Extra strength 500 mg oral two tablets daily pain. Interventions: Skilled Nurse : Instruct / reinstruct Patient, medications actions, uses, frequency, dose , side effects, interactions of all new/ change medications. Reconcile all medications. Frequencies: RN/ LPN once a day for one day starting 2/15/22; RN/ LPN twice a week for 2 weeks starting 2/20/22, end date 3/5/22; RN/LPN once a week for 2 weeks starting 3/6/22 , end date 3/19/22. On 3/15/2022 at 3:30PM,during an observational home visit, a review of the medications in the home identified the following: a bottle labeled Cilostazol 50 mg one tablet 30 minutes before or 2 hours after breakfast and dinner orally twice a day, date filled 11/3/21; a bottle labeled Ezetimibe 10-20 mg tablet orally once a day; a bottle labeled Tylenol 500 mg tab; Patient stated she takes 2 tablets in the morning and 2 tablets in the afternoon, and two tablets at night; A bottle labeled Aspirin 325 mg , the patient stated she takes one tablet every day; Metoprolol 2.5 mg oral tablet every day date filled 12/7/2021. The record document the following nursing visits: 2/15/22, 2/24/22, 3/2/22, 3/4/22, 3/8/22. There is no documented evidence of an order for Aspirin in the Plan Of Care. There is no documented evidence of a change in order for Tylenol, Cilostazol and Ezetimibe. There is no documented evidence of an order for Metoprolol in the Plan Of Care. There is no documented evidence of a review of all medications the Patient is receiving. There is no documented evidence the Plan Of Care is complete. On 3/16/22 at 2:30 PM, the Administrator was interviewed and did not provide an explanation. 2. Patient #6 has a start of care date of 02/03/2022 with diagnoses of Cerebral Infarction, Essential Hypertension, Depression and Unspecified Abnormalities of Gait Mobility as documented on the "Plan of Care" dated 02/03/2022 to 04/03/2022. The "Plan of Care" for certification period 02/03/2022 to 04/03/2022 documents an order for "PT/PTA (Physical Therapy/Physical Therapy Assistant) 2x week for 3 weeks (Two visits a week for three weeks), RN (Registered Nurse) 1x week for 2 weeks, 2x week for 1 week, 1x week for 1 week ( one visit a week for two weeks, two visits a week for one week, one visit a week for one week) to “assess neurological status”. The Plan of Care lacks documented evidence of the patient’s essential diagnosis of Left side Weakness to LUE, LLE, and Left Hemiplegia. The "Referral" for services dated 01/21/2022 documents the patients "Essential diagnosis" of Left side Weakness to LUE (Left Upper Extremity) LLE (Left Lower Extremity), Left Hemiplegia. A Home Visit was conducted on 03/15/2022 with the agency’s PT and PT Director. The patient was observed to have Left side weakness of LUE, LLE and Left Hemiplegia. The agency failed to ensure that an individualized patient Plan of Care was established that includes pertinent diagnoses of Left side weakness of LUE, LLE and Left Hemiplegia. The survey findings were reviewed on 03/16/2022 at 02:25 P.M with the agency’s Director of Patient Services, Clinical Manager, Physical Therapist Director, and Quality Improvement Manager. On 03/17/2022 at 01:00 P.M, the Clinical Manager was interviewed and acknowledged the findings. 3. Patient # 7 has a start of care date of 02/11/2022 with diagnoses of Fx (Fracture) Shaft of Right Fibula, Fx Unspecified Metatarsal Bone Left Foot, Hypertensive Heart Disease, Heart Failure, Unspecified Atrial Fibrillation, Atherosclerosis Heart Disease, Unspecified Urethral Stricture as documented on the "Plan of Care" dated 02/11/2022 to 04/11/2022. The "Plan of Care" for certification period from 02/11/2022 to 04/11/2022 documents an order for " PT/PTA (Physical Therapy/Physical Therapy Assistant) 1x week for 2 weeks, 2x week for 3 weeks ( one visit a week for two weeks, two visits a week for three weeks), RN 1x week for 1 week, 1x week for two weeks ( one visit a week for one week, one visit a week for two weeks) to "assess skin integrity". The "Referral" for services dated 02/08/2022, documents "Discharge Instructions" from the in-patient facility that the patient has "wound upon discharge". The in-patient facility list of "medications after discharge" includes "Dermawerx apply topically to affected area every12 (twelve) hours. A Home Visit (HV) observation was conducted on 03/15/2022 with the agency's PT and PT Director. During interview with the patient, the patient reported having a "wound" to the Right foot and wound care treatment is done by the Podiatrist. The Plan of Care dated 02/22/2022 to 04/11/2022 lacks an order for the patient's wound treatment including Dermawerx apply topically to affected area every12 (twelve) hours. The agency failed to ensure that an individualized patient Plan of Care was established that includes pertinent wound care treatment of Demawerx. The survey findings were reviewed on 03/16/2022 at 02:25 P.M with the agency’s Director of Patient Services, Clinical Manager, Physical Therapist Director, and Quality Improvement Manager. On 03/17/2022 at 01:15 P.M, the Clinical Manager was interviewed and acknowledged the findings.