Every finding on record at Visiting Nurse Association of Albany, Inc.

The following statement of deficiencies represents the results of a re-certification survey of VNA Home Health, a Certified Home Health Agency, conducted May 5, 2025 through May 9, 2025. A standard re-certification survey was initiated on May 5, 2025. Deficient practices were identified within Level 1 standards in 484.60 Condition, Care Planning Coordination, Quality of Care and 484.75 Condition, Skilled Professional Services resulting in a partial extended survey. The survey consisted of a review of seventeen clinical records including five discharge records, seven personnel records, and seven observational home visits. The survey included a review of pertinent policies and procedures, Quality Improvement Meeting Minutes for the past twelve months, the agency's Admission Packet, the Emergency Preparedness Plan and the Complaint Log. The census at the time of the survey was four hundred and fifty-two. Pre-survey activities consisted of review on May 1, 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 January 01, 2024, through December 31, 2024, and the agency's compliance with report submissions for the 2023 statistical report. Findings were reviewed at the exit conference on May 9, 2025. The following deficiencies are identified as a result of the survey: Federal: G0372, G0572, G0574, G0590 and G0726. State: J1108, J1148, J1168, J1260, J1412, J1440, R1022 and W0407.

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 the Home Health Agency (HHA) Error Summary by Agency Report for the period 01/01/2024 through 12/31/2024, the agency failed to encode and electronically transmit each completed Outcome and Assessment Information Set (OASIS), regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within thirty days of completing the assessment of the beneficiary. Failure to encode and electronically transmit each complete OASIS assessment, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within thirty days of completing the assessment of the beneficiary has the potential for incorrect and incomplete reporting data. FindingOn 04/29/2025 the surveyors reviewed the Certification and Survey Provider Enhanced Reports (CASPER), "Home Health Agency Error Summary Report by Agency" for report period 01/01/2024 - 12/31/2024. The report contains a warning code -3330 "Record Submitted Late": The submission date is more than thirty days after M0090 "Date Assessment Completed" on this new record. The CASPER Report states 23 (0.34%) out of 6733 assessments processed were submitted more than thirty days after M0090. Their is no documented evidence the agency submitted the required documents timely for 23 out of 6733, or for 0.34% of submissions. The finding was confirmed on 05/09/2025 at 11:00 AM with the Administrator and Executive Director of Clinical Operations; no additional evidence was provided.

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 ensure services are provided in accordance with the Plan of Care (POC) in one of seventeen records (Patient # 12). Failure to follow the POC has the potential for patients to receive care inconsistent with the physician's orders resulting in unmet patient needs and possible negative patient outcomes. Patient # 12 (start of care 12/12/2019) has diagnoses of Encounter for Adjustment and Management of Ventricular Assist Device (VAD) and Fistula of Intestine. The record contains Visit Note Reports (dated 03/18/2025, 03/25/2025, 04/01/2025 and 04/08/2025) that state "Central line dressing changed via sterile technique, cleaned, replaced Biopatch flushed with 10 milliliters (ml) normal saline (NS), 5 ml heparin, replaced cap and flushed with another 10 ml of NS." The POC for certification period 03/15/2025 through 05/13/2025 does not contain orders for a dressing change or flushes to the central line. The findings were confirmed on 05/07/2025 at 3:00 PM with the Administrator and Executive Director of Clinical Operations; no additional evidence was provided.