Every finding on record at Visiting Nurse Service of New York Home Care II

This Statement of Deficiencies is the result of an on-site complaint investigation of IQIES complaints #2725869, #2734440 and #2792150 from 03/04/2026 to 03/06/2026, conducted at VNS of NY Home Care CHHA, located at 220 E 42nd Street, 6th Floor, New York, NY 10017 as authorized by CMS (Centers of Medicare and Medicaid Services) to evaluate the Certified Home Health Agency's compliance with Federal Conditions of Participation (CoP): G 0406 - Patient Rights, G 0510 - Comprehensive Assessment of Patients, G 0560 - Discharge Planning, G 0570 - Care planning, Coordination, Quality of Care, G 0700 - Skilled Professional Services, and G 0750 - Home Health Aide Services. The active census at the time of the survey was 6, 970. The investigation consisted of a review of nine (9) clinical records and four (4) personnel records. Additionally, the Certified Home Health Agency's complaint/incident logs from December 2025 to March 2026 and Admission Packet were reviewed. Pre-survey activities consisted of a review on 03/03/2026 of the agency's Health Commerce System account and compliance history. The Vice President Quality, Vice President Regional Patient Care Services, Quality and Performance Improvement Director, Associate Director Quality Assurance Performance Improvement, Director of Quality, and Director of Quality Performance Improvement were interviewed. The Provider is considered to be in substantial compliance with the following Conditions of Participation: G 0406 - Patient Rights G 0510 - Comprehensive Assessment of Patients G 0560 - Discharge Planning G 0570 - Care planning, Coordination, Quality of Care G 0700 - Skilled Professional Services G 0750 - Home Health Aide Services. The IQIES complaints #2725869, #2734440 and #2792150 are substantiated. The following Standard deficiencies were identified as a result of the on-site complaint investigation: G 0478 Investigate complaints made by patient G 0572 Plan of Care G 0574 Plan of care must include the following G 0608 Coordinate care delivery G 0818 Home Health Aide supervision elements

Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) The HHA must— (i) Investigate complaints made by a patient, the patient's representative (if any), and the patient's caregivers and family, including, but not limited to, the following topics: (A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; (B) Mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on clinical record reviews and staff interviews, the agency failed to investigate patient complaints about the dissatisfaction of the services being provided. This was evident for two (2) of nine (9) clinical records reviewed (Patients #2 and #3). Failure to investigate complaints about the dissatisfaction of the services being provided has the potential to place patients at risk for negative outcomes. The findings are: 1.Patient #3 has a Start of Care date of 01/15/2026 and discharge date of 02/26/2026 with the following diagnoses Traumatic Subdural Hemorrhage without Loss of Consciousness, Cerebrospinal Fluid Leak documented on the Home Health Certification and Plan of Care for the Certification Period 01/15/2026 to 03/15/2026. The Visit Note dated 01/21/2026 documents: Supervisory visit not performed due to VNS HHA leaving just as SN (Skilled Nurse) arrived. Spouse and daughter voiced dissatisfaction with VNS HHA (Home Health Aide) services. Family states that HHA did not receive Paraprofessional Plan of Care prior to visit. Family voiced dissatisfaction with the way VNS scheduled HHA without informing family of the time the HHA would arrive and the task the HHA would assist with. Family states that they no longer want VNS Services and they will be contacting the CFM (Clinical Field Manager) to cancel HHA services. The Patient Note (from the vendor on HHAeXchange) dated 01/17/2026 documents HHA (P.D) assigned Mon/Wed/Friday effective 1/21-02/02 2 pm to 4 pm. Detailed VM (voice message) left for the member at 1:48 pm. The Clinical Record lacks documented evidence of the agency attempting any future contact the patient after 01/17/2026. The Clinical Record lacks documented evidence of a complaint investigation regarding the patient's spouse reporting their dissatisfaction with the HHA (Home Health Aide) services. There is no documented evidence of a complaint in the complaint log. On 03/04/2025 on 04:00 PM, the Associate Director Quality Assurance Performance Improvement was interviewed and stated that the nurse (Case Manager) thought if the patient refused HHA services, the complaint is resolved. The agency’s Patient Complaints policy and procedure, dated September 2021, documents in policy section 2a, Complaints for the purpose of this policy, are defined as reported problems concerns or dissatisfaction regarding the following: Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately. 1) Patient #2 has a Start of Care 12/18/2025 with diagnoses of aftercare following joint replacement surgery and presence of artificial knee joint documented on the Home Health Certification and Plan of Care for the Certification Period from 12/18/2025 to 02/15/2026. The Client Coordination Note Report dated 01/21/2026 documents Patient #2 called the agency on 01/21/2026 at 2:57 PM to report the following: I want to discharge from Visiting Nurse Service, there are too many issues related with my Home Health Aide services, I haven’t had a Home Health Aide visit since 01/12/26, also my insurance provided me a letter that the services should have been provided until 01/18/26, my Registered Nurse told me she is discharging me, the Physical Therapist has already discharged me but I didn’t continue receiving Home Health Aide services, I have contracted with another agency (name of agency) and just want a call from Visiting Nurse Service explaining why services were not rendered and I need this call to happen as soon as possible . . . . agent advised I will message the case manager, clinical field manager and branch for immediate call back . . . . . Follow up comment entered by (name of Registered Nurse, Clinical Field Manager) Case Manager contacted regarding patient’s request. There is no documented evidence of agency staff addressing and investigating the patient’s complaint about Home Health Aide services. On 03/05/2026 at 1:52 PM, the Vice President Regional Patient Care Services stated in an interview the complaint should have been escalated and the nurse (Case Manager) is no longer here to find out what was discussed with the patient about their complaint.

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 records review and staff interviews, the agency failed to ensure that all patients receive services as documented in their individualized plan of care. This was evident for one (1) of (9) clinical records reviewed (Patient #2). Failure to ensure that all patients receive services as documented in their individualized plan of care has the potential for negative patient outcomes. The findings are: 1. Patient #2 has a Start of Care 12/18/2025 with diagnoses of Aftercare Following Joint Replacement Surgery and Presence of Artificial Knee Joint documented on the Home Health Certification and Plan of Care for the Certification Period from 12/18/2025 to 02/15/2026. The Home Health Certification and Plan of Care (medical orders) with a Certification Period from 12/18/2025 to 02/15/2026 documents the following orders for Home Health Aide services: Home Health Aide effective 12/21/2025 3WK3, 1 WK1 (3 times a week for 3 weeks, then 1 time a week for 1 week). This equals to a total of ten (10) Home Health Aide visits. The agency contracts with a Licensed Home Care Services Agency vendor for Home Health Aide Services. The Home Health Aide (HHA) time and duty sheets document the HHA provided services to the patient on 01/06/2026, 01/07/2026, 01/08/2026, 01/09/2026 and 01/12/2026 for a total of five Home Health Aide visits. The patient did not receive Home Health Aide services as ordered on Health Certification and Plan of Care for the Certification Period from 12/18/2025 to 02/15/2026. On 03/05/2026 at 1:52 PM, the Vice President of Regional Patient Care Services stated in an interview, there was a problem with the patient’s phone number and apartment number. The patient provided two different phone numbers. The vendor did not have the patient’s apartment number. The patient’s apartment number did not get transferred to Home Health Aide Exchange. (Home Health Aide Exchange is a software program that can connect the Licensed Home Care Services Agency to the Certified Home Health Agency to allow for information to be shared). On 03/06/2026 at 12:30 PM, the Vice President of Regional Patient Care Services further stated in an interview, the Home Health Aide services should have started the week of 12/22/2025. The nurse placed the Home Health Aide services request on 12/19 and it would have made the visits start on 12/22 but because the nurse was late with her visit note documentation that did not happen. There was also the problem with the patient’s phone number and apartment number.

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 records reviews and staff interviews, the agency failed to ensure each individualized plan of care includes all the required information. This was evident for two (2) of nine (9) clinical records reviewed (Patients #1 and #6). Failure to ensure each individualized plan of care includes all the required information has the potential for negative patient outcomes. The findings are: 1.Patient #6 has a Start of Care date of 02/14/2026 with the following diagnoses Aftercare Following Surgery for Neoplasm, Malignant Neoplasm of Rectum documented on the Home Health Certification and Plan of Care for the Certification Period 02/14/2026 to 04/14/2026. The RN (Registered Nurse) OASIS (Outcome and Assessment Information Set) Admission Note dated 02/14/2026 documents: Genitourinary: Indicate Genitourinary Assessment: Indwelling/Suprapubic Catheter. Indicate Indwelling/Suprapubic Catheter Findings: WNL (within normal limit). The RN (Registered Nurse) Narrative dated 02/18/2026 documents: Patient received in no distress for disease management and Ileostomy education, JP Drain education/care, Foley cath. care. Patient's Foley Catheter is secured with 100cc of clear yellow urine bag. Patient denies abdominal pain/discomfort, or foul smelling uring when bag is emptied. The RN (Registered Nurse) Narrative dated 02/20/2026 documents: Patient reports she changed bag prior to VN arrival. VN observed removed Foley bag in trash can next to bed. VN reinforced importance of performing daily Foley Care and proper technique to secure leg bag. Patient verbalized understanding and able to perform return demonstration. The RN (Registered Nurse) Narrative dated 02/25/2026 documents: Patient reports she attended her Gynecology appointment yesterday and had Foley catheter removed. Patient denies pain or discomfort while voiding. There is no documented evidence of the Home Health Certification and Plan of Care for the Certification Period 02/14/2026 to 04/14/2026 including Foley care. On 03/06/2026 at 4:00 PM, The Vice President of Quality was interviewed and stated: "We don't have order for Foley." 1) Patient #1 has a Start of Care date of 02/19/2026 with diagnoses of aftercare following joint replacement surgery and presence of left artificial knee joint documented on the Home Health Certification and Plan of Care for the Certification Period from 02/19/2026 to 04/19/2026. The Visit Note Report documents the Registered Nurse conducted an initial nursing admission visit on 02/19/2026. The visit note report dated 02/19/2026 documents the patient’s surgical incision wound site was covered by a dsd (dry sterile dressing). A photograph dated 02/19/2026 included in the wound record report documents a white bandage covering the incision site. The Home Health Certification and Plan of Care (medical orders) dated 02/19/2026 to 04/19/2026 documents under treatment left knee incision, observation only at this time. The Home Health Certification and Plan of Care (medical orders) lack documented evidence of including when the bandage should be removed and what care should be provided to the incision site. On 03/05/2026 at 1:52 PM, the Vice President Regional Patient Care Services stated in an interview, they agreed that it should have been documented the coordination with the physician about what care was to be provide with the patient’s dressing and incision. 2) Patient #6 has a Start of Care date of 02/14/2026 with the following diagnoses Aftercare Following Surgery for Neoplasm, Malignant Neoplasm of Rectum documented on the Home Health Certification and Plan of Care for the Certification Period 02/14/2026 to 04/14/2026. The RN (Registered Nurse) OASIS (Outcome and Assessment Information Set) Admission Note dated 02/14/2026 documents: Genitourinary: Indicate Genitourinary Assessment: Indwelling/Suprapubic Catheter. Indicate Indwelling/Suprapubic Catheter Findings: WNL (within normal limit). The RN (Registered Nurse) Narrative dated 02/18/2026 documents: Patient received in no distress for disease management and Ileostomy education, JP Drain education/care, Foley cath. care. Patient's Foley Catheter is secured with 100cc of clear yellow urine bag. Patient denies abdominal pain/discomfort, or foul smelling uring when bag is emptied. The RN (Registered Nurse) Narrative dated 02/20/2026 documents: Patient reports she changed bag prior to VN (Visiting Nurse) arrival. VN observed removed Foley bag in trash can next to bed. VN reinforced importance of performing daily Foley Care and proper technique to secure leg bag. Patient verbalized understanding and able to perform return demonstration. The RN (Registered Nurse) Narrative dated 02/25/2026 documents: Patient reports she attended her Gynecology appointment yesterday and had Foley catheter removed. Patient denies pain or discomfort while voiding. There is no documented evidence of the Home Health Certification and Plan of Care for the Certification Period 02/14/2026 to 04/14/2026 including Foley care. On 03/06/2026 at 4:00 PM, The Vice President of Quality was interviewed and stated: "We don't have order for Foley."

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 records reviews and staff interviews, the agency failed to coordinate care delivery to meet the patient's needs and involve the patient. This was evident for one (1) of nine (9) clinical records reviewed (Patient #1) Failure to coordinate care delivery to meet the patient's needs and involve the patient has the potential for negative patient outcomes. The findings are: 1. Patient #1 has a Start of Care date of 02/19/2026 with diagnoses of Aftercare Following Joint Replacement Surgery and Presence of Left Artificial Knee Joint documented on the Home Health Certification and Plan of Care for the Certification Period from 02/19/2026 to 04/19/2026. The patient was discharged from the hospital on 02/18/2026. The Registered Nurse Visit Note Report documents the Registered Nurse conducted an initial nursing admission visit on 02/19/2026. The Visit Note Report dated 02/19/2026 documents the patient’s surgical incision wound site was covered by a dsd (dry sterile dressing). A photograph dated 02/19/2026 included in the wound record report documents a white bandage was covering the incision site. There is no documented evidence of the Registered Nurse coordinating with the patient about the patient’s discharge instructions from the hospital about when to remove the bandage and care of the incision site. On 03/05/2026 at 1:52 PM, the Vice President Regional Patient Care Services stated in an interview, they did not see any discharge instructions from the hospital in the clinical record. The nurse should have documented asking the patient about the discharge summary and going over it with the patient. The clinical record documents on 02/19/2026 at 10:29 AM, the patient signed the agency consent form, Facts About Your Home Care Services and Payment, informing the patient the initial plan of care for nursing visits was three (3) visits a week for 8 weeks. The Home Health Certification and Plan of Care (medical orders) dated 02/19/2026 to 04/19/2026 documents the frequency of nursing visits changed to Skilled Nurse, 1 WK1, 2 WK 1, 1 WK 2 (1 visit for 1 week, then 2 visits a week for 1 week, and then 1 visit a week for 2 weeks). The agency work week is from Sunday to Saturday. The initial nursing visit was on Thursday, 02/19/2026 during the work week starting on Sunday, 02/15/2026 and ending on Saturday 02/21/2026. The next work week began on Sunday, 2/22/2026 and ended on Saturday 02/28/2026. After the initial nursing visit on 02/19/2026, the next documented contact with the patient was a Coordination Notes Report dated 02/26/2026. The Coordination Notes Report dated 02/26/2026 documents the Registered Nurse entered a note for a missed visit, reason for missed visit: patient requesting no further nursing visits. From the time of the initial nursing visit on 02/19/2026 until the patient requested no further nursing visits on 02/26/2026, the clinical record lacks documented evidence of the patient being informed of the change of nursing visits from 3 times a week to 2 visits a week for 1 week, and then 1 visit a week for 2 weeks. On 03/06/2026 at 12:30 PM, the Vice President Regional Patient Care Services stated in an interview, they understood the findings but did not provide any further explanation.

HH aide supervision elements CFR(s): 484.80(h)(4)(i-vi) Home health aide supervision must ensure that aides furnish care in a safe and effective manner, including, but not limited to, the following elements: (i) Following the patient's plan of care for completion of tasks assigned to a home health aide by the registered nurse or other appropriate skilled professional; (ii) Maintaining an open communication process with the patient, representative (if any), caregivers, and family; (iii) Demonstrating competency with assigned tasks; (iv) Complying with infection prevention and control policies and procedures; (v) Reporting changes in the patient's condition; and (vi) Honoring patient rights. This ELEMENT is not met as evidenced by: Based on clinical record reviews and staff interviews, the agency failed to ensure that supervisory visits were conducted to evaluate whether home health aide services were furnished in a safe and effective manner. This was evident for one (1) of nine (9) clinical records reviewed (Patient #2). Failure to ensure that supervisory visits were conducted to evaluate whether home health aide services were furnished in a safe and effective manner has the potential for negative patient outcomes. The findings are: 1. Patient #2 has a Start of Care 12/18/2025 with diagnoses of Aftercare Following Joint Replacement Surgery and Presence of Artificial Knee Joint documented on the Home Health Certification and Plan of Care for the Certification Period from 12/18/2025 to 02/15/2026. The Home Health Aide (HHA) time and duty sheets document the Home Health Aide provided services to the patient on 01/06/2026, 01/07/2026, 01/08/2026, 01/09/2026 and 01/12/2026. From the start of Home Health Aide services on 01/06/206 until the end of Home Health Aide services on 01/12/2026 there was one skilled visit by the Registered Nurse. The Registered Nurse Visit Note Report dated 01/07/2026 documents, Visit Type: Registered Nurse plus supervision and under supervisory functions, was a supervisory visit performed? The answer was N/A (not applicable). There is no documented evidence of the Registered Nurse supervising the Home Health Aide to ensure the Home Health Aide is following the patient's plan of care for completion of tasks; maintaining an open communication process with the patient, representative (if any), caregivers, and family; demonstrating competency with assigned tasks; complying with infection prevention and control policies and procedures; reporting changes in the patient's condition; and honoring patient rights. On 03/06/2026 at 3:30 PM, the Vice President Regional Patient Care Services stated in an interview, they did not have any documentation of aide supervision.