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record reviews and interviews, the agency failed to ensure that Skilled Services are provided in accordance with the physician's orders. This was evident for four (4) of seven (7) clinical records reviewed. (Patients #1, #4, #5 and #6). Failure to ensure that patient care is provided in accordance with the physician's orders has the potential for negative patient outcomes. The findings are: 3. Patient #6 has a start of care date of 02/03/2022 with diagnoses of Cerebral Infarction, Essential Hypertension, Depression and Unspecified Abnormalities of Gait Mobility as documented on the "Plan of Care" dated 02/03/2022 to 04/03/2022.. The "Plan of Care" for certification period 02/03/2022 to 04/03/2022 documents an order for "RN (Registered Nurse) 1x week for 2 weeks, 2x week for 1 week, 1x week for 1 week ( one visit a week for two weeks, the two visits a week for one week, then one visit a week for one week)". The RN visit notes are dated 02/03/22, 02/18/22, 02/22/22, and 02/28/22. The RN did not visit the patient 1x week for 2 weeks. The clinical record lacks documented evidence of RN visits conducted in conformance to the Plan of Care/Physician's Orders. The survey findings were reviewed on 03/16/2022 at 02:25 P.M with the agency’s Director of Patient Services, Clinical Manager, Physical Therapist Director, and Quality Improvement Manager. On 03/17/2022 at 01:00 P.M, the Clinical Manager (CM) was interviewed and provided an "Interim Order" dated 03/09/2022 for "missed RN visits 02/09/22 and 02/16/22. The CM acknowledged the findings. 2. Patient #4 has a start of care date of 2/15/2022 with diagnosis that include Arthrodesis, Wedge Compression Fracture T 11, T 12 Vertebra, Essential Hypertension, Gastro Esophageal Reflux Disease with Esophagitis without Bleeding, Unspecified Abnormalities Of Gait and Mobility, Unspecified Fall as documented on the " Plan Of Care" for the Certification Period of 2/15/22 to 4/15/22. The " Plan Of Care" for the Certification Period of 2/15/22 to 4/15/22 document:" Interventions: Skilled Nurse : " Frequencies: RN/ LPN once a day for one day starting 2/15/22; RN/ LPN twice a week for 2 weeks starting 2/20/22, end date 3/5/22; RN/LPN once a week for 2 weeks starting 3/6/22 , end date 3/19/22". The record documents the following nursing visits: 2/15/22, 2/24/22, 3/2/22, 3/4/22 and 3/8/22. There is no documented evidence the skilled nursing services were provided in conformance with Physician's Orders. 3. Patient #5 has a start of care date of 2/23/22 with diagnosis that include Unspecified Open Wound Abdominal Wall, Muscle Wasting and Atrophy documented on the " Plan Of Care" for the Certification Period of 2/23/22 to 4/23/22. The " Plan Of Care" for the Certification Period of 2/23/22 to 4/23/22 document:" RN/LPN once a day for one day starting 2/23/22; RN/ LPN once a week for one week starting 2/24/22; RN/LPN twice a week for one week starting 2/28/22; RN/ LPN once a week for two weeks starting 3/6/22. Medications: Silver Sulfadiazine (Silvadene) 1% External one application daily, Mupirocin 2% External one application daily abdominal wound. Skilled Nurse wound care interventions: RN to measure wound weekly starting 2/23/22, Wound care to left thigh cleanse with Normal Saline, pat dry, apply Silvadene cream, cover with ABD pad, secure with tape daily. Patient care safely provide wound care. Skilled Nurse 1-2 a week to teach/ supervise wound care. Wound care to right abdomen #1 and #2. Cleanse with Normal Saline, apply Mupirocin 2% to wound bed, cover with dressing and secure with tape daily. patient can safely provide wound care. Skilled Nurse 1-2 week to teach wound care, signs and symptoms of infection". The record document the following nursing visits: 2/23/22, 2/26/22, 2/28/22 and 3/3/22. There is no documented evidence of nursing visits for the week of 3/6/22 to 3/12/22. The record document the following Licensed Practical Nurse ( LPN) visits: 2/26/22 and 2/28/22. On 2/26/22, There is no documented evidence of wound care and/or wound care education were provided . On 2/28/22 there is no documented evidence on wound care education , and there is no specific description of which wound site of the abdomen was provided and no wound care to the thigh was provided. There is no documented evidence the nursing services were provided in conformance with Physician's Orders. 