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview the agency failed to ensure a complete Plan of Care (POC) was developed to meet the individualized needs of the patient in five out of seventeen records (Patient # 2, 6, 11, 13 and 17). Failure to develop a comprehensive POC has the potential for unmet patient needs and places patients at risk for receiving incorrect and/or inappropriate care. Patient # 2 (start of care 05/04/2025) has diagnosis of Dehiscence of Amputation Stump. The POC for certification period 05/04/2025 through 07/02/2025 contains an order for: Oxygen (O2) gas for inhalation O2 - Continuous Positive Airway Pressure (CPAP) / Bilevel Positive Airway Pressure (BiPAP) and concentrator 2 Liter bedtime Patient / Caregiver manages. The order is incomplete as it is lacking the route of administration for the oxygen: mask and/or nasal canula and oxygen precautions.Patient # 6 (start of care 02/19/2025) has diagnoses of Spinal Stenosis, Lumbar Region without Neurogenic Caudation and Other Intervertebral Disc Displacement, Lumbar Region. The record contains POC's for certification periods 02/29/2025 through 04/19/2025 and 04/20/2025 through 06/18/2025 that both contain an order for: Fluticasone Propionate 50 micrograms (mcg) / actuation nasal 2 spray daily/as needed (PRN) as needed for nasal congestion-no more than 2 doses in 24 hours. The orders are incomplete as they are lacking instruction as to which Nare, or both to take the medication.Patient # 11 (start of care 02/28/2025) has diagnoses of Pressure Ulcer of Left Heel, Stage 3 and Atrial Fibrillation. The POC for certification period 04/29/2025 through 06/27/2025 contains an order for: Ibandronate 150 milligrams (mg) oral 1 tablet monthly Every 30 days, next dose due 03/01/2025 at 6 AM. The order requires clarification for the correct next due date, or if the medication has been discontinued.Patient # 13 (start of care 04/04/2024 discharged 11/29/2024 has diagnoses of Pressure Ulcer of Right Heel, Stage 2 and Unspecified Fracture Shaft of Left Tibia Subsequent for Closed Fracture with Routine Healing. The POC for certification period 10/01/2024 through 11/29/2024 contains orders for: Lidocaine 5 % Topical Patch topical 1 adhesive patch medicated daily Apply to lower back. The order requires clarification as to how long to leave the patch on and/or removal instructions and Silver Sulfadizine 1% Topical Cream Topical per instructions 3 times daily Apply to affected area 3 times (X) a day. The order is incomplete as it requires a specified anatomical location to apply the cream.Patient # 17 (start of care 01/15/2023 discharged 04/30/2025) has diagnoses of Other Chronic Pain and Bilateral Primary Osteoarthritis of Knee. The POC for certification period 01/04/2025 through 03/04/2025 contains an order for: Oxygen Gas for Inhalation 3% O2 continuous Supplied by (oxygen company) Oxygen for out of home. The order is incomplete as it is lacking the route of administration for the oxygen: mask and/or nasal canula and oxygen precautions;The POC for certification period 03/05/2025 through 05/03/2025 contains an order for: Oxygen Gas for Inhalation 2 Liter as directed Supplied by (oxygen company) Oxygen for out of home. The order is incomplete as it is lacking the dosage, route of administration for the oxygen: mask and/or nasal canula and oxygen precautions;Xarelto 15 mg tablet oral 1 tablet daily. The orders are incomplete as they are lacking bleeding precautions related to anticoagulant medication use.The findings were confirmed on 05/06/2025 at 3:15 PM, 05/07/2025 at 3:00 PM and 05/08/2025 at 1:45 PM with the Administrator and Executive Director of Clinical Operations; no additional evidence was provided.

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 clinical record review and staff interview evidence is lacking in one of seventeen records (Patient # 14) the physician was contacted regarding changes that alter or suggest the need to alter the Plan of Care (POC). Failure to consult with the physician when changes occur in the patient's condition has the potential for unmet patient needs and/or negative patient outcomes. Patient # 14 (start of care 11/15/2024 discharged 01/09/2025) has diagnoses of Encounter for Orthopedic Aftercare Following Surgical Amputation and Acquired Absence of Right Leg Below Knee. The POC for certification period 11/15/2024 through 01/13/2025 contains an order for: Wound care to suture site located on right lower extremity (RLE) below the knee amputation (BKA) using clean technique daily. Apply betadine paint, allow to dry, cover with bordered gauze dressing or non-adherent gauze and abdominal pad (ABD), secure with roll gauze/tape and ace wrap. The record contains a Visit Note Report (dated 12/05/2024) that states " Patient (Pt) seen by surgeon this week, all staples/sutures removed. Wound is well approximated, open to air (OTA). Pt states he would like me to wrap it with Kling gauze (which I did) and he then applied the shrinker". The record lacks documented evidence the physician was notified of the need to change the dressing order or to add the durable medical equipment of a shrinker. The finding was confirmed on 05/08/2025 at 1:45 PM with the Administrator and Executive Director of Clinical Operations; no additional evidence was provided.