This Statement of Deficiencies is a result of an on-site investigation of Complaint #114622, conducted at VNS of NY Home Care CHHA, located at 220 E. 42nd Street, New York, NY 10017 on 05/05/2025 to 05/06/2025. The agency reports a patient census of 6148. The investigation consisted of a review of three (3) clinical records (identified as Patient #1, #2, and #3), two (2) personnel records (identified as Employee #1 and #2), complaint log, pertinent policies and procedures, and interview with the Vice President of Quality, the Vice President Regional of Patient Care Services, and the Associate Director of Quality. Pre-survey activities consisted of review on 05/02/2025 of the agency's Health Commerce System account and compliance history. Findings were reviewed at the exit conference on 05/06/2025. The allegation in Complaint #114622 was determined to be substantiated. The following deficiencies are being cited as result of the survey: G0528 - Health, psychosocial, functional, cognition G0710 - Provide services in the plan of care G0716 - Preparing clinical notes

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: (1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on clinical record review, policies and procedures, and staff interview, the agency failed to ensure the registered nurse conducts a comprehensive assessment of the patient’s wound(s) to reflect the patient’s current status. This was evident for one (1) of three (3) clinical records reviewed (Patients #1). Failure to ensure the registered nurse conducts a comprehensive assessment of the patient’s wound(s) to reflect the patient’s current status has the potential for negative patient outcomes. The findings are: Patient #1 has a Start of Care date of 09/11/2024 with the diagnoses Pressure Ulcer of Right Heel, Stage 4; Hypertensive Heart Disease with Heart Failure, Peripheral Vascular Disease, Unspecified. Vascular Dementia, Anxiety Disorder documented in the Home Health Certification and Plan of Care for the Certification Period 03/10/2025 to 05/08/2025. The “Assessments: Initial Comprehensive and Update to Comprehensive Assessment:” Policy (Revised 03/2025) documents: “Patient specific comprehensive assessment must accurately reflect the patient’s current health status and include:” a comprehensive physical assessment. The “Wound Evaluation and Management” Policy (Revised 6/2023) documents the following procedures: evaluate patient’s health status - perform complete physical assessment; perform basic wound evaluation; and document wound evaluation in patient’s record. The Registered Nurse Start of Care comprehensive assessment note dated 09/11/2024 documents: “Patient has unstageable pressure ulcer to right heel. No signs or symptoms of infection noted to wound site.” The Registered Nurse Coordination Note – Wound Consult Request dated 09/12/2024 documents: “Visit Date/Photo Date 9/11;” the “Indicate additional wound details” section of the Wound Consult Request is blank. The Start of Care comprehensive assessment lacks documented evidence of the registered nurse documenting a wound assessment in accordance with agency policies. . The recertification assessment dated 11/06/2024, the resumption of care assessment dated 11/29/2024, and the recertification assessment dated 01/06/2025, document: "Stage 4 Pressure Ulcer Right Heel; “no signs or symptoms of infection noted” to wound site, with no additional wound description/evaluation noted in the assessments. The recertification assessments and the resumption of care assessment lack documented evidence of the registered nurse documenting the wound evaluation and progress, in accordance with agency policies. The comprehensive assessment and updates to comprehensive assessment lack documented evidence of an accurate reflection of the patient’s current wound status. On 05/06/2025 at 1:43PM, the Vice President of Quality, the Vice President of Regional Patient Care Service, and the Associate Director of Quality were interviewed about the findings. On 05/06/2025 at 3:45PM, Vice President of Quality stated the agency has “no” additional documentation to provide for the findings.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on clinical record review, policy and procedures, and staff interview, the agency failed to ensure the skilled nurse provide services as ordered by the physician as indicated in the plan of care. This was evident for one (1) of three (3) clinical records reviewed (Patient #1). Failure to provide services that are ordered by the physician as indicated in the plan of care, has the potential for negative patient outcomes. The findings are: 1. Patient #1 has a Start of Care date of 09/11/2024 with the diagnoses Pressure Ulcer of Right Heel, Stage 4; Hypertensive Heart Disease with Heart Failure, Peripheral Vascular Disease, Unspecified. Vascular Dementia, Anxiety Disorder documented in the Home Health Certification and Plan of Care for the Certification Period 03/10/2025 to 05/08/2025. The Home Health Certification and Plan of Care for the Certification Period 09/11/2024 to 11/09/2024 documents the following wound care order: “Unstageable Pressure Ulcer Right Heel: Cleanse with Normal Saline, paint with Betadine, apply Betadine soaked gauze to wound bed, cover with gauze dressing, wrap with Kling, secure with tape 3xWeekly.” The skilled nurse “subsequent visit” note dated 09/25/2024 documents: “right heel now Stage 4 Pressure Ulcer. VN (Visiting Nurse) obtained verbal order from MD (Medical Doctor) for change in wound care treatment.” The Physician Order dated 09/25/2024 documents the following verbal wound care order: “Stage 4 Pressure Ulcer Right Heel: Cleanse with Normal Saline, apply Calcium Alginate with Silver to wound bed, apply Betadine to eschar, cover with ABD (Abdominal) pad, wrap with Kling, secure with tape 3xWeekly.” The skilled nurse “subsequent visit” notes dated 10/04/2024, 10/07/2024, 10/23/2024, and 10/30/2024 document: "Wound care provided Unstageable Pressure Ulcer Right Heel Cleanse with Normal Saline, paint with Betadine, apply Betadine soaked gauze to wound bed, cover with gauze dressing, wrap with Kling, secure with tape 3xWeekly (three times a week);” and rendered wound care as ordered. The skilled nurse visit notes lack documented evidence of the nurse providing wound care as ordered by the physician during the visits on 10/04/2024, 10/07/2024, 10/23/2024, and 10/30/2024. The Resumption of Care Physician Order dated 11/29/2024 for documents the following wound care order: “Stage 4 Pressure Ulcer Right Heel. Cleanse with Normal Saline, apply Calcium Alginate with Silver to wound bed then paint eschar with Betadine, cover with Abdominal pad, wrap with Kling, secure with tape 3xWeekly.” The skilled nurse “subsequent visit” notes dated 12/05/2024, 12/07/2024, 12/08/2024, 12//16/2024, 12/18/2024, 12/20/2024,12/23/2024, 12/25/2024, and 12/27/2024 document: "Wound care provided Unstageable Pressure Ulcer Right Heel. Cleanse with Normal Saline, paint with Betadine, apply Betadine soaked gauze to wound bed, cover with gauze dressing, wrap with Kling, secure with tape 3xWeekly;” and rendered wound care as ordered. The skilled nurse visit notes lack documented evidence of the nurse providing wound care as ordered by the physician during the visits on 12/05/2024, 12/07/2024, 12/08/2024, 12//16/2024, 12/18/2024, 12/20/2024,12/23/2024, 12/25/2024, and 12/27/2024. The skilled nurse “subsequent visit” note dated 03/05/2025 documents: “VN (Visiting Nurse) obtained updated order for MD (Medical Doctor) wound care treatment. No eschar noted to wound bed, Betadine not needed to be applied.” The Physician Order dated 03/05/2025 documents the following verbal order: “Skilled Nurse to perform/teach wound care to PU (Pressure Ulcer) Stage 4 RT (Right) Heel. Cleanse with Normal Saline, apply Calcium Alginate with Silver to wound bed, cover with ABD (Abdominal) pad, wrap wit Kling, secure with tape, using clean/septic technique 3xWeek.” The Home Health Certification and Plan of Care for the Certification Period 03/10/2025 to 05/08/2025 documents the continuation of the wound treatment order dated 03/05/2025. The skilled nurse “subsequent visit” notes dated 03/21/2025 documents: Wound care provided “Stage 4 Pressure Ulcer Right Heel. Cleanse with Normal Saline, apply Calcium Alginate with Silver to wound bed then paint eschar with Betadine, cover with abdominal pad, wrap with Kling, secure with tape 3xWeekly;” and rendered wound care as ordered. The skilled nurse visit note dated 03/21/2025 lacks documented of the nurse providing wound care as ordered by the physician. There is no documented evidence that the skilled nurse is providing wound care as ordered by the physician as indicated in the plan of care. On 05/06/2025 at 1:43PM, the Vice President of Quality, the Vice President of Regional Patient Care Service, and the Associate Director of Quality were interviewed about the findings. On 05/06/2025 at 3:45PM, Vice President of Quality stated the agency has “no” additional documentation to provide for the findings.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on clinical records review, policy and procedures, and staff interview, the agency failed to ensure the skilled nurse documents wound evaluation(s) that reflect the wound’s progress. This was evident for one (1) of three (3) clinical records reviewed (Patient #1). Failure to ensure the skilled nurse documents wound evaluation(s) that reflect the wound’s progress has the potential for negative patient outcomes. The findings are: The “Wound Evaluation and Management” Policy (Revised 6/2023) documents: “Wounds require ongoing monitoring and assessment due to continual changes in wound status and/or change in patient’s condition, which may require change in treatment plans.” The Policy inlcludes the following instructions: “Re-evaluation of wounds on each visit;” “Re-evaluation and documentation of the wound should include:” “Weekly wound measurements, and more often if indicated,” “wound bed description,” “clinical evaluation of the wound progress,” and document wound evaluation in patient’s record. 1. Patient #1 has a Start of Care date of 09/11/2024 with the diagnoses Pressure Ulcer of Right Heel, Stage 4; Hypertensive Heart Disease with Heart Failure, Peripheral Vascular Disease, Unspecified. Vascular Dementia, Anxiety Disorder documented in the Home Health Certification and Plan of Care for the Certification Period 03/10/2025 to 05/08/2025. The Home Health Certification and Plan of Care for the Certification Period 09/11/2024 to 11/09/2024 documents orders for skilled nurse visits to perform wound care to unstageable pressure ulcer right heel three times a week. The skilled nurse “subsequent visit” notes dated 09/16/2024, 09/22/2024, 09/23/2024, 09/25/2024, 09/27/2024, 09/30/2024, 10/09/2024, 10/14/2024, 10/21/2024, 10/25/2024, and 11/01/2024 document the there is no signs or symptoms of infection noted to wound site, with no wound description noted. The skilled nurse “subsequent visit” dated 09/25/2024 documents: “right heel now Stage 4 Pressure Ulcer. VN (Visiting Nurse) obtained verbal order from MD (Medical Doctor) for change in wound care treatment.” The skilled nurse visit note lacks documentation of the re-evaluation of the wound to show the progress and change in stage of the right heel pressure ulcer. The Home Health Certification and Plan of Care for the Certification Period 11/10/2024 to 01/08/2025 documents orders for skilled nurse visits to perform wound care to stage 4 pressure ulcer right heel three times a week. The skilled nurse “subsequent visit” notes dated 12/13/2024, 12/14/2024, 01/01/2025, and 01/08/2025 document there was no signs or symptoms of infection noted to wound site, with no wound description in the visit notes. The Home Health Certification and Plan of Care for the Certification Period 01/09/2025 to 03/09/2025 documents orders for skilled nurse visits to perform wound care to stage 4 pressure ulcer right heel three times a week. The skilled nurse “subsequent visit” notes dated 01/10/2025, 01/13/2025, 01/15/2025, 01/20/2025, 01/27/2025, 02/24/2025, 02/28/2025 document there was no signs or symptoms of infection noted to wound site, with no wound description in the visit notes. The Home Health Certification and Plan of Care for the Certification Period 03/10/2025 to 05/08/2025 documents orders for skilled nurse visits to perform wound care to pressure ulcer right heel three times a week. The skilled nurse “subsequent visit” notes dated 03/24/2025, 03/28/2025, 03/31/2025, 04/02/2025, 04/19/2025, and 04/20/2025 document there was no signs or symptoms of infection noted to wound site, with no wound description in the visit notes. The clinical record lacks documented evidence of the nurse performing weekly wound measurement during the following weeks: 09/15/2024 - 09/21/2024, 09/22/2024 - 09/28/2024, 09/29/2024 - 10/05/2024,10/20/2024 - 10/26/2025, 10/27/2024 - 11/02/2024, 11/03/2024 - 11/11/2024, 12/29/2024 - 01/04/2025, 01/05/2025 - 01/11/2025, 01/12/2025 - 01/18/2025, 01/19/2025 - 01/25/2025, 03/16/2025 - 03/22/2025, and 03/30/2025 - 04/05/2025 The Skilled Nurse visit notes dated 09/18/2024, 09/20/2024,10/02/2024, 10/09/2024, 10/18/2024, 11/04/2024, 11/11/2024, 01/17/2025, 03/05/2025, 03/17/2025, 03/19/2025, document the nurse was unable to access wound care management application/tool used for wound documentation due to “frozen screen,” “error message the internet connection is offline” or “application not responding.” The clinical record lacks documentation of the skilled nurse preparing clinical notes that include weekly wound measurements and re-evaluation of the wound each visit in accordance with the agency’s Policy. The clinical record lacks documented evidence of providing a complete picture of the patient’s wound status/condition to assist with monitoring the patient’s progress toward meeting plan of care goal. On 05/06/2025 at 1:43PM, the Vice President of Quality, the Vice President of Regional Patient Care Service, and the Associate Director of Quality were interviewed about the findings. On 05/06/2025 at 3:45PM, Vice President of Quality stated the agency has “no” additional documentation to provide for the findings.

This Statement of Deficiencies is a result of an on-site investigation of Complaint 112385, conducted at VNS of NY Home Care CHHA, located at 220 E 42nd St., New York, NY 10017 on 02/04/2025. The investigation consisted of a review of three (3) clinical records (identified as Patients #1, #2, and #3), one (1) personnel record (Employees #1), complaint log/reports from Novermber 2024 to present, pertinent policies and procedures and interviews with the Vice President of Quality, the Regional Vice President, and the Associate Director of QAPI (Quality Assurance and Performance Improvement). Pre-survey activities consisted of review on 02/03/2025 of the agency's Health Commerce System account and compliance history. Findings were reviewed at the exit conference on 02/04/2025. The allegations in Complaint 112385 were determined to be substantiated. The following deficiencies are being cited as result of the survey: G0428 – Property and Person Treated with Respect G0478 – Investigate Complaint Made by Patient G0514 – RN Performs Assessment G0548 - Within 48 Hours of The Patient's Return G0608 - Coordinate Care Delivery

Property and person treated with respect CFR(s): 484.50(c)(1) Have his or her property and person treated with respect; This ELEMENT is not met as evidenced by: Based on record reviews and staff interview, the agency failed to respect the preferences of the patient/family regarding the services that will be delivered and failed to keep the patient/family informed of the visit schedule and changes requested. This was evident for one (1) of three (3) clinical records reviewed (Patients #1). Failure to respect the preferences and to keep patient/family informed of services to be delivered has the potential risk for negative patient outcomes. The finding is: Patient #1 has a Start of Care date of 12/26/2024, Discharge Date of 12/31/2024, with diagnoses COVID-19, Acute Respiratory Failure with Hypoxia, Unspecified Dementia, Pneumonitis Due to Inhalation of Food and Vomit, Essential Hypertension, Bed Confinement Status documented in the Home Health Certification and Plan of Care for the Certification Period 12/26/2024 to 02/23/2025. The Home Health Certification and Plan of Care for the Certification Period 12/26/2024 to 02/23/2025 documents an order for Physical Therapy services: “1WK2 (one visit a week for two weeks);” “Physical Therapist to evaluate, to determine condition, physical therapy plans and rehabilitation potential.” The Physical Therapist Evaluation dated 12/27/2025 (Friday) documents the Physical Therapist conducted an initial evaluation and the “MD (Medical Doctor) was updated about POC (Plan of Care) 1-2xWx4W (one to two visits a week for four weeks).” The Coordination Note dated 12/27/2024 documents that after the initial evaluation, the patient’s family called (at 2:30PM) and “requested a new PT (Physical Therapist) for rest of services.” The Coordination Note dated 12/27/2024 documents the Regional Vice President’s follow-up call: The patient’s family “wants change in PT (Physical Therapist) as (Physical Therapist) was verbally rough in asking (patient) to get up. (The family) states (family) wants someone more patient.” “(The family) requested change in PT (Physical Therapist).” The Coordination Note dated 12/28/2024 (Saturday) documents the patient’s family called again and stated the following: “called about request for PT (Physical Therapist) change. Doesn’t like one assigned, not comfortable with them. No other request found sent to w/e (weekend) team for follow up.” There is no documented evidence of the agency’s follow-up to the family’s request for a change in the assigned Physical Therapist. The Coordination Note – PT (Physical Therapist) Visit Time Exception dated 12/31/2024 documents the same Physical Therapist that the family requested to be changed is scheduled to visit on 12/31/2024 (Monday). The Coordination Note dated 12/31/2024 documents: the family “called to cancel services immediately,” “CFM (Clinical Field Manager) cancelled services and informed to call MD (Medical Doctor) office for (family) to have referral sent elsewhere.” There is no documented evidence to the agency informing the patient/family that the same Physical Therapist will be returning on 12/31/2024 and if the family is in agreement. There is no documented evidence of the agency considering and respecting the family’s preference and request to change the assigned Physical Therapist with “someone more patient.” On 02/04/2025 at 03:30PM, the Vice President of Quality, the Regional Vice President and the Associate Director of QAPI (Quality Assurance and Performance Improvement) were interviewed. The Regional Vice President stated, the agency “did not have another Physical Therapist available that week” due to the holiday, and “I did not” review the calendar and discuss the scheduled visits with the family.

Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) The HHA must— (i) Investigate complaints made by a patient, the patient's representative (if any), and the patient's caregivers and family, including, but not limited to, the following topics: (A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; (B) Mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on record reviews and staff interview, the agency failed to ensure there is a complete investigation and resolution of all patient/family complaints. This was evident for one (1) of three (3) clinical records reviewed (Patient #1). Failure to ensure the complete investigation and resolution of all patient/family complaints, has the potential for negative patient outcomes. The finding is: Patient #1 has a Start of Care date of 12/26/2024, Discharge Date of 12/31/2024, with diagnoses COVID-19, Acute Respiratory Failure with Hypoxia, Unspecified Dementia, Pneumonitis Due to Inhalation of Food and Vomit, Essential Hypertension, Bed Confinement Status documented in the Home Health Certification and Plan of Care for the Certification Period 12/26/2024 to 02/23/2025. The Home Health Certification and Plan of Care for the Certification Period 12/26/2024 to 02/23/2025 documents an order for Physical Therapy services: “1WK2 (one visit a week for two weeks);” “Physical Therapist to evaluate, to determine condition, physical therapy plans and rehabilitation potential.” The complaint log dated 12/26/2024 documents a complaint received from the patient’s family regarding “Timely Care.” The complaint/grievance report dated 12/26/2024 documents: “Complaint subcategory: Delay in admitting;” “Issue Status: Resolved – Unsubstantiated;” “Issue Resolution Date: 12-26-2024;” “Findings/Investigation Details: Resolved by VP (Vice President) who documented the following: Follow up call with (family) who reports to VP (Vice President) nursing visit when well;” “(Family) reports (family) wants change in PT (Physical Therapist) as (Physical Therapist) was verbally rough in asking (patient) to get up. (Family) wants someone more patient.” “(Family) requested change in PT (Physical Therapist).” The complaint/grievance report documents a complaint investigation/resolution for timely care- Delay in admitting and includes documentation of another complaint about Physical Therapy services. The Coordination Note dated 12/27/2024 documents that after the Physical Therapist evaluation on 12/27/2024 (Friday), the patient’s family called (at 2:30PM) and “requested a new PT (Physical Therapist) for rest of services.” The Coordination Note dated 12/27/2024 documents the Regional Vice President’s communication with the family: “Follow up call with (family) who reports to VP (Vice President) nursing visit when well;” “(family) wants (to) change PT (Physical Therapist) as (Physical Therapist) was verbally rough in asking (patient) to get up. (Family) wants some more patient." “(Family) requested change in PT (Physical Therapist).” The complaint log lacks documented evidence of the complaint received on 12/27/2024 about Physical Therapy services. There is not documented evidence of the agency conducting a complete investigation of the family’s complaint about the Physical Therapist, including interviewing the Physical Therapist and responding to the family’s request for a change in the assigned Physical Therapist. On 02/04/2025 at 03:30PM, the Vice President of Quality, the Regional Vice President, and the Associate Director of QAPI (Quality Assurance and Performance Improvement) were interviewed. The Regional Vice President of Patient Care Services stated, the “Physical Therapist was interviewed” and the family was told that the agency “did not have any Physical Therapist available that week” due to the holiday. The Regional Vice President stated, “I did not” document it.

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 record reviews and staff interview, the agency failed to ensure that initial assessments are conducted within the required time frames for all patients. This was evident for one (1) of three (3) clinical records reviewed (Patient: #1). Failure to ensure that initial assessments are conducted within the required time frames for all patients, has the potential for negative outcome. The finding is: Patient #1 has a Start of Care date of 12/26/2024, Discharge Date of 12/31/2024, with diagnoses COVID-19, Acute Respiratory Failure with Hypoxia, Unspecified Dementia, Pneumonitis Due to Inhalation of Food and Vomit, Essential Hypertension, Bed Confinement Status documented in the Home Health Certification and Plan of Care for the Certification Period 12/26/2024 to 02/23/2025. The agency’s First Visit Policy (June 2022) documents: “All referrals are initially in Pending Referrals status until accepted by Clinical Field Manager (CFM);” “Acceptance of the referral must occur timely to meet state and federal requirements for initial assessment visit;” and “Registered Nurse or Physical Therapist make the initial home visit within 24 hours of receipt and acceptance of a community referral or return from institutional placement unless: (1) the patient’s authorized practitioner orders otherwise, or (2) there is written documentation that the patient or family refuses the visit.” The Coordination Note dated 12/17/2024 documents the agency received a referral from an inpatient hospital and the patient’s family was called and a message left at (718 - telephone number).” The Coordination Note – BD (Branch Director) Intake Assessment dated 12/18/2024 documents: “Requested Start of Care: 12/19/2024,” “Anticipated Discharge Date? 12/18/2024,” “Patient agreeable to homecare & visit address confirmed[Y/N]: Yes, confirmed by (family) (718 - telephone number).” The Coordination Notes – Clinical Comment Intake dated 12/19/2024 document: “Several attempts made to reach physician’s office all unsuccessful;” “Reached out to (family) regarding VMD (visiting medical doctor; I am unable to reach physician’s office and do not want to delay SOC any further. (718 - telephone number)) Left MSG (message).” The Coordination Note – Clinical Comment Intake dated 12/20/2024 documents: Family called to follow up on the referral and was informed “referral case is pending;" “email sent to IC (Intake Coordinator);“ "request reason: referral follow-up;" (family) alternate callback number (917- telephone number). The Coordination Note – Intake Coordinator dated 12/21/2024 documents: “Called placed to patient (family) to confirm acceptance of HVMD (home visit medical doctor). No answer / message left.” The VNS Health Referral Form dated 12/23/2024 documents the agency received second referral from the physician who will coordinate and sign the Home Health orders. The second referral documents the patient was discharged from the hospital on 12/18/2024 and list the patient/family’s primary phone (917 - telephone number). The Coordination Note - Follow up dated 12/23/2024 documents: Family called regarding “referral follow-up (SOC(Start of Care) inquiry);” "pending per note. VM (Voicemail) left on 12/21/24 for acceptance call." "Called CFM (Clinical Field Manager); got VM (voicemail message; sent to the (Clinical Field Manager) for follow-up;" family callback number (917- telephone number). The Coordination Note – Follow up dated 12/26/2024 documents: "Call Notes: (Family) waiting for RN (Registered Nurse) visit. Has been 8 days / paperwork from (Doctor) faxed over and (received)/informed would have CFM (Clinical Field Manager follow up/stated wanted to speak to someone now;” Follow-up comments: "VP (Vice President) called (family) and informed we are following up on (family) call. (Family) does not understand the need to have a community physician for (patient) for home care as hospital physician should be enough.” “VP confirmed address and phone number are correct. (Family) prefers VNS to use (family) cell (917 – telephone number).” “(Clinical Field Manager) followed up with intake and (family) to assign visit for today. RN (Registered Nurse) SOC (Start of Care) today. PT (Physical Therapist) Eval tomorrow is the plan.” The coordinator notes document the family providing an alternate callback number (917 – telephone number) on 12/20/2024 and 12/23/2024. The agency failed to use the alternate callback number the family provided for timely referral acceptance and the coordination of the initial assessment/start of care visit. The “RN OASIS Admission” Visit Note dated 12/26/2024 documents a Start of Care assessment and Inpatient Discharge Date: 12/18/2024. The initial/Start of Care assessment visit is eight (8) days after the patient’s discharge from the hospital. There is no documented evidence of the agency conducting the Initial Assessment visit within 24 hours of receipt and acceptance of community referral or return home from hospital, as specified in the agency’s First Visit Policy. On 02/04/2025 at 03:30PM, the Vice President of Quality Assurance and Performance Improvement, the Regional Vice President of Patient Care Services and the Associate Director of QAPI was interviewed. The Regional Vice President of Patient Care Services stated that we confirmed the preferred phone number (917 – telephone number) on 12/26/2024.

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on record reviews, agency policy and staff interview, the agency failed to ensure comprehensive assessments are updated and revised within forty-eight (48) hours of the patient's return to the home from a hospital admission of twenty-four (24) hours or more. This was evident for one (1) of three (3) clinical records reviewed (Patient #2). Failure to ensure comprehensive assessments are updated within 48 hours of a patient's return from a hospital admission, has the potential for negative patient outcomes. The finding is: Patient #2 has a Start of Care date of 12/23/2024, Discharge Date of 12/31/2024, with diagnoses Pressure Ulcer of Sacral Region Stage 4, Fracture of femur, Hypertensive Heart Disease, Chronic Systolic Congestive Heart Failure, Unspecified Dementias, History of Falling documented in the Home Health Certification and Plan of Care for the Certification Period 12/23/2024 to 02/20/2025. The agency’s Resumption of Care Policy (March 2022) documents: “Resumption of Care visit and comprehensive OASIS assessment to be done within 48 hours of the patient’s return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on a physician-ordered resumption date;" “CFM (Clinical Field Manager) reviews ROC (Resumption of Care) coordination note and adds follow-up comments when processing the ROC (Resumption of Care);””CFM (Clinical Field Manager) creates order Schedule ROC (Resumption of Care) Visit for the Registered Nurse;” and “Scheduler assigns ROC (Resumption of Care) visit to a registered nurse to be made within 48 hours of discharge from an inpatient facility.” The Coordinator Note dated 12/27/2024 documents: “Informed by patient’s (family)/(Caregiver) that patient fell out of the hospital bed. (Caregiver) called 911. Patient taken to (Hospital). As per CG (Caregiver), patient was evaluated. No injuries noted. Patient admitted to hospital for pneumonia.” The hospital Inpatient Clinical Summary dated 12/30/2024 documents the patient was hospitalized from 12/25/2024 to 12/30/2024 and discharged “under the care of Home Health Services.” The Coordinator Note - Resumption of Care dated 12/30/2024 documents a request for the resumption of care to "resume all prior services" and "Follow-up comment entered by (name) CFM (Clinical Field Manager) on 01/03/2025: ROC (Resumption of Care) set up.” The Physician Order entered and dated 01/03/2024 by the Clinical Field Manager documents an order for the Resumption of Care visit: “SN (Skilled Nurse) effective 12/29/2224 (week of) 1WK1(One visit for one week).” The January 2925 visit calendar documents a Registered Nurse/Skilled Nurser visit scheduled for 01/03/2025. The clinical record documents the agency received and entered the physician order to conduct the Resumption of Care visit four (4) days after the patient was discharged from the hospital. There is no documented evidence of the Clinical Field Manager reviewing the Resumption of Care coordination note in a timely manner to prevent delays in processing Resumption of Care, as specified in the agency’s policy. The Coordination Note dated 01/03/2025 documents the agency's initial communication with the family/caregiver to schedule and confirm the Resumption of Care visit was four days after the patient’s discharge from the hospital. The Coordination Note documents the patient’s family/caregiver “requested the ROC (Resumption of Care) for Monday 1/6/25.” The compliant/grievance report dated 01/14/2025 documents the family/caregiver complained about timely care: “(caregiver) upset about the nurses coming in without sufficient notice.” The clinical record lacks documented evidence of the agency’s communicating with the patient or caregiver immediately after the hospital discharge and/or prior to 01/03/2025 to schedule the resumption of care visit. The clinical record documents a delay in communication with the patient/caregiver regarding the resumption of care visit. The RN Resumption of Care Assessment/ OASIS (Outcome and Assessment Information Set) dated 01/06/2025documents: Date of Assessment Completed: 01/06/2025 and Inpatient Discharge Date: 12/30/2024, seven (7) days after the patient was discharged from the hospital. There is no documented evidence of a Registered Nurse completing the resumption assessment visit within 48 hours of the patient's return to the home from a hospital admission. On 02/04/2025 at 03:30pm, the Vice President of Quality Assurance and Performance Improvement, the Regional Vice President of Patient Care Services and the Associate Director of QAPI was interviewed. The Regional Vice President of Patient Care Services stated, “the Manager (Clinical Field Manager) did not review the ROC (Resumption of Care) request until 1/3.”

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 record reviews, and staff interviews, the agency failed to coordinate care delivery to meet the patient's needs and involve the patient/family. This was evident for one (1) of three (3) clinical records reviewed (Patient #1). Failure to coordinate care delivery to meet the patient's needs and involve the patient/family, has the potential for negative patient outcomes. The finding is: Patient #1 has a Start of Care date of 12/26/2024, Discharge Date of 12/31/2024, with diagnoses COVID-19, Acute Respiratory Failure with Hypoxia, Unspecified Dementia, Pneumonitis Due to Inhalation of Food and Vomit, Essential Hypertension, Bed Confinement Status documented in the Home Health Certification and Plan of Care for the Certification Period 12/26/2024 to 02/23/2025. The Home Health Certification and Plan of Care for the Certification Period 12/26/2024 to 02/23/2025 documents an order for Physical Therapy services: “1WK2 (one visit a week for two weeks);” “Physical Therapist to evaluate, to determine condition, physical therapy plans and rehabilitation potential.” The Physical Therapist Evaluation dated 12/27/2025 (Friday) documents the Physical Therapist conducted an initial evaluation and “MD (Medical Doctor) was updated about POC (Plan of Care) 1-2xWx4W (one to two visit a week for four weeks).” The Coordination Note dated 12/27/2024 documents that after the initial evaluation on 12/27/2024, the patient’s family called (at 2:30PM) and “requested a new PT (Physical Therapist) for rest of services.” The Coordination Note dated 12/27/2024 documents the Regional Vice President’s follow-up call: The patient’s family “wants change in PT (Physical Therapist) as (Physical Therapist) was verbally rough in asking (patient) to get up. (Family)) states (family) wants someone more patient.” “Family)) requested change in PT (Physical Therapist).” The Coordination Note dated 12/28/2025 (Saturday) documents the patient’s family called again and stated the following: “called about request for PT (Physical Therapist) change. Doesn’t like one assigned, not comfortable with them. No other request found sent to w/e (weekend) team for follow up.” The clinical record lacks documented evidence of the agency communicating with patient/family on 12/27/2024 or on 12/28/2024 regarding the family’s request to change the assigned Physical Therapist. The Coordination note – PT (Physical Therapist) Visit Time Exception dated 12/31/2024 documents the same Physical Therapist, that the family accused of being “verbally rough” and lacking patience, is scheduled to visit on 12/31/2024 (Monday). The clinical record lacks documented evidence of the agency informing the patient/family that the same Physical Therapist is scheduled to return on 12/31/2024 and if they are in agreement. The clinical record lacks documented evidence of the agency coordinating and involving the patient/family in care delivery of physical therapy services and the request for changes. On 02/04/2025 at 03:30PM, the Vice President of Quality, the Regional Vice President, and the Vice President Director of QAPI was interviewed. The Regional Vice President of Patient Care Services stated, the agency “did not have another Physical Therapist available that week” due to the holiday, and "I did not” review the calendar and discuss the scheduled visits with the family.