1. Patient #1 has a start of care date of 4/13/19 with a diagnosis of Autistic Disorder as documented on the Plan of Care dated 1/27/22 through 3/27/22.. The Plan of Care dated 1/27/22 through 3/27/22 documents: SN (Skilled Nurse) PRN (as needed) for assessment; OT (Occupational Therapist) two times a week for 8 weeks; ST (Speech Therapist) one time a week for one week then 3 times a week for 8 weeks to improve oral communication; assess pain; functional limitations include speech; mental status is forgetful. The OT notes dated between 1/26/22 through 3/14/22 document the Patient’s pain is being assessed using the numeric scale. The ST notes dated between 1/29/22 through 3/14/22 document the Patient’s pain is being assessed using the numeric scale. The OT and ST notes lack documented evidence the Wong-Baker Faces pain scale is being used to assess the Patient's pain. The record lacks documented evidence the Patient's pain is being fully assessed. The record lacks documented evidence of conformance to the Plan of Care/physician's order. During an interview on 3/16/22 at 2:42 PM with the Administrator/Director of Patient Services, the Administrator did not provide an explanation as to the reason the Faces scale was not being used.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record reviews and staff interviews, the agency failed to ensure the Physician was alerted of the changes in the Patient's condition that may suggest the Plan of Care need to be altered. This was evident for two (2) of seven (7) Patient Care records reviewed. ( Patients #1 and #4). Failure failed to ensure the Physician was alerted of the changes in the Patients' conditions that may suggest the Plan Of Care need to be altered has the potential for negative patient outcomes. 2. Patient #4 has a start of care date of 2/15/2022 with diagnosis that include Arthrodesis, Wedge Compression Fracture T 11, T 12 Vertebra, Essential Hypertension, Gastro Esophageal Reflux Disease with Esophagitis without Bleeding, Unspecified Abnormalities Of Gait and Mobility, Unspecified Fall as documented on the " Plan Of Care" for the Certification Period of 2/15/22 to 4/15/22. The " Plan Of Care" for the Certification Period of 2/15/22 to 4/15/22 document: " Medications: Cilostazol 50 mg oral one tablet three times a day, Omeprazole 40 mg oral one capsule daily, Famotidine 20 mg tablet oral one tablet every night, Ezetimibe 10 mg tablet oral one tablet twice a day, Acetaminophen Extra strength 500 mg oral two tablets daily pain. Interventions: Skilled Nurse : Instruct / reinstruct Patient, medications actions, uses, frequency, dose , side effects, interactions of all new/ change medications. Reconcile all medications. Frequencies: RN/ LPN once a day for one day starting 2/15/22; RN/ LPN twice a week for 2 weeks starting 2/20/22, end date 3/5/22; RN/LPN once a week for 2 weeks starting 3/6/22 , end date 3/19/22. RN to assess location, intensity, duration, precipitating factors. RN to assess pain management measures, pain medication, RN to assess effectiveness of interventions to mitigate pain". On 3/15/22 at 3:30 PM, during an observational home visit, a review of the medications in the home identified the following: a bottle labeled Cilostazol 50 mg one tablet 30 minutes before or 2 hours after breakfast and dinner orally twice a day, date filled 11/3/21; a bottle labeled Ezetimibe 10-20 mg tablet orally once a day; a bottle labeled Tylenol 500 mg tab; Patient stated she takes 2 tablets in the morning and 2 tablets in the afternoon, and two tablets at night; A bottle labeled Aspirin 325 mg , the patient stated she takes one tablet every day; Metoprolol 2.5 mg oral tablet every day date filled 12/7/2021.The Patient reported a pain rating of 7, located on the rib cage. The record document the following nursing visits: 2/15/22, 2/24/22, 3/2/22, 3/4/22, 3/8/22. The record document the following LPN visits: 2/24/22, 3/2/22 and 3/4/22. On 2/24/22, the LPN document the following : " Pain location: joints. What makes pain worse: pain rating :4, movement How often is breakthrough medication needed: two or three times a day". On 3/2/22, the LPN document the following : " Pain location: joints. What makes pain worse: pain rating :4, movement How often is breakthrough medication needed: two or three times a day". On 3/4/22, the LPN document the following : " Pain location: joints. What makes pain worse: pain rating :4, movement How often is breakthrough medication needed: two or three times a day". On 3/8/22, the RN visit document:" Pain rating :6. Patient understanding to report to Physician any discomforts, none reported, reports adhering to above medications instructed as per action and frequency that she is adhering to medications". On 3/8/22, the record document a Physician order for Celecoxib 200 mg one capsule daily as needed pain". There is no documented evidence the Physician was alerted that the patient was taking Aspirin. There is no documented evidence the Physician was notified the patient was taking the Tylenol more frequently ( 2 tablets three times a day) than the Orders prescribed. There is no documented evidence the Physician was alerted to review the orders for Cilostazol and Ezetimibe and Metoprolol. There is no documented evidence of communication with the Physician. On 3/17/2at 2:45 PM, the Administrator and the Regional Clinical Manager were interviewed and did not provide an explanation for the findings. 