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview the agency failed to ensure adequate supervision of the Licensed Practical Nurse (LPN) staff in two of seventeen records reviewed (Patient # 4 and 14). Failure to adequately supervise LPN staff has the potential to result in the provision of inappropriate and/or incorrect care and negative patient outcomes. Patient # 4 (start of care 04/02/2025) has diagnoses of Pressure Ulcer of Sacral Region, Stage 4 and Pressure Ulcer of Other Site, Stage 2. The record contains Visit Note Reports (dated 04/11/2025, 04/14/2025, 04/18/2025, 04/23/2025, 04/28/2025, 04/30/2025 and 05/02/2025) and a Client Episode Coordination Note (dated 04/16/2025) completed by the licensed practical nurse (LPN) that state "no signs or symptoms of infection noted". Performing a nursing assessment is outside the LPN's scope of practice. Also, the record lacks documented evidence the Registered Nurse (RN) reviewed the LPN Visit Note Reports to ensure the supervision of appropriate care. Patient # 14 (start of care 11/15/2024 discharged 01/09/2025) has diagnoses of Encounter for Orthopedic Aftercare Following Surgical Amputation and Acquired Absence of Right Leg Below Knee. The record contains Visit Note Reports (dated 11/20/2024, 11/26/2024) completed by the LPN. The record is lacking documented evidence the RN reviewed the LPN Visit Notes to ensure the supervision of appropriate care. The findings were confirmed on 05/06/2025 at 3:15 PM and 05/08/2022 at 1:45 PM with the Administrator and Executive Director of Clinical Operations; no additional evidence was provided.

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 clinical record review and staff interview evidence is lacking in one of six clinical records reviewed (Patient # 5) the physician was contacted regarding changes that alter or suggest the need to alter the Plan of Care (POC). Failure to consult with the physician when changes occur in the patient's condition has the potential for unmet patient needs and/or negative patient outcomes. Patient # 5 (start of care 1120/20222) has diagnoses of Encounter for Surgical After Care Following Surgery on the Digestive System and Encounter for Surgical After Care Following Surgery on the Genital Urinary System. The clinical record contains an order (dated 11/27/2022) for the Skilled Nurse to conduct 3 visits the week of 12/04/2022. The clinical record contains documentation of only two Skilled Nurse visits conducted (12/04/2022 and 12/07/2022) in that week. The clinical record lacks documented evidence the physician was notified of a missed Skilled Nurse visit the week 12/04/2022. The finding was confirmed on 01/11/2023 at 1 PM with the Vice President/Chief Operation Officer, the Director of Quality Assurance and the Director of Clinical Services; no further evidence was provided.

The following statement of deficiencies represents the results of a standard re-certification survey of Visiting Nurse Association of Albany, Certified Home Health Agency conducted on July 11 through July 15, 2022. The survey consisted of a review of eighteen clinical records, including five discharge records, seven observational home visits and ten personnel records for professional and paraprofessional personnel. The survey included a review of pertinent policies and procedures, Quality Improvement Meeting minutes for the past four meetings, the agency's Governing Authority meeting minutes for the past twelve months, the Admission packet, the Emergency Preparedness Plan, and Complaint Log. The agency's census at the time of the survey was 341. Pre-survey activities consisted of review on July 8, 2022 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 04/01/2021 through 03/31/2022, and the agency's compliance with statistical report submissions for 2020 and 2021 and the Emergency Drill conducted June 11 through June 13, 2019. A COVID-19 policy and procedure and vaccination survey was conducted in conjunction with the re-certification survey. The agency's Vice President of Care Transitions, Vice President/Chief Operation Officer, Director of Corporate Compliance, Director of Clinical Strategy, Director of Clinical Services and Vice President of Human Resources and staff were interviewed. The following deficiencies are identified as a result of the survey: Federal: G0514 Registered Nurse Performs Assessment; G0572 Plan of Care; G0574 Plan of Care Must Include; G1010 Contents of Clinical Record; State: J0452 Policies and Procedures of Service Delivery; J1108 Governing Authority; J1426 Personnel; and L0001 Unacceptable Infection Control.