This Statement of Deficiencies is a result of an on-site investigation of complaints 105590 and 105861, conducted at VNS of NY Home Care CHHA, located at 220 E 42nd St., New York, NY 10017 on 04/04/2024. The active patient census is 5,486. The investigation consisted of a review of six (6) clinical records (identified as Patients #1, #2, #3, #4, #5, and #6), five (5) personnel records (Employees #1, #2, #3, #4, and #5), the agency's complaint log and accident/incident report from July 2023 to March 2024, and interviews with the Vice President of Quality, the Vice President of Regional Patient Services, the Administrator/Director of Patient Services, and the Associate Vice President of Quality. Pre-survey activities consisted of review on 04/03/2024 of the agency's Health Commerce System account. Findings were reviewed at the exit conference on 04/04/2024. The Complaint 105590 was withdrawn. The allegations in Complaint 105861 were determined to be Substantiated. A Statement of Deficiencies will be issued. The following deficiencies are being cited as result of the survey: G – 0484 - Document complaint and resolution G - 0574 - Plan of Care must include the following G - 0580 - Only as ordered by a Physician G - 0584 - Verbal Orders G - 0602 – Communication with all Physician G - 0608 - Coordination Care Delivery G - 0710 - Provide services in the plan of care

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on clinical records review and staff interview the agency failed to complete an investigation of all complaints. This was evident for one (1) of six (6) patient care records reviewed (Patient #1). Failure to complete an investigation of all complaints, has the potential for negative patient outcomes. The Finding Are: 1. Patient #1 has a Start of Care date of 07/21/2023 with the following diagnoses "Pressure Ulcer of Right Buttock, stage 4, other Dystonia, other Hydronephrosis " documented on the Home Health Certification and Plan of Care for the Certification Period 01/17/2024 to 03/16/2024. The Client Episode Coordination Note dated 03/16/2024 documents: "Numerous calls today from patient Advocate The are the complaints: VNS are responsible for the wounds/conditions, should, be treating differently The clinician should not be packing a wound when it is infected? It appears the patient has been recommended for surgery-and we VNS are responsible Considers it is our responsibility to refer to other MD's such as wound specialist No VNS folder in the home(Explained as the patient has been active for several months-folder may have been mislaid I explained to the Advocate the Nurse follows the MD orders and there is communication between the clinician and the MD Wound care orders are under the direction of the MD as is all patient care She/and the patient and her sister state they do not know the MD an the Doctor has not seen the patient Note: There is COC Note the MD had an appointment with the patient on 03/08/23 and the documentation indicates constant communication between the Nurse and the MD. .." There is no documented evidence of a complaint in the complaint log. On 04/04/2024 at 02:00pm, the Vice President of Quality and the Vice President of Regional Patient Services were interviewed and did not provide an explanation for 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 staff interview, the agency failed to ensure each patient's individualized plan of care included all the required information. This was evident for two (2) of six (6) patient care records reviewed (Patient’s #2 and #3). Failure to ensure individualized plan of care is established for all patients has the potential risk for negative patient outcomes. The findings are: 1. Patient #2 has a Start of Care date of 03/19/2024 with the following diagnoses "Chronic Obstructive Pulmonary Disease with Lower Respiratory Infection, Pneumonia" documented in the Home Health Certification and Plan of Care dated 03/19/2024 to 05/17/2024. The Home Health Certification and Plan of Care dated 03/19/2024 to 05/17/2024 documents: “SN (skilled nurse) 2WK1 (twice a week for one week), 1WK1 (once a week for one week), 1 every 3WK3 (once every three weeks for three weeks).” The Order dated 03/22/2024 documents: “Skilled nurse to perform/teach wound care to R (right) posterior lower leg Skin graft recipient site, cleanse with NS (normal saline), cover with DSD (dry sterile dressing) & gauze wrap TIW (three times a week) & PRN (as needed), may leave open to air if no drainage.” The Client Calendar Report documents the registered nurse visits on: 03/19/2024, 03/22/2024, and 03/29/2024. The Plan of Care lacks documented evidence of the correct frequency for skilled nursing visit including three times a week as per the wound care order. There is no documented evidence of a complete plan of care to meet the patient needs. On 04/04/2024 at 02:00pm, the Vice President of Quality and the Vice President of Regional Patient Services were interviewed and did not provide an explanation for the findings. 2. Patient #3 has a Start of Care date of 07/24/2021 with the following diagnoses "Pressure Ulcer of Sacral Region stage 3, Parkinson’s Disease" documented in the Home Health Certification and Plan of Care dated 03/10/2024 to 05/08/2024. The Home Health Certification and Plan of Care dated 03/10/2024 to 05/08/2024 documents: “SN (skilled nurse) 1WK1 (once a week for one week), 1every2WK8 (once every two weeks for eight weeks).” “Skilled nurse to perform/teach stage III pressure ulcer care. Cleanse with NS (normal saline) apply MediHoney cover with Foam dressing using clean/aseptic technique. QOD (every other day) nurse for skilled observation. Family perform wound care other times.” The Plan of Care lacks documented evidence of the correct frequency for skilled nursing visit including every other day as per the wound care order. There is no documented evidence of a complete plan of care to meet the patient needs. On 04/04/2024 at 02:00pm, the Vice President of Quality and the Vice President of Regional Patient Services were interviewed and did not provide an explanation for the findings.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to ensure that treatments are provided as ordered by a physician. This was evident for one (1) of six (6) patient care records reviewed (Patient #3). Failure to ensure that treatments are provided as ordered by the physician has the potential for negative patient outcomes. The findings are: 1. Patient #3 has a Start of Care date of 07/24/2021 with the following diagnoses "Pressure Ulcer of Sacral Region stage 3, Parkinson’s Disease" documented in the Home Health Certification and Plan of Care dated 03/10/2024 to 05/08/2024. The Home Health Certification and Plan of Care dated 03/10/2024 to 05/08/2024 documents: “Skilled nurse to perform/teach stage III pressure ulcer care. Cleanse with NS (normal saline) apply MediHoney cover with Foam dressing using clean/aseptic technique. QOD (every other day) nurse for skilled observation. Family perform wound care other times.” The Visit Note Report dated 03/14/2024 and 03/28/2024 documents: “Skilled nurse for skilled observation of wound cleanse with NS (normal saline) apply Aquacel AG Allevyn QOD (every other day). There is no documented evidence that the wound treatments were administered only as ordered by the physician – order is MediHoney but being treated with Aquacel AG Allevyn. There is no documented evidence of the treatment being provided in accordance with the plan of care. On 04/04/2024 at 02:00pm, the Vice President of Quality and the Vice President of Regional Patient Services were interviewed and did not provide an explanation for the findings.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on clinical record reviews, and staff interview, the agency failed to ensure all verbal orders are put in writing. This was evident for one (1) of six (6) patient care records reviewed (Patient #2). Failure to ensure all verbal order are put in writing, has the potential risk for negative patient outcomes. The findings are: 1. Patient #2 has a Start of Care date of 03/19/2024 with the following diagnoses "Chronic Obstructive Pulmonary Disease with Lower Respiratory Infection, Pneumonia" documented in the Home Health Certification and Plan of Care dated 03/19/2024 to 05/17/2024. The Home Health Certification and Plan of Care dated 03/19/2024 to 05/17/2024 documents “Medication: Eliquis 2.5 mg (milligram) tablet 1 tablet 2 times daily; Methocarbamol 500 mg (milligram) tablet 2 tablets 4 times daily.” The Client Episode Coordination Notes Report dated 03/29/2024 documents: “Patient states that Eliquis & (and) Methacarmol (Methocarbamol) were discontinued.” The clinical record lacks documented evidence of the verbal order being put in writing and sent to the physician for verification/authentication of the change in medications. On 04/04/2024 at 02:00pm, the Vice President of Quality and the Vice President of Regional Patient Services were interviewed and did not provide an explanation for the findings.

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on clinical record reviews, and staff interviews, the agency failed to ensure that patient’s care is communicated with the physician. This was evident for one (1) of six (6) patient care records reviewed (Patient #2). Failure to ensure that patient’s care is communicated with the physician, has the potential for negative patient outcomes. The findings are: 1. Patient #2 has a Start of Care date of 03/19/2024 with the following diagnoses "Chronic Obstructive Pulmonary Disease with Lower Respiratory Infection, Pneumonia" documented in the Home Health Certification and Plan of Care dated 03/19/2024 to 05/17/2024. The Home Health Certification and Plan of Care dated 03/19/2024 to 05/17/2024 documents: “OT (Occupation Therapy) effective 03/24/2024 1WK1 (once a week for one week); SN (skilled nurse) 2WK1 (twice a week for one week), 1WK1 (once a week for one week), 1 every 3WK3 (once every three weeks for three weeks).” The Client Episode Coordination Notes Report documents: 03/22/2024 “she is requesting for all visits to be in the afternoon.” 03/26/2024 “per HHAX (home health aide exchange) soc (start of care) 3/29/24.” 04/01/2024 “Spoke with patient; she had multiple issues she wanted to discuss” “she is asking for an OT (occupational therapy) evaluation” “She is also asking for the HHA (home health aide). It was 2:10pm and the aide had not arrived. (Aide service is scheduled from 1-4pm).” 04/01/02024 “Visit Discipline: OT (occupational therapy)” “Reason for missed visit: schedule overload.” The Order dated 03/22/2024 documents: “Skilled nurse to perform/teach wound care to R (right) posterior lower leg Skin graft recipient site, cleanse with NS (normal saline), cover with DSD (dry sterile dressing) & gauze wrap TIW (three times a week) & PRN (as needed), may leave open to air if no drainage.” The Client Calendar Report documents: OT (Occupational Therapy) add-on evaluation on 04/03/2024 and registered nurse visits on: 03/19/2024, 03/22/2024, and 03/29/2024. The Visit Note Report dated 03/29/2024 documents “wound care not provided – observation only”. There is no documented evidence that the physician was notified of no occupational therapy evaluation from 3/24/2024 until 04/02/2024; skilled nurse: missed two visit the week of 03/24/2024, no visits scheduled for the week of 03/31/2024 and wound not treated on 03/29/2024; and delay in aide services. The clinical record lacks documented evidence of all the Clinicians coordinating with the physician to meet the care needs of the patient. On 04/04/2024 at 03:30pm, the Vice President of Quality and the Vice President of Regional Patient Services were interviewed and did not provide an explanation for the findings.

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 reviews, and staff interviews, the agency failed to coordinate care delivery and involve the patient to ensure patient needs are addressed. This was evident for one (1) of six (6) patient care records reviewed (Patient #2). Failure to ensure that patient’s care is coordinated, and all patient needs are addressed, has the potential for negative patient outcomes. The findings are: 1. Patient #2 has a Start of Care date of 03/19/2024 with the following diagnoses "Chronic Obstructive Pulmonary Disease with Lower Respiratory Infection, Pneumonia" documented in the Home Health Certification and Plan of Care dated 03/19/2024 to 05/17/2024. The Home Health Certification and Plan of Care dated 03/19/2024 to 05/17/2024 documents: “OT (Occupation Therapy) effective 03/24/2024 1WK1 (once a week for one week).” The Client Episode Coordination Notes Report documents: 03/22/2024 “Pt (patient) calling about a complaint.” “she is requesting for all visits to be in the afternoon.” “did not get P/T (physical therapy) and OT (occupational therapy).” 03/26/2024 “Pt (patient name and number) express concern about requesting change P/T (physical therapy), need O/T (occupational therapy) visit update and hha schedule.” 03/26/2024 “CFM (case field manager) returned call to patient and addressed her concerns. She was told that (name) will be her PT (physical therapy) and OT (occupational therapy name) is scheduled to see her on Thursday.” 03/26/2024 “per HHAX (home health aide exchange) soc (start of care) 3/29/24.” 03/28/2024 “Pt (patient name and number) call in regards to a visit P/T (physical therapy) and O/T (occupational therapy) suppose to come today which was a no show. The same thing happen on Tuesday. If I don’t get a call from VNS the next time to cancel visit I am going to the board of health.” “Pt (patient) request status of HHA (home health aide). In reviewing HHA (home health aide) Exchange Auth# 86903 from 03/29/24 to 4/20/24. Informed caller. HHA (home health aide) assigned for 3/29/24 from 9am to 12:00m (noon). Informed caller. Patient is requesting HHA (home health aide) services for in the afternoon for 1 pm to 4 pm.” Agency was notified of afternoon services only on 03/22/2024. 03/28/2024 “CFM (case field manager) called patient and there was no answer. Left VM (voice message) to call back. Follow up needed.” 03/29/2024 “Patient is awaiting occupational therapy.” 04/01/2024 “Spoke with patient; she had multiple issues she wanted to discuss” “she is asking for an OT (occupational therapy) evaluation” “She is also asking for the HHA (home health aide). It was 2:10pm and the aide had not arrived. (Aide service is scheduled from 1-4pm).” 04/01/02024 “Visit Discipline: OT (occupational therapy)” “Reason for missed visit: schedule overload.” The Client Calendar Report documents: OT (Occupational Therapy) add-on evaluation on 04/03/2024. There is no documented evidence that the patient was notified of delay and cancellation in services for occupational therapy and aide services. The clinical record lacks documented evidence of all the Clinicians coordinating with the patient to meet the care needs of the patient. On 04/04/2024 at 03:30pm, the Vice President of Quality and the Vice President of Regional Patient Services were interviewed and did not provide an explanation for the findings.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on clinical care record review and staff interviews, the governing authority failed to provide services that are ordered by the physician as indicated in the plan of care. This was evident for two (2) of six (6) patient care records reviewed (Patient’s #2 and #6). Failure to provide services that are ordered by the physician as indicated in the plan of care, has the potential for negative patient outcomes. The findings are: 1. Patient #2 has a Start of Care date of 03/19/2024 with the following diagnoses "Chronic Obstructive Pulmonary Disease with Lower Respiratory Infection, Pneumonia" documented in the Home Health Certification and Plan of Care dated 03/19/2024 to 05/17/2024. The Home Health Certification and Plan of Care dated 03/19/2024 to 05/17/2024 documents: OT (Occupation Therapy) effective 03/24/2024 1WK1 (once a week for one week). The Order dated 03/22/2024 documents: “Skilled nurse to perform/teach wound care to R (right) posterior lower leg skin graft recipient site, cleanse with NS (normal saline), cover with DSD (dry sterile dressing) & gauze wrap TIW (three times a week) & PRN (as needed), may leave open to air if no drainage.” The Client Calendar Report documents: OT (occupational therapy) add-on evaluation on 04/03/2024 and registered nurse visits on: 03/19/2024, 03/22/2024, and 03/29/2024. The Visit Note Report dated 03/29/2024 documents “wound care not provided – observation only”. The clinical record lacks documented evidence that the patient received occupational therapy the week of 03/24/2024, missed one visit; and skilled nurse missed two visit the week of 03/24/2024, and no visits scheduled for the week of 03/31/2024. There is no documented evidence of the treatment of wound by the skilled nurse on 03/29/2023. The clinical record lacks documented evidence of the patient receiving occupational therapy and skilled nurse services as ordered on the plan of care. On 04/04/2024 at 03:30pm, the Vice President of Quality and the Vice President of Regional Patient Services were interviewed and did not provide an explanation for the findings. 2. Patient #6 has a Start of Care date of 02/17/2024 with the following diagnoses "Chronic Obstructive Pulmonary Disease, Interstitial Pulmonary Disease" documented in the Home Health Certification and Plan of Care dated 02/17/2024 to 04/16/2024. The Resumption of Care dated 03/21/2024 documents: SN (skilled nurse) effective 03/17/2024 2WK3 (twice a week for three weeks); PT (physical therapy) effective 03/24/2024 1WK1 (once a week for one week).” The Client Calendar Report documents: skilled nurse visit on 3/21/2024 and 04/02/2024 and a missed visit on 03/29/2024. The clinical record lacks documented evidence that the patient received skilled nurse: missed one visit the week of 03/17/2024 and 03/24/2024; and physical therapy: missed one visit the week of 03/17/2024. The clinical record lacks documented evidence of the patient receiving skilled nurse services and physical therapy as ordered on the plan of care. On 04/04/2024 at 03:30pm, the Vice President of Quality and the Vice President of Regional Patient Services were interviewed and did not provide an explanation for the findings.