1. Patient #1 has a start of care date of 10/14/21 and a discharge date of 12/2/21 with diagnoses of Hypertension, Chronic Obstructive Pulmonary Disease and Congestive Heart Failure as documented on the Plan of Care dated 10/14/21 through 12/12/21.. The Plan of Care dated 10/14/21 through 12/12/21 documents: SN (Skilled Nurse) one visit for three weeks then 2 visits for one week for assessment. The SN notes dated between 10/14/21 through 11/1/21 document the Patient has pitting edema plus 2 to the lower extremities. The SN note dated 11/1/21 documents "Patient does not have a scale, insurance will not pay for it". There is no documented evidence of communication with the Nursing Supervisor and physician regarding the Patient's edema and daily weights. During an interview with the Director of Patient Services/Administrator on 3/16/22 at 2:00 PM, the Administrator stated "the agency has scales for the nurses to use". No other explanation was provided.

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 one (1) of seven (7) Clinical Records reviewed. (Patient #2) 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 finding is: Patient #1 has a start of care date of 10/14/21 and a discharge date of 12/2/21 with diagnoses of Hypertension, Chronic Obstructive Pulmonary Disease and Congestive Heart Failure as documented on the Plan of Care dated 10/14/21 through 12/12/21.. The Plan of Care dated 10/14/21 through 12/12/21 documents: SN (Skilled Nurse) one visit for three weeks then 2 visits for one week; PT (Physical Therapist) one time one week then 2 times a week for 2 weeks, then 1 time a week for 4 weeks; Oxygen 2 liters per minute continuously. The PT note dated 10/19/21 documents the Patient was discharged home on Oxygen 2 to 3 liters per minute PRN (as needed). The SN visits document the Patient is on 2 liters per minute continuously. The PT notes dated 10/21/21 through 12/2/21 lack documented evidence as to whether the Patient is using 2 or 3 liters per minute and either PRN or continuous. There is no documented evidence of communication between the PT and the RN regarding the Oxygen. During an interview with the Administrator on 3/17/22 at 2:00 PM, the Administrator did not provide an explanation.

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 record reviews and staff interviews , the agency failed to ensure that only Registered Nurses perform assessments, and that nursing services are provided under the supervision of a Registered Nurse (RN). This was evident for two (2) of seven (7) patient care record reviewed. (Patient #4 and #5). Failure to ensure that only Registered Nurses perform assessments and that nursing services are provided under the supervision of a Registered Nurse has the potential for negative patient outcomes. The findings are: 1. Patient # 4 has a start of care date of 2/15/22 with diagnosis that include Arthrodesis, Wedge Compression Fracture T 11, T 12 Vertebrae, Essential Hypertension, Unspecified Fall, Unspecified Abnormalities of Gait and Mobility as documented on the " Plan Of Care" for the Certification Period of 2/15/2022 to 4/15/2022. The " Plan Of Care" for the Certification Period of 2/15/2022 to 4/15/2022 document:" Interventions: Patient shall receive Registered nurse (RN)/ Licensed Practical Nurse ( LPN) during the this Certification Period. RN to assess Patient knowledge in disease process and management of health conditions/ vital signs complications. LPN to reinstruct RN to assess Patient knowledge in disease process and management of health conditions/ vital signs complications. RN to conduct all Patient's nursing assessments including comprehensive assessments and assist in the establishment of care plan every 60 days and as needed . Skilled Nurse instruct reinstruct Patient / patient caregiver : Medications actions, uses, frequency, dose, side effects, interactions of all new/ change medications. Reconcile all the medications. RN to assess Patient adherence to medication /treatment regimen. LPN to reinstruct Patient on adherence to medication/ treatment regimen". RN to assess neurological status. RN to assess cardiovascular