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 evidence is lacking in three of eighteen records (Patient # 2, 11 and 15) the initial assessment visit was conducted within 48 hours of receiving the referral for services, within 48 hours of the patient's return home or on the physician ordered start of care date. Failure to conduct the initial assessment within the required time frame has the potential to result in unmet patient needs and negative patient outcomes. Findings: Patient # 2 (start of care 07/09/2022) has a diagnosis of Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris. The record contains a hospital referral dated 07/01/2022 with no specific physician ordered start of care date. The patient discharged from the hospital on 07/03/2022. The initial assessment was conducted on 07/09/2022, six days after the patient's hospital discharge. The record is lacking documented evidence of notification to the physician for the delay in the start of care. Patient # 11 (start of care 06/30/2022) has diagnoses of Encounter for Surgical Aftercare Following Surgery on the Circulatory System and Peripheral Vascular Angioplasty Status with Implants and Grafts. The record contains an in-agency referral document that states the referral was first received on 06/20/2022 with no specific physician ordered start of care date. The patient discharged from the hospital on 06/24/2022. The initial assessment was conducted on 06/30/2022, ten days after the patient's discharge from the hospital. The record is lacking documented evidence of notification to the physician for the delay in the start of care. Patient # 15 (start of care 01/09/2022) has diagnoses of Parkinson's Disease and Repeated Falls. The clinical record contains an in-agency form (dated 12/11/2021) and signed by the physician with an ordered start of care date of 12/28/2021. The initial assessment was conducted on 01/09/2022, twelve days after the patient's discharge from the rehabilitation center. The record lacks documented evidence of notification to the physician for the delay in the start of care. The findings were confirmed on 07/12/2022 at 3:45 PM and 07/13/2022 at 3:40 PM with the Vice President of Care Transitions, Vice President/Chief Operation Officer, Director of Corporate Compliance, Director of Clinical Strategy and Director of Clinical Services; no additional evidence was presented.

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 ensure services are provided in accordance with the Plan of Care (POC) in three of eighteen records (Patient # 5, 11 and 18). Failure to follow the POC has the potential for patients to receive care inconsistent with the physician's orders resulting in unmet patient needs and possible negative patient outcomes. Findings: Patient # 5 (start of care 06/28/2022) has diagnoses of Traumatic Subdural Hematoma without Loss of Consciousness and History of Falling. The POC for certification period 06/28/2022 through 08/26/2022 contains an order for Skilled Nurse visits twice a week for one week, the once a week for two weeks. The clinical record lacks documented evidence of a second Skilled Nurse visit being conducted the week 07/03/2022. Also, the POC contains an order for a Physical Therapy (PT) assessment to be conducted the week of 06/28/2022. The clinical record lacks any documented evidence of a PT assessment being conducted. Patient # 11 (start of care 06/30/2022) has diagnoses of Encounter for Surgical Aftercare Following Surgery on the Circulatory System and Peripheral Vascular Angioplasty Status with Implants and Grafts. The POC for certification period 06/30/2022 through 08/28/2022 contains an order for Licensed Professional to report vital signs falling outside the following established parameters: Temperature less than () 99.5, Pulse 100, Systolic Blood Pressure (BP) 180, Diastolic BP 110, Random Blood Sugar (RBS) 180 and Oxygen saturation 100. A PT visit note (dated 07/01/2022) notes the patient's pulse was 48, below the established parameter. The PT marked the physician was not notified. Also, on 07/05/2022, an RN visit note states the patient's pulse reading was 58, below the established parameter. The physician was not notified. A note was written under Comments, "Patient normal." The RN failed to follow the POC and notify the MD of the low pulse. Further, on 07/06/2022, an Occupational Therapist (OT) note states the patient's vital signs were not checked at all. The OT failed to follow the POC and check vital signs. The MD was not notified. Patient # 18 (start of care 06/22/2022) has diagnoses of Pneumonia, Unspecified Organism and Atelectasis. The POC for certification period 06/22/2022 through 08/20/2022 contains an order for the Licensed Professional to report vital signs falling outside the following established parameters. Temperature 99.5, Pulse 