The following statement of deficiencies represents the results of a complaint investigation of Complaints 102911 and 103075 conducted at VNS OF NY Home Care CHHA located at 220 E. 42nd Street, New York, NY 10017, from 12/06/203 to 12/07/2023 to evaluate compliance with Federal regulations. The agency’s active patient census was 5676. The investigation consisted of a review of six (6) clinical records (identified as Patient #1, #2, #3, #4, #5, and #6), four (4) personnel records (identified as Employee #1, #2, #3, and #4), the agency's complaint log, and interviews with the Associate Vice President of Quality, the Senior Vice President for Patient Care Services, the Vice President for Patient Care Services, the Vice President for Regional Patient Care Services, and the Associate Director of Quality. Pre-survey activities consisted of review on 12/05/2023 of the agency's Health Commerce System account and compliance history. Findings were reviewed at the exit conference. The allegations in Complaint 103075 were determined unsubstantiated. The allegations in Complaint 102911 were determined substantiated. The following deficiencies are being cited as result of the survey: G428 - Property and person treated with respect G580 – Only as ordered by a physician

Property and person treated with respect CFR(s): 484.50(c)(1) Have his or her property and person treated with respect; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to ensure that respect for all patient’s preferences regarding services that will be delivered. This was evident for one (1) of six (6) clinical records reviewed (Patient #1). Failure to ensure that patient is treated with consideration, respect, and full recognition of her dignity has the potential for negative patient outcomes. The findings are: 1. Patient #4 has a Start of Care date of 11/12/2023, Discharge Date of 11/16/2023, with diagnoses Primary Osteoarthritis Right Shoulder and Strain of Muscle/Tendon of the Rotator Cuff of Right Shoulder Subsequent Encounter documented in the Home Health Certification and Plan of Care dated 11/12/2023 to 01/10/2024. The Coordination Note dated 11/15/2023 documents the following telephone call from the patient: “Time of Call 11/15/2023 5:08PM;” Call Notes: “(Patient #4) states VNS staff keeps call her and want it to stop. Pt (Patient) states want a message to be sent to (Branch Director). (Patient) wants the staff at VNS Health to stop calling her or she will call police for harassment.” The Clinical Field Manager Coordination Note dated 11/16/2023 (Last Update 11/16/2023 8:53AM) documents the following: “MD (name) is notified about patient refusal of all services from VNS Health.” The Discharge/Transfer Summary Report documents: “Discharged 11/16/2023.” The Home Health Certification and Plan of Care dated 11/12/2023 to 01/10/2024 documents orders for home health aide services three days a week. The Coordination Note dated 11/16/2023 documents the following call from the home health aide vendor: “Time of Call: 11/16/2023 1:57PM;” “Supervisor from personal care (vendor) calling on behalf of (Patient #4) to inform the Branch Clinical manager she contact(ed) the patient to inform her the start (of) services for the (home health aide) schedule for tomorrow starting at 10:00AM to 1:00PM and also inform the name of the (home health aide) assign(ed) for her services; patient refuse to talk to the Supervisor and request she only will speak with (Branch Director) and hang up the phone.” The Coordination Note-(Home Health Aide) Assignment Notification note dated 11/16/2023 documents: “Time of Call: 11/16/2023 2:41PM;” “Comments: Per (Home Health Aide vendor). (start of care) - 11/17/2023; schedule M/W/F, 3hrs (hours), Time 10-1pm; (Permanent) (home health aide’s name)." The Coordination Note dated 11/17/2023 documents: “Time of Call 11/17/2023 9:59 AM;” personal care (vendor) “called about (start of care) for (home health aide) today; (aide) is at door; but patient will only speak to (Branch Director) only or (Registered Nurse). (Patient) D/C(Discharged) 11/16/23.” The Coordination Note dated 11/17/2023 12:01 PM documents another communication from the vendor: “9:40am 11/17 tc (telephone call) rec’d from (home health aide) to inform (vendor supervisor) she arrived at (Patient #4) home and spoke to (patient) who said (patient) told her the nurse or (Branch Director) should be calling her with details of her services. (Supervisor) attempt to speak to (Patient #4) who refused to speak to me. (Home health aide) advised to wait till reach out to Team. 9:47am (telephone call) made to CHHA Team. (Customer Service Representative) was advised (patient) refusing to speak with (vendor Supervisor) or accept (home health aide) into her home, requesting nurse or (Branch Director) to (contact) her. Per (Customer Service Representative) Mbr’s (Member’s) case is discharged as of 11/16 but she will contact Team for confirmation.” There is no documented evidence of the agency immediately communicating with the vendor of the patient’s discharge on 11/16/2023, after notifying the physician on 11/16/2023 in AM. There is no documented evidence of the agency communicating with the patient about the aide arriving to start services on 11/17/2023. There is no documented evidence of the patient being treated with consideration and respect. On 12/07/2023 at 04:30 pm, the Associate Vice President of Quality, the Senior Vice President for Patient Care Services/Administrator/Director of Patient Services, the Vice President for Patient Care Services, the Vice President for Regional Patient Care Services, and the Associate Director of Quality were interviewed and did not provide an explanation for the finding.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to ensure that services and treatments are administered only as ordered by the physician for each patient. This was evident for one (2) of six (6) clinical records reviewed. (Patient #2 and #6). Failure to ensure that treatments are administered only as ordered by the physician has the potential to result in poor quality of care. The findings are: 1. Patient #4 has a Start of Care date of 11/12/2023, Discharge Date of 11/16/2023, with diagnoses Primary Osteoarthritis Right Shoulder and Strain of Muscle/Tendon of the Rotator Cuff of Right Shoulder Subsequent Encounter documented in the Home Health Certification and Plan of Care dated 11/12/2023 to 01/10/2024. The Registered Nurse Start of Care assessment notes dated 11/12/2023 document: patient has a non-removeable dressing in place on the Right Shoulder Surgical Incision site; “presents for right should scope, SAD (Shoulder Subacromial Decompression), RCR (Rotator Cuff Repair), distal clavicle resection with Dr. (name) on 11/08/23; same day surgency under regional anesthesia for a pre-operative diagnosis of traumatic tear of right rotator cuff, arthritis of right shoulder region, and biceps tenonitis on right.” “Surgical wound covered by steri-strip and 1 incision.” The After Visit Summary/Discharge Instructions dated 11/08/2023 document the following postoperative care instructions for the patient: “You may shower on postoperative day #3. Remove the Dressing and all the gauze pads. Leave steri-strips (special white band-aids) in place;” “you may apply soap to your neck and allow the soapy water to run over your shoulder;” “Pat the shoulder dry with a towel and apply new waterproof band-aids over the surgical incision;” “Do not submerge the incision in water;” “November 20, 2023 Post-OP (visit) with PA (Physician Assistant).” The Home Health Certification and Plan of Care dated 11/12/2023 to 01/10/2024 documents: “Skilled Nurse (SN) to perform teach wound care to surgical incision at right shoulder coved with steri strips, observation only.” The Registered Nurse/Skilled Nurse Start of Care assessment notes dated 11/12/2023 document: patient has a non-removeable dressing in place on the Right Shoulder Surgical Incision; “presents for right should scope, SAD (Shoulder Subacromial Decompression), RCR (Rotator Cuff Repair), distal clavicle resection with Dr. (name) on 11/08/23; same day surgency under regional anesthesia for a pre-operative diagnosis of traumatic tear of right rotator cuff, arthritis of right shoulder region, and biceps tenonitis on right.” “Surgical wound covered by steri-strip and 1 incision not included in the picture attached by Dermabind (Dermabond).” The subsequent Skilled Nurse Visit note dated 11/15/2023 documents: “Right shoulder incision site dressing removed by VN (visiting nurse). VN (Visiting nurse) covered the incision site with gauze because (Patient #4) insisted to cover the incision site despite the fact MD recommendation remove dressing 3 days post-surgery and leave it open to air.” The Coordination Note date 11/15/2023 documents the patient called and reported the following: “Your RN (Registered Nurse/Skilled Nurse) did not have tape and couldn’t dress the wound properly.” The clinical record lacks documented evidence of an order for the Skilled Nurse to remove the surgical dressing and cover with gauze. There is no documented evidence of the Skilled Nurse communicating with the physician to clarify postoperative wound care instructions. including the Post-op instructions given to the patient on 11/08/2023 to apply waterproof band-aid, and to obtain the wound care orders to change the dressing. There is no documented evidence that the services and treatments were administered only as ordered by the physician. On 12/07/2023 at 04:30 pm, the Associate Vice President of Quality, the /Senior Vice President for Patient Care Services/Administrator/Director of Patient Services, the Vice President for Patient Care Services, the Vice President for Regional Patient Care Services, and the Associate Director of Quality were interviewed and did not provide an explanation for the finding. 2. Patient #6 has a Start of Care date of 10/29/2023 with diagnoses Pressure Ulcer pf Sacra; Region Stage 2, Encounter for Fitting and Adjustment of Urinary Device, Other Retention of Urine, Personal History of Urinary (Tract) Infections Primary, Bed Confinement Status documented in the Home Health Certification and Plan of Care dated 10/29/2023 to 12/27/2023. The Registered Nurse SOC assessment notes dated 10/29/2023 document: Patient “hospitalized from 10/11 – 10/27 for complicated UTI (Urinary Tract Infection), Course of ABT (Antibiotic) completed;” “(Patient) has Foley (catheter) urine retention;” “Per (Patient), Foley (catheter) change is due this week between 11/1 – 11/3.” “(Patient) requested if possible, can nurse take over Foley (catheter) change since he is bedbound. (Patient) was instructed that (Medical Doctor) will need to be contacted to get order to do so.” The Coordination Note-Physician Communication dated 10/30/2023 documents: “Summary of information provided: Attempted to reach (Medical Doctor) to reconfirm wound care frequency and if (visiting nurse) can start providing monthly (catheter) change for (Patient). (Visiting nurse) was instructed to call back (tomorrow) when (Medical Doctor) office open.” The Registered Nurse Visit Note dated 11/05/2/2023 documents: “Patient) inquired about Foley and if could be changed;” “(Patient) was last seen by Urologist (name) in June. But voiced that Foley was changed early in October. (Visiting nurse) suggested to (family member) if Foley is due now he will need to go to ER to have it changed.” The Registered Nurse Visit Note dated 11/06/2023 documents: “Patient inquiring about replacing Foley catheter. (Visiting nurse) has ordered supplies in the meantime. Patient unwilling to go to (Emergency Room) for treatment at this time.” The Registered Nurse Visit Note dated 11/08/2023 documents: “Foley (catheter) in Parachute (Medical Equipment/Supplies ordering and tracking system) pending delivery.” The Coordination Note dated 11/10/2023 documents: “(Patient’s family member) states the (Patient) catheter is leaking. (Patient) has supplies at home. Requests (Registered Nurse) visit for today." The Registered Nurse Visit Note dated 11/10/2023 documents: “(Patient) received Foley bag and Foley (catheter), but not universal tray to perform Foley care. Foley not in proper placement as (Patient)) was found soiled in own urine and feces and drainage bag was noted empty.” “EMS (Emergency Medical Services) activated.” The clinical record lacks documented evidence of the nurse obtaining an order to perform Foley catheter change, including the required supplies. On 12/07/2023 at 04:30 pm, the Associate Vice President of Quality, the Senior Vice President for Patient Care Services/Administrator/Director of Patient Services, the Vice President for Patient Care Services, the Vice President for Regional Patient Care Services, and the Associate Director of Quality were interviewed and did not provide an explanation for the finding.

The following Statement of Deficiencies represents the results of a partial extended re-certification survey and includes complaints investigation # 98940, # 71530, # 62901, # 62664, # 61834, # 61461, # 61364, # 61317, # 58363, of VNS Health located at 220 East 42nd Street, 6th floor, New York, NY 10017 conducted on 10/23/2023 through 10/27/2023. The active patient census is 5769. A standard re-certification survey was initiated on 10/23/2023. Deficient practices were identified within Level 1 standards in 484.55 Comprehensive Assessment resulting in a partial extended survey. The survey consisted of a review of twelve (12) personnel records identified as Employee #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, and #12, twenty three (23) clinical records identified as Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, and #23, seven (7) home visits. The survey included a review of pertinent policies and procedures, Quality Improvement Meeting Minutes for past 12 months, PIP (Performance Improvement Projects), Admission Packet, Emergency Preparedness Plan, Complaint Log, Three (3) contracts, and the agency's Infection Control and Flu policy and procedure. Pre-survey activities consisted of a review on 10/18/2023 of the agency's Health Commerce System account, Certification and Surveyor Provider Enhanced Reports (CASPER) for the period 08/2022 – 07/2023, and the agency compliance with report submissions for the 2021 statistical report and the Emergency Drill for 2019. The complaints #61317, #62664, #61364, #62901, #58363 were determined to be unsubstantiated. The complaints # 61464, # 61834, # 98940, # 71530 were determined to be substantiated. The Associate VP Quality, Associate Directors Quality, VP Patient Care Services, Branch Directors, and staff were interviewed. Findings were reviewed at the exit conference on 10/27/2023. The following deficiencies are identified as a result of the survey: G0434 – Participate in care G0514 – RN Performs assessment G0536 – A review of all current medications G0548 - Within 48hours of the patient’s return G0574 – Plan of care must include the following G0580 - Only as ordered by a physician G0608 - Coordinate care delivery G0710 – Provide services in plan of care G0716 – Preparing clinical notes G0718 – Communication with physicians G0800 – Services provided by HH aide

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on clinical record review, and staff interview, the governing authority failed to inform Patients of changes in frequency of services. This was evident for one (1) of twenty - three (23) clinical records reviewed. (Patient #9). Failure to ensure that patients are informed of changes in frequency of services, has the potential for negative patient outcomes. The Findings Are: 1. Patient #9 has a Start of Care (SOC) date of 1/24/2022 with the diagnoses: " (Idiopathic) Normal Pressure Hydrocephalus, Hypothyroidism, Unspecified” documented on the Home Health Certification and Plan of Care for the Certification Period 1/24/2022 to 3/24/2022. The agency’s SOC – Facts About Your Home Care Services And Payment dated 1/24/2023 documents: “Initial Plan Of Care: Home Health Aide 3 HRS/DAY For 3 DAYS FOR 3 WEEKS.” The Client Episode Coordination Notes Report dated 1/24/22 documents: “Note: HHA Service Request: Initial Order: Order Details: Requested HHA Start Date: 1/26/22 – Requested HHA End Date: 02/11/22: Three (3) hours per day- Monday-Wednesday- Friday”. The Client Episode Coordination Notes Report dated 1/26/22 document: Start Date: 1/28/22 – End Date: 02/9/22: Two (2) hours per day- Monday-Wednesday- Friday”. The Client Episode Coordination Notes Report dated 1/28/22 documents: “Call notes: Patient called, stated two (2) hours per day HHA (home health aide) visit is insufficient she patient was told before HHA/SOC service would be provided four (4) hours per visit, patient wants to know reason hours was reduced.” The HHAeXchange Duty Sheet By Visit Date documents: Visit Date: 1/28/2022: Scheduled Time : 1115- 1315: Billed Hours :2:00 Visit Date: 1/31/2022: Scheduled Time : 1100- 1300: Billed Hours :2:00 The clinical record lacks documented evidence of the patient being informed and agreeing to the decision of decreasing the hha service hours. On 10/26/23 at 4:00 pm, the Associate Director of Quality was interviewed and did not provide an explanation for the findings.

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 the ensure Register Nurse conducts the initial assessment visit to determine the immediate care and support needs of the patient. This was evident for one (1) of twenty – three (23) clinical records reviewed (Patient: #10). Failure to ensure Register Nurse conducts the initial assessment visit to determine the immediate care and support needs of the patient has the potential risk for negative patient outcomes. The Findings Are: 1.Patient #10 has a Start of Care date of 10/16/2021 with diagnoses: “ Pressure Ulcer of Sacral Region, Stage 2, Essential (Primary ) Hypertension, Hyperlipidemia, Unspecified, Anxiety Disorder, Unspecified, Parkinson’s Disease, Dementia in other Disease Classified Elsewhere W/O (without) Behavioral Disturbance, Dependence on Wheelchair” documented in Home Health Certification and Plan of Care for Certification Period 10/16/2021 to 12/14/2021. The referral fax from the Physician’s office documents: “To: Agency Name: Date: 10/11/2021: From: Patient’s Physician Name: Urgent : For Review." The RN Oasis Admission documents the Start of Care date as 10/16/2021. The clinical record lacks documented evidence of an initial RN assessment within 48 hours of the Physician’s referral to determine the immediate and urgent needs of the patient. There is no documented evidence that the physician was notified of the patient not being seen for the urgent referral on 10/11/21. On 10/27/23 at 11:00 am, the Associate Director of Quality was interviewed and stated, “a welcome call was made on 10/13/21 and a message was left." No additional information was provided.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on clinical record reviews and staff interview, the agency failed to ensure that all patient's medications were reviewed and accurately reflected in the patient's plan of care. This was evident for three (3) of twenty-three (23) clinical records reviewed (Patient: #1, #2, and #14). Failure to ensure that all patient's medications are reviewed and accurately reflected in the patient's plan of care, has the potential for negative patient outcomes. The Findings Are: 1. Patient #1 has a Start of Care (SOC) date of 08/19/2023 with diagnoses Hypertensive Heart Diseas4e with Heart Failure, Acute Diastolic (Congestive) Heart Failure, Atrial Fibrillation, Pulmonary Hypertension, Hypokalemia documented in the Home Health Certification and Plan of Care dated 10/18/2023 to 12/16/2023. The Resumption of Care (ROC) coordination note dated 09/29/2023 documents: “Hospital admission date 9/26;” “Sent in by Cardiologist for progressive SOB (shortness of breath) and LE (lower extremity) edema;” “(Privately hired aide) has noted 10lb weight gain and worsening LE edema.” The Hospital “Inpatient Discharge Summary” dated 09/29/2023 documents the following discharge instructions: “New Medications: 1. Bactrim DS (Sulfamethoxazole and trimethoprim antibiotic)– Take 1 Tablet by mouth twice daily for 3 days; Changed Medications: 1. Furosemide (diuretic) 80mg – Take 1 Tablet by mount once daily, 2. KlorCon (Potassium Chloride) 10 mEq - Take 2 Tablets by mouth once daily;" and "prescriptions were electronically sent to" the patient's pharmacy. The RN ROC/Update to the comprehensive assessment dated 10/04/2023 lacks documented evidence of that the RN reviewed and reconciled the new and changed medications. There is no documented evidence the updated assessment includes a comprehensive review of all medications the patient currently takes for compliance, possible side effects and possible drug interactions. On 10/25/2023 at 02:30 PM the Administrator/Senior Vice President of Patient Services, Senior Vice President/Chief Quality Officer, Associate VP Quality, Associate Director Quality, VP Patient Care Services and Branch Director were interviewed, and did not provide an explanation for the finding. 2. Patient #2 has a Start of Care (SOC) date of 09/08/2023 with diagnoses Polyosteoarthritis, Unspecified Fracture of Unspecified Foot Subsequent Encounter for Fracture with Routine Healing, Hypertensive Heart Disease with Heart Failure documented in the Home Health Certification and Plan of Care dated 09/08/2023 to 11/06/2023. The Start of Care assessment note dated 09/08/2023 documents the Physical Therapist (PT) reviewed of all the medications the patient is taking. The PT “Client (Patient) Medication Report” Date Reviewed 09/08/2023 and printed 10/23/2023 documents: “Bumetanide 1mg Tablet, as directed, cardiovascular therapy agents, Start Date 9/8/23.” The medication review lacks documentation of the frequency the patient takes the medication Bumetanide. On 10/23/2023 an observational home visit was completed with the Physical Therapist. Following the completion of the visit, the surveyor reviewed current medications with the patient. The patient showed the surveyor a document entitled “Your Medication List as of August 31, 2023” and the Bumetanide prescription bottle that documents the following: “Bumetanide 1mg, Take 2 Tablets by mouth Daily.” The Plan of Care dated 09/08/2023 to 11/06/2023 documents the PT and RN Clinical Review Manager (CRM) signatures dated 09/08/2023, and frequency to take Bumetanide, “as directed.” The agency failed to ensure a drug regimen review is completed accurately for this therapy only case. On 10/25/2023 at 02:30 PM the Administrator/Senior Vice President of Patient Services, Senior Vice President/Chief Quality Officer, Associate VP Quality, Associate Director Quality, VP Patient Care Services and Branch Director were interviewed, and did not provide an explanation for the finding. 3.Patient#14(HV) has a Start of Care date of 07/27/2023 with the following diagnoses “Venous Insufficiency (Chronic)(Peripheral), Non-Pressure Chronic Ulcer of other Part Right Lower Leg with Fat Layer Exposed, Non-Pressure Chronic Ulcer of other Part Left Lower Leg with Fat Layer Exposed, Heart Failure” documented on the Home Health Certification and Plan of Care dated 09/25/2023 to 11/23/2023. The Home Health Certification and Plan of Care for the Certification Period 09/25/2023 to 11/23/2023 documents:” Eliquis 5 mg tablet 1 tablet oral every 12 hours; Metoprolol Succinate ER 25 mg, Extended Release 24 HR 1 tablet oral daily.” On 10/23/2023, a home visit was conducted, the patient showed the surveyor a bag with all the medications that the patient takes every day, and the following medications were observed: " Eliquis 2.5 mg oral 2 times daily; Metoprolol Succinate ER 50 mg, Extended Release 24 HR oral 3 times daily. " There is no documented evidence of the Plan of Care dated 09/25/2023 to 11/23/2023 including the medications: "Eliquis 2.5 mg" and "Metoprolol Succinate ER 50 mg". There is no documented evidence of all medications being reviewed and reconciled. On 10/25/2023 at 03:00 pm, the Administrator/Senior VP of Patient Services, the Senior VP President/Chief Quality Officer, the Associate Director Quality, the VP Patient Care Services and the Branch Director were interviewed and did not provide an explanation for the finding.