status. LPN to reinstruct Patient/ Caregiver on cardiovascular disease management/ complications and appropriate interventions. RN to assess / instruct Patient / Caregiver on GERD etiology and treatment. RN to assess location, intensity, duration, precipitating factors. RN to assess pain management measures, pain medication, RN to assess effectiveness of interventions to mitigate pain". A Skilled Nurse Visit Note" dated 2/24/22 conducted and signed by the LPN document : Skilled Assessment : Pupillary reaction: Right PERLA, Left PERLA; Cardiopulmonary, Capillary refill, Pedal Pulse , Breath Sounds". Plan for next visit: reeducate on disease process". A Skilled Nurse Visit Note" dated 3/2/22 conducted and signed by the LPN document : Skilled Assessment : Pupillary Reaction Right PERLA, Left PERLA; Cardiopulmonary, Capillary refill, Pedal Pulse , Breath Sounds. Plan for next visit: Reinstruct on signs and symptoms of decompensation of disease process". A Skilled Nurse Visit Note" dated 3/4/22 conducted and signed by the LPN document : Skilled Assessment : Pupillary Reaction Right PERLA, Left PERLA; Cardiopulmonary Capillary refill, Pedal Pulse , Breath Sounds. Plan for next visit: Assessment: Reinstruct in diet and food to avoid". There is no documented evidence the nursing services were provided in accordance with the Licensed practical Nurse education, Licensure and Scope of Practice. The record document the following LPN visits: 2/24/22, 3/2/22, 3/4/22. On 2/24/22, the LPN visit note document: " Scale used, numeric. Pain rating:4; Causes of pain different positions and movement; What makes pain worse: movement; Frequency of pain on impact and activities: daily limits on activities and interrupts activities. How often is breakthrough needed: 2-3 times a day". On 3/2/22, the LPN visit note document: " Scale used, numeric. Pain rating:4; Causes of pain different positions and movement; What makes pain worse: movement; Frequency of pain on impact and activities: daily limits on activities and interrupts activities. How often is breakthrough needed: 2-3 times a day". On 3/4/22, the LPN visit note document: " Scale used, numeric. Pain rating:4; Causes of pain different positions and movement; What makes pain worse: movement; Frequency of pain on impact and activities: daily limits on activities and interrupts activities. How often is breakthrough needed: 2-3 times a day". There is no documented evidence the LPN communicate with the rn the Patient was taking the pain medication two or three times a day. There is no documented evidence of adequate supervision 2. Patient # 5 has a start of care date of 2/23/2022 with diagnosis that include Unspecified Open Wound Abdominal Wall , Muscle Wasting and Atrophy, Urethral Discharge as documented on the " Plan Of Care" for the Certification Period of 2/23/22 to 4/23/22. The " Plan Of Care" for the Certification Period of 2/23/22 to 4/23/22 document :"Interventions: Patient shall receive Registered nurse (RN)/ Licensed Practical Nurse ( LPN) during the this Certification Period. RN to assess Patient knowledge in disease process and management of health conditions/ vital signs complications. LPN to reinstruct RN to assess Patient knowledge in disease process and management of health conditions/ vital signs complications. RN to conduct all Patient's nursing assessments including comprehensive assessments and assist in the establishment of care plan every 60 days and as needed . Skilled Nurse instruct reinstruct Patient / patient caregiver : Medications actions, uses, frequency, dose, side effects, interactions of all new/ change medications. Reconcile all the medications. RN to assess Patient adherence to medication /treatment regimen. LPN to reinstruct Patient on adherence to medication/ treatment regimen". A Skilled Nurse Visit Note" dated 2/26/22 conducted and signed by the LPN document : Skilled Assessment : Pupillary Reaction Right (Pupils Equal and Reactive to Light Accommodation) PERLA, Left PERLA; Cardiopulmonary, Capillary refill, Pedal Pulse , Breath Sounds. Plan for next visit: Assessment: monitor vital signs and teaching: taking medication as per physician orders". A Skilled Nurse Visit Note" dated 2/28/22 conducted and signed by the LPN document : Skilled Assessment : Pupillary Reaction Right PERLLA, Left PERLLA; Cardiopulmonary, Capillary refill, Pedal Pulse , Breath Sounds. Plan for next visit: Assessment: monitor Blood Pressure and teaching a low salt diet". There is no documented evidence the nursing services were provided in accordance with the Licensed practical Nurse education, Licensure and Scope of Practice. There is no documented evidence of adequate RN supervision. On 3/17/22 at 12:15 PM, the Administrator was interviewed and did not provide an explanation