100, Respirations 29, Systolic BP 180, Diastolic BP 110, RBS 180 and Oxygen saturation 100. A PT visit note (dated 07/05/2022) lacks any documented evidence the PT checked the patient's BP. Also, the physician was not notified of the failure to follow the POC. Also, an RN visit note (dated 07/12/2022) lacks any documented evidence the RN assessed the patient's BP, pulse, respirations or oxygen saturation. The physician was not notified of the failure to follow the POC. The findings were confirmed on 07/13/2022 at 3:40 PM and 03:45 PM with the Vice President of Care Transitions, Vice President//Chief Operation Officer, Director of Corporate Compliance, Director of Clinical Strategy and Director of Clinical Services; no additional evidence was provided.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview the agency failed to ensure a complete Plan of Care (POC) was developed to meet the individualized needs of the patient in seven of eighteen records (Patient # 2, 3, 5, 6, 15, 16 and 17). Failure to develop a comprehensive POC has the potential for unmet patient needs and places patients at risk for receiving incorrect and/or inappropriate care. Findings: Patient # 2 (start of care 07/09/2022) has a diagnosis of Atherosclerotic Heart Disease of Native Coronary without Angina Pectoris. The physician's POC for certification period 07/09/2022 through 09/06/2022 contains an order for Flonase Allergy Relief 50 micrograms (mcg)/Actuations Nasal, daily, two sprays. The order is incomplete as it does not state which nare or both, to apply the medication to. Patient # 3 (start of care 07/06/2022) has diagnoses of Hypertensive Heart and Chronic Kidney Diseases with Heart Failure and Stage 1-4 unspecified Chronic Kidney Disease, and Acute on Chronic Systolic (Congestive) Heart Failure. The physician's POC for certification period 07/06/22 through 09/03/2022 contains orders for: - Carboxymethylcellulose Sodium 0.5 percent (%) Eye Drops, one drop, four times daily. The order is incomplete as it lacks directions as to which eye to apply the medication to or both; - Diclofenac 1 % Topical Gel, apply four grams (gm) three times daily/as needed (prn). The order is incomplete as it lacks directions to which anatomical location to apply the medication to; - Fluticasone Propionate 50 mcg/actuation nasal, two spray daily. The order is incomplete as it lacks directions as to which nare to apply the medication or both; and - Latanoprost 0.005% eye drops, one drop at bedtime. The order is incomplete as it lacks directions as to which eye to apply the medication or both. Patient # 5 (start of care 07/03/2022) has diagnoses of Encounter for Attention to Gastrostomy and Trauma Subdural Hematoma without Loss of Consciousness. The POC for certification period 07/03/2022 through 08/31/2022 contains orders for: - Acetaminophen 325 mg tablet, every six hours/prn via Peg tube. The order is incomplete as it does not state to crush the medication prior to administration; - Amlodipine 5 mg tablet, daily at 8 AM via Peg tube. The order is incomplete as it does not state to crush the medication prior to administration; - Atorvastatin 40 mg tablet at 8 PM via Peg tube. The order is incomplete as it does not state to crush the medication prior to administration; - Donepezil 5 mg tablet at 8 PM via Peg tube. The order is incomplete as it does not state to crush the medication prior to administration; - Levothyroxine 50 mcg tablet at 6 AM via Peg tube. The order is incomplete as it does not state to crush the medication prior to administration; - Methotrexate Sodium 2.5 mg tablet, Mondays at 8 AM via Peg tube. The order is incomplete as it does not state to crush the medication prior to administration; and - Sertraline 50 mg tablet at 8 AM via Peg tube. The order is incomplete as it does not state to crush the medication prior to administration. Patient # 6 (start of care 11/05/2021) has diagnoses of Pressure Ulcer of Sacral Region, Stage 4 and Hypertensive Heart Disease with Heart Failure. The physician's POC for certification period 05/04/2022 through 07/02/2022 contains an order for oxygen via Bilevel Positive Airway Pressure (BiPAP), 2 liters, every PM. The POC is incomplete as it lacks oxygen precautions. Further, the Registered Nurse (RN) assessment (dated 07/01/2022) contains Durable Medical Equipment (DME) specifically a rolling walker. The POC is incomplete as it lacks DME, specifically a rolling walker. Patient # 15 (start of care 01/09/2022) has diagnoses of Parkinson's Disease and Repeated Falls. The physician's POC for certification period 01/09/2022 through 03/09/2022 contains an order for Acetaminophen 325 mg tablet, two tablets, as needed/prn, 3 times daily for moderate pain 4 - 7, Maximum Daily Dosage (MDD) 3. The order is incomplete as it does not state the time range between dosages. Further, the