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on clinical record review, and staff interview the agency failed to ensure comprehensive assessments are updated and revised within forty-eight (48) hours of the patient's return to the home from a hospital admission of twenty-four (24) hours or more. This was evident for two (2) of twenty - three (23) clinical records reviewed (Patient #1, and #6). Failure to ensure the comprehensive assessment are updated within 48 hours of a patient's return from a hospital admission, has the potential for negative patient outcomes. The Findings Are: 1. Patient #1 has a Start of Care (SOC) date of 08/19/2023 with diagnoses Hypertensive Heart Diseas4e with Heart Failure, Acute Diastolic (Congestive) Heart Failure, Atrial Fibrillation, Pulmonary Hypertension, Hypokalemia documented in the Home Health Certification and Plan of Care dated 10/18/2023 to 12/16/2023. The Resumption of Care (ROC) coordination note dated 09/29/2023 documents: “Request Resumption of Care Date 9/30,” “Hospital admission date 9/26;” “Sent in by Cardiologist for progressive SOB (shortness of breath) and LE (lower extremity) edema;” “(Private pay aide) has noted 10 lb weight gain and worsening LE edema;” The coordination note dated 09/30/2023 documents: “Patient still in the hospital and scheduled for discharge today 9/30 as per daughter.” The Healthix (public Health Information Exchange) -Alert Note dated 09/30/2023 documents: “Discharge Date 09/30/2023 02:46PM.” The coordination note dated 10/3/2023 documents: “Reason for Call: Resumption of Care;” “Patient’s private pay aide (name) (phone number) called for status on the resumption of care, stating the pt was released from (Hospital) on 9/30/23 afternoon and she really need her PT visits resume. HHA (Home Health Aide) is requesting the nurse please call her or call the patient on her mobile phone.” The coordination note documents: "Follow-up Comment by Clinical Field Manager (CFM): Spoke with patient’s aide who was inquiring about resumption of care. CFM apologized about the delay over the weekend. CFM to set up ROC 10/04/2023. Aide agreed and informed patient.” The RN ROC/update to the comprehensive assessment dated 10/04/2023 documents the ROC assessment was conducted on 10/04/2023, four days after the patient’s return to home from a hospital admission of more than 24 hours. The “Resumption of Care” Policy documents: “Scheduler assigns ROC visit to a skilled clinician to be made within 24 hours of discharge from an inpatient facility.” There is no documented evidence of a Registered Nurse completing the resumption assessment visit within 48 hours of the patient's return to the home from a hospital admission or in accordance with the agency’s ROC policy. On 10/25/2023 at 02:30 PM, the Administrator/Senior Vice President of Patient Services, Senior Vice President/Chief Quality Officer, Associate VP Quality, Associate Director Quality, VP Patient Care Services and Branch Director were interviewed, and did not provide an explanation for the finding. 2. Patient #6(PAE) has a Start of Care (SOC) date of 06/07/2023, Discharge Date of 08/05/2023, with diagnoses Other Complications of Amputation Stump, Infection of Amputation Stump Right Lower Extremity, Type 2 Diabetes Mellitus with Other Specified Complication, Other Acute Osteomyelitis Right Ankle and Foot, Type 2 Diabetes Mellitus with Diabetic Peripheral Angiopathy without Gangrene, Chronic Kidney Disease Stage 3B documented in the Home Health Certification and Plan of Care dated 06/07/2023 to 08/05/2023. The SN (Skilled Nurse) Visit Note Report dated 07/14/2023 documents: “Patient seen for wound care to Rt (Right) foot TMA (Transmetatarsal amputation) site. Care provided as ordered. Care tolerated well. Serosanguineous drainage increased, blood clots noted. MD to be notified. SN instructed patient if drainage saturating dressing within an HR (hour)/blood gushing out to go the ED (emergency department). Patient verbalized understanding." The SN Physician Communication note dated 07/14/2023 documents: “SN left message with office assistant requesting call back from MD regarding change in wound to Rt foot. Wound drainage (serosanguineous large amounts) has increased. Blood clots noted in wound. Bone exposed.” The Healthix ((public Health Information Exchange) – Alert Note dated 07/14/2023 documents patient’s hospital admission on 07/14/2023. The RN Visit Note Report dated 07/17/2021 documents: “Transferred to an Inpatient Facility – Patient not discharged from agency.” The Healthix ((public Health Information Exchange) – Alert Note dated 08/02/2023 documents: Inpatient discharge – “Patient was discharged on Aug. 2, 2023 07:04PM” The ROC coordination note dated 08/03/2023 documents: Patient “is calling to inquire about the status of her services b/c (because) she has been hospitalized for the past 2-3 weeks. Member’s (Patient’s) d/c(discharge) summary was posted by (Hospital) on 8/2; but still has a hold status on her acct (account). Agent attempted to reach CFM (Clinical Field Manager) was unsuccessful. Agent informed caller over the hold status and informed a message will be sent to CFM + CM (Clinical Review/Manager) to f/u (follow-up) in regards to resumption of care.” The ROC coordination note dated 08/07/2023 documents the patient called again to inquire about the resumption of care. The note documents: Patient “calling to check on status of care since she just got out of the hospital. Advised case on hospital hold. Advised I would message team to follow up on resumption of care. “ The coordination notes document the patient called the agency twice to request ROC. The “Resumption of Care” Policy documents: “If the request for ROC comes from patient or family, the CFM or clinician must call physician to ascertain services need and obtain order to ‘Schedule ROC Visit’;” “CFM creates order ‘Schedule ROC Visit’ for the Registered Nurse;” “Scheduler assigns ROC visit to a skilled clinician to be made within 24 hours of discharge from an inpatient facility.” The “Discharge Transfer Summary Report” dated 08/05/2023 documents the patient was discharged from the agency on 08/05/2023 – Administrative Discharge. The clinical record lacks documented evidence of the agency communicating with the physician about the ROC. The clinical record lacks documented evidence of the agency conducting a ROC assessment prior to discharging the patient from the agency. There is no documented evidence of the agency conducting a resumption assessment within 48 hours of the patient's return to the home from a hospital admission or in accordance with the agency’s ROC policy. On 10/27/2023 at 11:30 AM the Associate VP Quality, Associate Director Quality, VP Patient Care Services and Branch Director were interviewed, and did not provide an explanation for the finding. On 10/27/2023 at 2:45PM, the Branch Director stated that the expectation is to call the physician to get a ROC order to go back into the home.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record reviews, and staff interview, the agency failed to ensure each patient's individualized plan of care included all the required information. This was evident for three (3) of twenty - three (23) clinical records reviewed (Patients #1, #2, and #6). Failure to ensure individualized plan of care is established for all patients has the potential risk for negative patient outcomes. The Findings Are: 1. Patient #1 has a Start of Care (SOC) date of 08/19/2023 with diagnoses Hypertensive Heart Disease with Heart Failure, Acute Diastolic (Congestive) Heart Failure, Atrial Fibrillation, Pulmonary Hypertension, Hypokalemia documented in the Home Health Certification and Plan of Care dated 10/18/2023 to 12/16/2023. The referral/hospital admission note dated 8/11/2023 documents: “Allergies: 1. Bee Pollen - Itching, 2. Pollen Extract – Itching.” The hospital referral coordination note dated 09/28/2023 documents: “Allergies – Bee Pollen, Pollen Extract.” The Plans of Care dated 08/19/2023 to 10/17/2023 and 10/18/2023 to 12/12/16/2023 document: "Allergies: NKA (No Known Allergies).” The Plan of Cares lacks documented evidence of the patient’s known allergies. There is no documented evidence that the individualized plan of care is complete. On 10/25/2023 at 02:30 PM, the Administrator/Senior Vice President of Patient Services, Senior Vice President/Chief Quality Officer, Associate VP Quality, Associate Director Quality, VP Patient Care Services and Branch Director were interviewed, and did not provide an explanation for the finding. 2. Patient #2 has a Start of Care (SOC) date of 09/08/2023 with diagnoses Polyosteoarthritis, Unspecified Fracture of Unspecified Foot Subsequent Encounter for Fracture with Routine Healing, Hypertensive Heart Disease with Heart Failure documented in the Home Health Certification and Plan of Care dated 09/08/2023 to 11/06/2023. The Plan of Care dated 09/08/2023 to 11/06/2023 documents the patient is to take the following medication: “Bumetanide 1mg (milligram) Tablet, as directed, oral.” On 10/23/2023 an observational home visit was completed with the Physical Therapist. Following the completion of the visit, the surveyor reviewed current medications with the patient. The patient showed the surveyor a document entitled “Your Medication List as of August 31, 2023” and the Bumetanide prescription bottle that documents the following: “Bumetanide 1mg, Take 2 Tablets by mouth Daily.” The Plan of Care lacks documented evidence of the frequency the patient should take the medication Bumetanide. On 10/25/2023 at 02:30 PM the Administrator/Senior Vice President of Patient Services, Senior Vice President/Chief Quality Officer, Associate VP Quality, Associate Director Quality, VP Patient Care Services and Branch Director were interviewed, and did not provide an explanation for the finding. 3. Patient #6(PAE) has a Start of Care (SOC) date of 06/07/2023, Discharge Date of 08/05/2023, with diagnoses Other Complications of Amputation Stump, Infection of Amputation Stump Right Lower Extremity, Type 2 Diabetes Mellitus with Other Specified Complication, Other Acute Osteomyelitis Right Ankle and Foot, Type 2 Diabetes Mellitus with Diabetic Peripheral Angiopathy without Gangrene, Chronic Kidney Disease Stage 3B, Long Term Use of Insulin documented in the Home Health Certification and Plan of Care dated 06/07/2023 to 08/05/2023. The Home Health Certification and Plan of Care dated 06/07/2023 to 08/05/2023 documents the following: “Skilled Nurse (SN) for instructions/reinforcement of diabetic care to include diet; skin care, diabetic foot care,” “Skilled Nurse to report blood glucose levels greater than 350 mg/dl or less than 70 mg/dl, or a pattern) three or more) of blood glucose levels that deviate from baseline. Glucose testing to be performed by patient/caregiver Q (every) 4/Day;” “Nutritional Requirements: Low Cholesterol, Low Sodium.” The SN Visit Note Report dated 06/21/2023 documents that the patient checks blood sugar “Daily3x (three times daily).” The SN Visit Note Reports dated 06/23/2023, 06/26/2023, 06/28/2023, and 07/03/2023 document that blood sugar is checked “Daily.” The Plan of Care lacks documented evidence of including the nutritional requirement for a diabetic patient and the correct daily frequency to check blood glucose level. There is no documented evidence of a complete plan of care to meet the patient needs. On 10/27/2023 at 11:30 AM, the Associate VP Quality, Associate Director Quality, VP Patient Care Services and Branch Director were interviewed, and did not provide an explanation for the finding.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to ensure that treatments are provided as ordered by a physician. This was evident for one (1) of twenty -three (23) clinical records reviewed (Patient #6). Failure to ensure that treatments are provided as ordered by the physician has the potential for negative patient outcomes. The Findings Are: 1. Patient #6(PAE) has a Start of Care (SOC) date of 06/07/2023, Discharge Date of 08/05/2023, with diagnoses Other Complications of Amputation Stump, Infection of Amputation Stump Right Lower Extremity, Type 2 Diabetes Mellitus with Other Specified Complication, Other Acute Osteomyelitis Right Ankle and Foot, Type 2 Diabetes Mellitus with Diabetic Peripheral Angiopathy without Gangrene, Chronic Kidney Disease Stage 3B documented in the Home Health Certification and Plan of Care dated 06/07/2023 to 08/05/2023. The Home Health Certification and Plan of Care dated 06/07/2023 to 08/05/2023 documents: “SN (Skilled Nurse) 3WK8 (three visit a week for eight weeks); Skilled Nurse to cleanse wound to RT (Right) foot Mid Dorsum surgical incision with NS (Normal Saline), prepare area with skin prep., fill entire cavity with black foam. Apply tubing and cover with transparent drape. Apply negative pressure device at 125mmhg. Change dressing every 72 HRS (Hours).” The SN Visit Note Report dated 06/23/2023 documents: Patient “has new (wound) treatment order from yesterday’s appointment with her surgeon. Vac (negative pressure device) treatment discontinued. New order cleanse right foot amputation with NS apply Xeroform then cover with Kerlix wrap then Coban wrap. Email sent to CFM (Clinical Field Manager) regarding new order and to follow up with supplies.” The Physician Order entered by the CFM and dated 06/23/2023 documents: “The new order cleanse the right foot wound with NS apply Xeroform on wound bed cover with Kerlix wrap then check ban wrap.” The Physician Order lacks documentation of the following instructions: to wrap with Coban (a self- adhesive wrap) and the frequency to perform the new wound treatment. The Physician Order dated 06/23/2023 lacks no documented evidence of being a complete wound treatment order. The Physician Order dated 07/05/2023 documents the following revised wound treatment orders, twelve days later: “Skilled Nurse to Teach/Assess/Provide wound care to amputation site to Rt (right) foot. Cleanse with Normal Saline, apply Xeroform, cover with DSD (dry sterile dressing), secure with Kerlix and Coban daily using clean aseptic technique. Patient to provide care when SN doesn’t visit.” The SN Visit Note Report dated 06/30/203 documents: Patient “needs Xeroform, Coban.” The SN Visit Note Report dated 07/05/2023 again documents the need for wound care supplies: “Wound Care Supplies Coban gauze, Xeroform needed.” The clinical record lacks documented evidence of wound care supplies being ordered to provide the new wound treatment. The SN Visit Note Report dated 07/07/2023 documents: “New wound care orders in home. Supplies met in home. Aquacel Ag to be applied to wound bed. Care proved as ordered. Care tolerated well. SN instructed patient to perform wound care daily.” The clinical record lacks documented evidence of a physician order to discontinue the treatment with Xeroform and to start the new wound treatment with Aquacel Ag. The SN Visit Note Report dated 07/10/2023 documents the SN provided wound care using the initial wound treatment of applying negative pressure wound treatment. The clinical record lacks documented evidence of a Physician Order to discontinue the initial wound care order, as specified in the SN visit note dated 06/23/2023. There is no documented evidence the services were provided in accordance with the Plan of Care. On 10/27/2023 at 11:30 AM the Associate VP Quality, Associate Director Quality, VP Patient Care Services and Branch Director were interviewed, and did not provide an explanation for the finding. On 10/27/2023 at 2:45PM, the Branch Director stated there was no physician order for Aquacel Ag wound treatment, and the SNs were using Xeroform found in the patient’s home to provide wound care.

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 review of clinical record reviews, and staff interviews, the agency failed to coordinate care delivery and ensure patient needs are addressed. This was evident for two (2) of twenty -three (23) clinical records reviewed (Patient #10, and #17). Failure to ensure that patient’s care is coordinated, and all patient needs are addressed, has the potential for negative patient outcomes. The Findings Are: 1.Patient#17 has a Start of Care date of 08/11/2022 and discharge date of 09/14/2022 with the following diagnoses “Angioimmunoblastic T-Cell Lymphoma, Unspecified Diastolic (Congestive) Heart Failure, Chronic Kidney Disease, stage 3” documented on the Home Health Certification and Plan of Care dated 08/11/2022 to 10/09/2022. The Home Health Certification and Plan of Care for the Certification Period 08/11/2022 to 10/09/2022 documents: “HHA (home Health Aide) effective 08/14/2022 1WK1 (once a week for one week), 2WK4 (twice a week for four weeks), HHA frequency 2 days x 4 hours” The Client Coordination Note Information Call dated 08/17/2022 documents:” Reason for Call: HHA Call Note: Personal Care(vendor) called to state that the patient son in law wants to speak to someone he is not satisfied with the dates given for HHA services. Caller states she told him patient would get an aide on Tues/Thurs at which point he got very rude with her and told that we do not decide the days they do. She tried to explain to him that the nurse determines what the patient needs but did not want to hear it and told her he wants to speak to a supervisor. Temp aide is canceled for tomorrow as the patient has a Dr. appointment. Should call back next visit with aide is Tuesday, 08/23/2022 and that is also a temp aide. They have not found a perm aide yet. She will be there from 2pm-6pm on Tuesday. Needs CFM (Clinical Field Manager) f/u. Msg (message) sent to RN as well.” The Client Coordination Note Information Call dated 08/23/2022 documents:” Call Note: Personal Care reports hha arrived and patient was at MD appointment.” The Client Coordination Note Information Call dated 08/24/2022 documents:” Call notes: Patient son in law calling very upset requesting all hha services be cancelled stating they were very specific at the time of patient assessment that the patient cannot be visited Tuesday or Thursday, but they were scheduled those days anyway and were told they refused services. Also wanting to ensure they are not billed for missed hha visits.” The clinical record lacks documented evidence of an aide providing care for the week of 08/14/2022 and 08/21/2022. The clinical record lacks documented evidence of the agency coordinating hha services with the patient/patient caregiver including arranging an alternate date to meet the patient’s needs. On 10/27/2023 at 03:00 pm, the Administrator/Senior VP of Patient Services, the Senior VP President/Chief Quality Officer, the Associate Director Quality, the VP Patient Care Services and the Branch Director were interviewed and did not provide an explanation for the finding. Patient #10 has a Start of Care date of 10/16/2021 with diagnoses: “ Pressure Ulcer of Sacral Region, Stage 2, Essential (Primary ) Hypertension, Hyperlipidemia, Unspecified, Anxiety Disorder, Unspecified, Parkinson’s Disease, Dementia in other Disease Classified Elsewhere W/O (without) Behavioral Disturbance, Dependence on Wheelchair” documented in Home Health Certification and Plan of Care for Certification Period 10/16/2021 to 12/14/2021. The Home Health Certification and Plan of Care for Certification Period 10/16/2021 to 12/14/2021 documents: SN 1wk2, 2wk1, 1wk2, 2wk1, 1wk1 PT Effective 10/17/2021 : 1wk1 OT Effective 10/17/2021 1wk1 The Client Episode Coordination Notes Report dated 10/16/21 11 AM documents: Informed MD that patient was seen , daughter refused PT/OT Orders will be faxed.” The Client Episode Coordination Notes Report dated 10/18/21 documents: “Narrative PT called multiple times 10/18/ and 10/19. Left message .Will delay PT.” The clinical record lacks documented evidence of coordinated communication with all clinicians ( OT and PT) and the physician to ensure the ongoing care needs of the patient is being met. The Client Episode Coordination Notes Report dated 10/29/21 9:32:46AM documents: “Note: daughter would like to stop the services ASAP if they are not covered by Medicare. She is concerned about paying for the services.” The Client Episode Coordination Notes Report dated 10/29/21 documents: “Note: Daughter called back, very angry requesting in writing proof of full coverage of all services by Medicare” The Client Episode Coordination Notes Report dated 11/1/21 4:00PM documents: “Note : Information call: Agency Name calling to check if patient was active. Informed Agency patient was active.” The Client Episode Coordination Notes Report dated 11/1/21 4:00PM documents: “Note : Information call: (Another agency) Name calling to confirm if patient is active. Caller was informed case active as of 10/16.” The Client Episode Coordination Notes Report dated 11/2/21 1PM documents: ‘ Patient declined services , stated they no longer wants visits because they do not have Medicaid.” The clinical record lacks documented evidence of all the Clinicians coordinating with the physician and the caregiver/family to meet the care needs of the patient. There is no documented evidence of an appropriate referral to the Social Worker for the family's Medicare/Medicaid concerns and eligibility, and the option of transfer to another agency for continuation of care to meet the needs of the patient. On 10/26/23 at 4:00 pm the Associate Director of Quality was interviewed and did not provide an explanation for the findings.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on clinical record review, and staff interviews, the agency failed to provide services that are ordered by the physician as indicated in the plan of care. This was evident for three (3) of Twenty - three (23) clinical records reviewed (Patient: #12, #16, and #17). Failure to provide services that are ordered by the physician as indicated in the plan of care, has the potential for negative patient outcomes. The Findings Are: Patient#16 has a Start of Care date of 05/17/2023 and discharge date of 07/14/2023 with the following diagnoses “Other Fracture of Right Low Leg, Unspecify Dementia, Anxiety Disorder” documented on the Home Health Certification and Plan of Care dated 05/17/2023 to 07/15/2023. The Home Health Certification and Plan of Care for the Certification Period 05/17/2023 to 07/15/2023 documents:” “HHA (Home Health Aide) 1WK1 (once a week for one week), 2WK1 (twice a week for one week), 1WK1 (once a week for one week), duration 3 hours.” The Physician Order dated 06/05/2023 documents:” HHA effective 06/04/2023 1WK1 (once a week for one week), 2WK1 (twice a week for two weeks), 1WK1 (once a week for one week). The clinical record lacks documented evidence of an aide providing care for the week of: 05/17/2023 to 05/20/2023 - one missed visit, week of 05/28/2023to 06/03/2023 - one missed visit, week of 06/04/2023 to 06/10/2023 - two missed visits. There is no documented evidence of the patient receiving aide services as ordered on the plan of care. On 10/27/2023 at 01:00 pm, the Administrator/Senior VP of Patient Services, the Senior VP President/Chief Quality Officer, the Associate VP Quality, the Associate Director Quality, the VP Patient Care Services and the Branch Director were interviewed and did not provide an explanation for the finding. Patient#17 has a Start of Care date of 08/11/2022 and discharge date of 09/14/2022 with the following diagnoses “Angioimmunoblastic T-Cell Lymphoma, Unspecified Diastolic (Congestive) Heart Failure, Chronic Kidney Disease, stage 3” documented on the Home Health Certification and Plan of Care dated 08/11/2022 to 10/09/2022. The Home Health Certification and Plan of Care for the Certification Period 08/11/2022 to 10/09/2022 documents:” HHA effective 08/14/2022 1WK1(once a week for one week), 2WK4(two times a week for four weeks) duration 4 hours” The clinical record lacks documented evidence of an aide providing care for the week of 08/14/2022 and 08/21/2022. There is no documented evidence of the patient receiving aide services as ordered on the plan of care. On 10/27/2023 at 03:00 pm, the Administrator/Senior VP of Patient Services, the Senior VP President/Chief Quality Officer, the Associate VP Quality, the Associate Director Quality, the VP Patient Care Services and the Branch Director were interviewed and did not provide an explanation for the finding. Patient#20 has a Start of Care date of 09/20/2023 with the following diagnoses “Bilateral Primary Osteoarthritis of Knee, Essential (Primary) Hypertension” documented on the Home Health Certification and Plan of Care dated 09/20/2023 to 11/18/2023. The Home Health Certification and Plan of Care for the Certification Period 09/20/2023 to 11/18/2023 documents: “OT effective 09/24/2023 1WK 1(one visit for 1 week) Occupational Therapist to evaluate patient for OT services and develop Plan of Care to be signed by the Physician.” There is no documented evidence of the OT (Occupational Therapist) conducting a visit and no documented evidence of a reason for the visit not being conducted. There is no documented evidence of an OT evaluation week of 09/24/2023 and no documented evidence of the patient receiving OT services as ordered on the Plan of Care. On 10/27/2023 at 02:30 pm, the Vice President of Patient Services was interviewed and did not provide an explanation for the finding. Patient #12 has a Start of Care (SOC) date of 9/20/2023 with the diagnoses “ Paroxysmal Atrial Fibrillation, Essential (Primary) Hypertension, Athscl Heart Disease of Native Coronary Artery W/O Ang Pctrs (Atherosclerosis of native coronary artery without angina pectoris)…” documented on the Home Health Certification and Plan of Care for the Certification Period 9/20/23 to 11/18/23. The Home Health Certification and Plan of Care dated 09/20/2023 to 11/18/2023 documents:" SN ( Skilled Nurse) :1WK 1, 2WK3, 1WK1( one time a week, two times a week for three weeks, one time a week). HHA (home health aide) effective week of 09/24/2023 2WK1, 3WK2 (two times a week for one week, three times a week for two weeks) ." The clinical record lacks documented evidence of the aide providing care for the week of: 09/23/2023 to 09/29/2023 - one missed visit and 09/30/23 to 10/06/23 one missed visit. The clinical record lacks documented evidence of SN services for the week of 09/23/2023 to 09/29/2023 – one missed visit: 10/7/23 – 10/13/230- one missed visit and 10/14/230- 10/20/23- one missed visit. The clinical record lacks documented evidence of the patient receiving home health aide and skilled nurse services as ordered in the plan of care. On 10/26/23 at 4:00pm the Associate Director of Quality was interviewed and did not provide an explanation for the finding.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on review of clinical record reviews, and staff interviews, the agency failed to prepare and document complete and accurate clinical and progress notes. This was evident for three (3) of twenty -three (23) clinical records reviewed (Patient #6, #10, and #19). Failure to document complete and accurate clinical and progress notes, has the potential for negative patient outcomes. The Findings Are: Patient#19 has a Start of Care date of 02/27/2023 with the following diagnoses “Pressure Ulcer of Left Buttock, stage 2, Type 2 Diabetes Mellitus without Complications, Polyosteoarthritis” documented on the Home Health Certification and Plan of Care dated 08/26/2023 to 10/24/2023. The Home Health Certification and Plan of Care for the Certification Period 08/26/2023 to 10/24/2023 documents:” Skilled Nurse to perform/teach Pressure Ulcer Care to stage 2 Left Buttock.” The SN notes dated 09/18/2023, 09/22/2023, 10/06/2023, 10/09/2023, 10/13/2023, 10/23/2023 documents:” Wound Assessment section: Wound#1- Low Buttock, LT, Pressure Injury-External." The SN note dated 09/01/2023, 09/05/2023, 09/08/2023, 09/15/2023, 10/20/2023 documents:” Wound Assessment section: Wound#2 – Coccyx, Pressure Injury – External.” The SN note dated 09/29/2023 documents:” Wound Assessment section: Wound#3 – Coccyx, Pressure Injury – External.” The SN note dated 10/02/2023 documents:” Wound Assessment section: Wound#1- Low Buttock, LT, Pressure Injury-External and Wound Assessment section: Wound#3 – Coccyx, Pressure Injury – External.” There is no documented evidence of the SN accurately and consistently documenting wound location and number. On 10/27/2023 at 11:00 am, the Branch Director was interviewed and stated that this patient has one wound Pressure Ulcer on Left Buttock stage, 2. The Home Health Certification and Plan of Care for the Certification Period 08/26/2023 to 10/24/2023 documents:” Diagnoses: Type 2 Diabetes Mellitus without Complications” The SN Visit Note dated 08/29/2023, 09/11/2023, 10/06/2023, 10/16/2023 documents:” Endocrine section: Does the patient have a Diagnosis of Diabetes? NO” There is no documented evidence of the SN clinical notes accurately reflecting the patient's status. On 10/26/2023 at 03:00 pm, the Administrator/Senior VP of Patient Services, the Senior VP President/Chief Quality Officer, the Associate VP Quality, the Associate Director Quality, the VP Patient Care Services and the Branch Director were interviewed and did not provide an explanation for the finding. Patient #10 has a Start of Care date of 10/16/2021 with diagnoses: “ Pressure Ulcer of Sacral Region, Stage @, Essential (Primary ) Hypertension, Hyperlipidemia, Unspecified, Anxiety Disorder, Unspecified, Parkinson’s Disease, Dementia in other Disease Classified Elsewhere W/O (without) Behavioral Disturbance, Dependence on Wheelchair” documented in Home Health Certification and Plan of Care for Certification Period 10/16/2021 to 12/14/2021. The agency’s “Documentation guidelines for the use of electronic Medical Records System – VNSNY Certified Home Health Agency” documents: All notes are to be completed and synced as soon as possible but no later than 24 hours of visit. Discharges: As soon it is known that the patient will be discharge from the agency the scheduler must assign visit to clinician to complete DC OASIS timely. Use “Case Conference” coordination note is written to document communication with the physician.” The Visit Note Report documents: Visit Date: 11/06/21 RN 44 TIF Data collection only – No visit made. Time: 11/06/21 12:AM Incomplete: Resumed: 01/07/2022 07:41AM: Completed 01/07/2022 07:55AM Transferred to an inpatient facility. Patient not discharge from agency. Signature: 1/7/2022 07:55AM On 10/27//23 at 11:18 AM the Associate Director of Quality was interviewed; the VNS Health Timeline of events (no author) was presented, and it documents: “11/10/21 Skilled Nurse learns from the patient spouse that patient died in the hospital on 11/6/21. 11/15/21 Skilled Nurse documents that according to the patient spouse, the patient died at home on 11/06/21. Physician notified on 11/15/2021. The clinical record lacks documented evidence of the Skilled Nurse notes for the dates 11/10 and 11/15/21. The Client Coordination Notes Report documents: Note Date: 11/15/2021: Last Update: 12/17/2021 10:46:05AM: Physician office contacted regarding missed visit, Missed visit due to patient expired. The clinical record lacks documented evidence of timely and accurate documentation. The clinical record lacks documented evidence of the physician being informed of the patient’s visit to an inpatient facility. On 10/27/23 at 11:30 am the Associate Director of Quality was interviewed and did not provide additional information. 1. Patient #6(PAE) has a Start of Care (SOC) date of 06/07/2023 with diagnoses Other Complications of Amputation Stump, Infection of Amputation Stump Right Lower Extremity, Type 2 Diabetes Mellitus with Other Specified Complication, Other Acute Osteomyelitis Right Ankle and Foot, Type 2 Diabetes Mellitus with Diabetic Peripheral Angiopathy without Gangrene, Chronic Kidney Disease Stage 3B, Long Term Use of Insulin documented in the Home Health Certification and Plan of Care dated 06/07/2023 to 08/05/2023. The Home Health Certification and Plan of Care dated 06/07/2023 to 08/05/2023 documents: “Skilled Nurse to assess/evaluate co-morbid conditions and other conditions that present themselves during the course of this episode to identify changes and intervene to minimize complications.” The Plan of Care documents the following goals for the patient’s right foot amputation/wound: “Patient will demonstrate improved status as evidenced by decrease in size/drainage, absence of infection, and decreased pain in 8 weeks.” The “Wound Evaluation and Management’ Policy documents the following instruction to the Skilled Nurse: “Re-evaluate the wound each visit using by performing a Complete Basic Wound Evaluation;” “If unable to complete some or all parts of the basic wound evaluation, including capturing wound measurements, document the reason for not performing a wound evaluation;” The policy documents the “Complete Basic Wound Evaluation” for all wounds includes – location of wound, age of wound, etiology of wound, dimensions, wound bed tissue, wound edges, surrounding skin, drainage (e.g. amount, color, consistency, odor), and pain. The “Wound Care – Dressing Change” Policy documents the SN is to “assess wound per policy” after removing soiled dressing. The SN Visit Note Reports dated 06/21/2023, 06/23/2023, 07/03/2023, 07/07/2023, 07/12/2023, and 07/14/2023 document the SN performed wound care treatment to the right foot amputation. The SN Visit Note Reports lack documented evidence of the SN including a complete description (wound bed tissue, wound edges, surrounding skin, drainage, and pain) of the wound as specified in the agency’s wound policies. The SN Visit Note Report dated 07/12/2023 documents: “Temp (Temperature) elevated 101.2 oral Temp. Patient was treated at ED (Emergency Department) on Monday (07/10/2023) for hyperglycemia (and) was told by MD WBC (white blood cell count) elevated. She (was) sent home with new Meds. Patient has to pick up, antibiotics from pharmacy;” “Wound care provided to RLE (Right Lower Extremity) TMA (Transmetatarsal amputation) site. No signs of infection noted at time of visit, large amount of serosanguineous drainage.” The SN Visit Note Report dated 0712/2023 lacks documented evidence that the SN note contains the names/dosages of the new medications/antibiotic, and a compete wound description, including wound bed tissue, wound edges, surrounding skin, drainage odor, and pain. The SN Telehealth Communication Note 07/13/2023 documents: “SN called patient at 1PM to check in. Patient verbalized she feels much better, BG 240. She stated after taking Tylenol Temp went down. No longer feels tired, Urination back to normal.” The SN clinical notes lack documentation that the SN followed up with patient about picking up and taking the new medications/antibiotic from the pharmacy, which was prescribed during ED visit on 07/10/2023. The SN Visit Note Report dated 07/14/2023 documents: “Patient seen for wound care to Rt (right) foot TMA site. Care provided as ordered. Care tolerated well. Serosanguineous drainage increased, blood clots noted. MD to be notified. SN instructed patient if drainage saturated dressing within an HR (hours)/blood gushing out to go to ED.” The Physician Communication note dated 07/14/2023 documents the following: “SN left message with office assistant requesting call back from MD (Medical Doctor) regarding change in wound to Rt foot. Wound drainage (Serosanguineous large amount) has increased. Blood clots noted in wound. Bone exposed. Patient vital stable at time of visit.” The SN Visit Note Report dated 0714/2023 lacks documented evidence that the SN note contains a compete wound description, including wound bed tissue (bone exposed, blood clots), wound edges, surrounding skin, drainage amount/odor, and pain. The clinical record lacks documented evidence of the SN preparing complete clinical notes, including visit and communication notes, to reflect the patient’s current health status. The clinical record lacks documented evidence of providing a complete picture of the patient status/condition to assist with monitoring the patient’s progress toward meeting plan of care goals, and to assist with revising plan of care to meet the patient’s skilled care needs. On 10/27/2023 at 11:30 AM the Associate VP Quality, Associate Director Quality, VP Patient Care Services and Branch Director were interviewed, and did not provide an explanation for the finding. On 10/27/2023 at 2:45PM, the Branch Director (BD) was interviewed and stated that the SN asked the patient about the antibiotic during the communication on 07/13/2023. The BD stated that the patient told the SN she did not pick up the medication from the pharmacy. The Branch Director confirmed the SN did not document the complete communication with the patient.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on review of clinical record reviews, and staff interviews, the agency failed to ensure ongoing communication with physician is maintained This was evident for two(2) of twenty -three (23) clinical records reviewed (Patient #6, and #10). Failure to ensure ongoing communication with physician is maintained, has the potential for negative patient outcomes. The Findings Are: 1. Patient #6(PAE) has a Start of Care (SOC) date of 06/07/2023, Discharge Date of 08/05/2023, with diagnoses Other Complications of Amputation Stump, Infection of Amputation Stump Right Lower Extremity, Type 2 Diabetes Mellitus with Other Specified Complication, Other Acute Osteomyelitis Right Ankle and Foot, Type 2 Diabetes Mellitus with Diabetic Peripheral Angiopathy without Gangrene, Chronic Kidney Disease Stage 3B documented in the Home Health Certification and Plan of Care dated 06/07/2023 to 08/05/2023. The Home Health Certification and Plan of Care dated 06/07/2023 to 08/05/2023 documents: "Skilled Nurse (SN) to assess/evaluate co-morbid conditions and other conditions that present themselves during the course of this episode to identify changes and intervene to minimize complications." The SN Visit Note Report dated 07/10/2023 documents: “Patient reports nausea and vomiting x 3 days, unable to keep food down, chills;” “Patient performed fingerstick in presence of nurse – BG (Blood Glucose) 520 after having coffee with creamer and 2 Equals. Patient self-administered 20 Units Novolog SQ to abdomen. Patient rechecked BG 25 minutes after administering insulin, BG 555. MD (Medical Doctor) notified instructed SN to activate EMS (Emergency Medical Services). EMS activated” The subsequent SN Visit Note Report dated 07/12/2023 documents: “Temp elevated 101.2 oral Temp. Patient was treated at ED (Emergency Department) on Monday (07/10/2023) for hyperglycemia (and) was told by MD WBC (white blood cell count) elevated. She (was) sent home with new Meds. Patient has to pick up,antibiotics from pharmacy. Patient denies any pain. States she feels tired, increase urination, increased thirst. Patient performed fingerstick but it was after directly after meals, reading 420. Patient administered 20 units of insulin per ordered by MD. SN instructed patient to take Tylenol, increase fluids, monitor temp and BG.” The SN Physician Communication note dated 07/12/2023 documents: “Summary of information provided. SN left message with office assistant requesting call back. Informing MD patient Temp 101.2. She reports tiredness, increase urination, no pain, redness or foul odor from wound.” The SN Telehealth Communication Note 07/13/2023 documents: “SN called patient at 1PM to check in. Patient verbalized she feels much better, BG 240. She stated after taking Tylenol Temp went down. No longer feels tired, Urination back to normal.” There is no documented evidence of the medication Tylenol in the patient’s individualized plan of care dated 06/07/2023 to 08/05/2023 and in “Client Medication Report (Profile)” printed 10/26/2023. There is no documented evidence of an SN communication with the physician about the following changes: the new medications/antibiotics prescribed during the patient’s ED visit on 07/10/2023; the SN instructing the patient to take Tylenol for the elevated temperature on 07/12/2023; and to update the plan of care. On 10/27/2023 at 11:30 AM the Associate VP Quality, Associate Director Quality, VP Patient Care Services and Branch Director were interviewed, and did not provide an explanation for the finding. Patient #10 has a Start of Care date of 10/16/2021 with diagnoses: “ Pressure Ulcer of Sacral Region, Stage @, Essential (Primary ) Hypertension, Hyperlipidemia, Unspecified, Anxiety Disorder, Unspecified, Parkinson’s Disease, Dementia in other Disease Classified Elsewhere W/O (without) Behavioral Disturbance, Dependence on Wheelchair” documented in Home Health Certification and Plan of Care for Certification Period 10/16/2021 to 12/14/2021. The Home Health Certification and Plan of Care documents: SN 1wk2, 2wk1, 1wk2, 2wk1, 1wk1 PT Effective 10/17/2021 : 1wk1 OT Effective 10/17/2021 1wk1 The RN Oasis Admission Visit Note Report dated 10/16/2021 documents: “daughter has declined PT and OT services.” The Client Episode Coordination Notes Report dated 10/29/21 documents: “Biller Notification: Daughter would like to stop the services ASAP.” The clinical record lacks documented evidence of ongoing communication and notification with the physician regarding the patient declining services (SN,PT,OT) documented in the plan of care. On 10/26/23 at 10:26 am the Associate Director of Quality was interviewed and did not provide an explanation for the findings.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on review of clinical record reviews, and staff interviews, the agency failed to ensure services were provided in accordance with the aide Plan of Care. This was evident for two (9) of seven (7) clinical records with Home Health Aides Services reviewed (Patient #9, and #12). Failure to ensure services were provided in accordance with the aide Plan of Care, has the potential for negative patient outcomes. The Findings Are: 1. Patient #9 has a Start of Care (SOC) date of 1/24/2022 with the diagnoses: " (Idiopathic) Normal Pressure Hydrocephalus, Hypothyroidism, Unspecified” documented on the Home Health Certification and Plan of Care for the Certification Period 1/24/2022 to 3/24/2022. The Aides Care Plan Report documents :“Start of Episode: 01/24/2022 : Frequency: HHA 2WK1, 3WK2.” Care Plan Category/ Service: Bath/Shower: Foot Care: Skin Care: Dressing: Walking: Assist with Medications: Frequency: Every Visit.” The HHAeXchange Duty Sheet By Visit Date lacks documented evidence of the following services being provided by the aide on every visit for the dates: Shower/Bath: Foot care: Skin care: 1/28,1/31, 2/2, 2/7, 2/9, 2/11, 2/14, 2/16, 2/18/22. Dressing: 1/31, 2/2, , 2/7, 2/9, 2/11, 2/14, 2/16, 2/18/22 Assist with Medications: 2/2, 2/7, 2/9, 2/11, 2/14, 2/16, 2/18/22. The clinical record lacks documented evidence of the Aide providing services that are documented in the plan of care. On 10/26/23 at 10:30 am, the Associate Director of Quality was interviewed and did not provide an explanation for the findings. 2. Patient #12 has a Start of Care (SOC) date of 9/20/2023 with the diagnoses “ Paroxysmal Atrial Fibrillation, Essential (Primary) Hypertension, Athscl Heart Disease of Native Coronary Artery W/O Ang Pctrs (Atherosclerosis of native coronary artery without angina pectoris)…” documented on the Home Health Certification and Plan of Care for the Certification Period 9/20/23 to 11/18/23. The Aides Care Plan Report documents :“Start of Episode: 09/20/2023:Frequency: HHA Effective 09/24/23: 2WK1, 3WK2.: Care Plan Category/ Services: Bath/Shower: Mouth Care: Foot Care: Shampoo: Skin Care: Dressing: Frequency: Three Times a Week.” The Duty Sheet documents the following services being provided by the aide : 203-Prepare Meal: 9/27 205- Feed Patient: 9/27 206-Assist with feeding: 9/27 501- Laundry: 9/27, 10/6, 10/9, 506- Grocery Shopping: 9/27, 10/9 513- Assist clean dressing change: 10/4, 10/6, 10/9, 10/11, 516- Assist with Medication :10/4, 10/9 522-Do Not Leave Patient Home Alone if there is no one: 9/27 533- Clean : 9/27, 10/4,10/6, 10/9, 10/11 534-Home Program: 10/4, 10/9, 10/11 There is no documented evidence that the Aide Care Plan Report dated 9/20/23 includes : 203-Prepare Meal, 205- Feed Patient: 206-Assist with feeding: 501- Laundry: 506- Grocery Shopping: 513- Assist clean dressing change: 516- Assist with Medication : 522-Do Not Leave Patient Home Alone if there is no one: 533- Clean :534- Home Program: The Aide’s Duty Sheet lack documented evidence of aide services being provided as ordered for the following weeks: Week 9/23- 9/29/23. Mouth Care: Foot Care: Shampoo: Skin Care: Dressing Week 9/30- 10/6/23: Mouth Care: Foot Care: Skin Care: Week 10/7- 10/13/23: Mouth Care: Foot Care: Skin Care: The clinical record lacks documented evidence of the aides providing patient care services in accordance with the Aide’s Plan of Care. On 10/26/23 at 10:30 am, the Associate Director of Quality was interviewed and did not provide an explanation for the finding.