clinical record contains a Medical Social Worker Visit Note (dated 01/14/2022) that states the patient utilizes a LIFELINE (Personal Emergency Response System). The POC lacks any documentation the LIFELINE was added to DME. Patient # 16 (start of care 09/22/2021) has diagnoses of Unspecified Fracture of the Lower End of Right Radius, Subsequent Encounter for Open Fracture Type I or II with Routine Healing and Unspecified Fracture of Lower End of Right Ulna, Subsequent Encounter for Open Fracture Type I or II with Routine Healing. The physician's POC for certification period 11/21/2021 through 01/19/2022 and certification period 01/20/2022 through 03/20/2022 contain orders for: - Cyclobenzaprine 5 mg tablet as needed. Take one tablet up to three times a day for muscle spasms. The order is incomplete as it does not state the time interval between dosages; and - Tizanidine 2 mg capsule, twice daily/prn, as needed for pain, MDD two. The order is incomplete as it does not state the time interval between dosages. Further, the POC for certification period 01/20/2021 contains DME, specifically oxygen supplies. The POC is incomplete as it does not contain orders for oxygen. Patient # 17 (start of care 01/24/2022) has diagnoses of Encounter for Change or Removal of Surgical Wound Dressing and Encounter for Orthopedic Aftercare Following Surgical Amputation. A supplemental order (dated 04/22/2022) states Skilled Nurse to perform wound care to left skin tear, cleanse with normal saline, apply Xeroform and cover with Optifoam three times a week and PRN. The order is incomplete does not state the number of PRN visits to be made for additional changes to wound if necessary. The findings were confirmed on 07/12/2022 at 3:30 PM, 3:45 PM, and 07/13/2022 at 3:40 PM, 3:45 PM and 3:50 PM with the Vice President of Care Transitions, Vice President/Chief Operation Officer, Director of Corporate Compliance, Director Clinical Strategy and Director of Clinical Services; no additional evidence was provided.

Contents of clinical record CFR(s): 484.110(a) Standard: Contents of clinical record. The record must include: This STANDARD is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to ensure in four of eighteen records (Patient # 3, 6, 10 and 14) professional staff maintain an accurate, current and clearly documented record related to the provision of the patient's care. Failure to maintain an accurate, current and clearly documented record has the potential for staff to make clinical decisions based on inaccurate and/or missing information with the potential to result in negative patient outcomes. Findings: Patient # 3 (start of care 07/06/2022) has diagnoses of Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1-4/Unspecified Chronic Kidney Disease. The physician's Plan of Care (POC) for certification period 07/06/2022 through 09/03/2022 states the patient utilizes Durable Medical Equipment (DME), specifically bed rails, grab bars/rail and a hand held shower. The Registered Nurse (RN) initial assessment (date 07/06/2022) fails to document the patient utilizes DME, specifically bed rails, grab bars/rail and a hand held shower. Patient # 6 (start of care 11/05/2021) has diagnoses of Pressure Ulcer of Sacral Region, Stage 4 and Hypertensive Heart Disease with Heart Failure. The POC for certification period 07/03/2022 through 08/31/2022 contains DME, specifically a rolling walker. The RN reassessment (dated 07/01/2022) fails to document the patient utilizes DME, specifically a rolling walker. Patient # 10 (start of care 06/19/2022) has diagnoses of Pulmonary Hypertension and Hypertensive Heart Disease with Heart Failure. The POC for certification period 06/19/2022 through 08/17/2022 contains DME, specifically a commode, Continuous Positive Airway Pressure (CPAP), an elevated toilet seat and wound care supplies. The RN initial assessment (dated 06/19/2022) fails to document the patient utilizes DME, specifically a commode, CPAP, an elevated toilet seat and wound care supplies. Patient # 14 (start of care 03/02/2022) has diagnoses of Pressure Ulcer of Left Buttock, Unstageable and Pressure of Right Buttock, Unstageable. The POC for certification period 03/02/2022 through 04//30/22 contains DME, specifically a pressure reducing support surface, walker, Intravenous (IV) supplies, Ostomy supplies and wound care supplies. The RN initial assessment (dated 03/02/2022) fails to document the patient utilizes DME, specifically a pressure reducing support surface, walker, IV supplies, Ostomy supplies and wound care supplies. The findings were confirmed on 07/13/2022 at 3:50 PM with the Vice President of Care Transitions, Vice President/Chief Operating Officer, Director of Corporate Compliance, Director of Clinical Strategy and Director of Clinical Services; no additional evidence was proficed.