This Statement of Deficiencies is a result of an on-site investigation of complaint IQIES 96382 and IQIES # 96670 conducted on 4/25/23 - 4/26/23 at VNS Home Care - CHHA ID# 337008 ,located at 220 E. 42nd Street, NY, NY 10017. The agency reports an active patient census of 5872. The investigation consisted of a review of five(5) clinical records identified as (Patient #1, #2 ,#3, #4, and #5), four personnel records identified as (Employee #1, #2, #3, and #4), the agency’s complaint/ Incident logs for the period 1/1/23 – 4/15/23. Interviews were conducted throughout the survey with the SVP, Chief Quality Officer and the AVP, Quality and Performance Improvement. The findings were reviewed at the Exit conference on 4/26/23. The Allegations in Complaint # 96382 were determined to be substantiated The Allegations in Complaint # 96670 were determined to be substantiated The following deficiencies are being cited as a result of the survey: G 0476 Investigation of Complaints G 0512 Standard: Initial assessment visit J 1444 Personnel

Investigation of complaints CFR(s): 484.50(e)(1) Standard: Investigation of complaints. The HHA must-- This STANDARD is not met as evidenced by: Based on review of the agency’s complaint log, record review, and staff interview, the agency failed to ensure the complete investigation and resolution of all patient complaints. This was evident for one (1) of five (5) clinical records reviewed.(Patient #4). Failure to ensure the complete investigation and resolution of all patient complaints, has the potential for negative patient outcomes. The findings are: 1.Patient #4 has a Start of Care date of 2/3/23 with diagnoses “Pressure Ulcer of Sacral Region Stage 2 , Pressure Ulcer of right heel, Stage 2, Pressure Ulcer of Other site , unstageable," documented on the Home Health Certification and Plan of Care for Certification Period 2/3/23 to 4/3/2023. The Client Coordination Notes Report documents: "2/28/2023 11:58AM : Caller stated she is unsatisfied with agency, patient not receiving services. Request to speak with (BD) Branch Director, tel (telephone to BD for follow up ,email sent to CFM (Clinical Field Manager). 2/28/2023 2:33PM Call Note: Patient’s family called requesting CFM regarding issues with the patient. States the treatment received is terrible. Stated call earlier today to complain about it. Unable to connect with CFM, BD, or CS. Advised a message will be sent over.” On 4/25/23 and 4/26/23 the agency’s complaint and incident logs were reviewed. The logs lacks documented evidence of Patient’s #1 complaint and investigation. On 4/26/23 at 4:30PM the Vice President was interviewed and acknowledge assisting Patient’s #1 daughter with her complaint but did not enter it on the log .

Standard: Initial assessment visit. CFR(s): 484.55(a) Standard: Initial assessment visit. This STANDARD is not met as evidenced by: Based on record review and staff interview the agency failed to ensure that the initial assessment visit was conducted within 48 hours of referral to determine the patient’s immediate care needs. Failure to conduct the initial assessment within the required time frame has the potential to result in unmet patient needs and negative patient outcomes. The findings are: 1.Patient #1 has a referral date of 1/25/23 with the diagnoses “ Anxiety/Depression: Hypothyroidism: GERD(Gastroesophageal reflux disease ) Pyoderma Gangrenosum: Severe Aortic Stenosis.” The agency’s Phone Referral form documents: “ Date: 1/25/2023: Patient Information: Name: Patient #1: Requested Start of Care Date: 1/26/2023: For Home Health Service Under Medicare: Encounter Date: 1/25/2023: Skilled Nursing Services: Evaluation for safety at home: Wound Care: Pyoderma Gangrenosum Ulcer: Therapy Services: Physical Therapy: Frequent falls and hospitalization, pt. (patient) weak: Occupational Therapy.” The letter from Physician: (Name) Date: 1/25/2023 at 1:55PM : TO: email address .org documents: “I am writing to you to ask you to re-open the APS (Adult Protective Services) case for Patient #1. I ask that you re-evaluate her regarding her ability to safely stay at home. I feel that she would be safer and happier in a nursing home or assisted living facility, and I feel that she lacks capacity to make that decision for herself. She is often left alone for extended periods of time without an aide and without anyone to clean, feed or bathe her. She has had numerous falls. The patient is non-compliant with medical care and has numerous hospitalizations for infection from her chronic ulcers. The patient’s medical issues are too complex to be managed in the home and at a facility she would have access to more consistent medical care since she often does not show up for medical visits.” PS. Advance warning! She is very good at manipulating people into thinking that she is fine.” The Agency's Health Provider Services Policy : Title : Admission To Home Care Number: Origin Date: December 2022: Reviewed 12/2022:Number: CP.130 documents: “ Policy Statements: Patients will be accepted for care without discrimination based on race, color, creed, sex, age, sexual orientation, disability (mental or physical), disease, service need intensity and place of national origin, place of residence in the service area or source of payment. The initial patient visit shall be made within 24 hours of receipt and acceptance of a community referral. Conditions under which the agency is not required to admit or readmit a patient: Referral source and the patient and /or patient representative will be notified if the acceptance of the referral is delayed or has been denied when the patient is inappropriate for services. NOTE: If determination is made that patient is not admitted based on VNS HEALTH and regulatory admission criteria, but the patient appears to be eligible for services from Adult Protective Services (APS), then VNS HEALTH in collaboration with referrer MUST notify the referring physician, and a referral to APS may be based on the patient’s circumstances. Any patient who is assessed as inappropriate for agency services shall be assisted by the agency, in collaboration with the discharge planner and other case management entity with obtaining the services of an alternate provider.” The Client Coordination Notes Report documents: Note Date: "1/25/2023:4:42PM Last Updated 1/25/2023 9:13:58PM “Name/Daughter calling to arrange homecare for mother (Patient#1) PT’s (patient's) case pending with intake. Message sent for F/U. 1/26/2023 10:51AM: Call Note: pt daughter called with regards to status, per case review case pending, connected to Intake Coordinator (Name). 1/26/2023 : 11:20AM call from Name (Patient #1 physician’s office) calling to check on SOC (Start of Care) for pt. Dr. (Name) requested 1/26/23. 1/26/2023 Last Update 2/1/2023 5:06:47 PM Intake Assessment: requested start of care 2/2/2023. Patient agreeable to home care and visit address confirmed: yes Referral Source: Physician: Treatment Orders/Special Instructions: RN for wound care Unna Boot WC (wound care) 3X (three times a week)WK. Caregiver Support: Lives alone currently has someone (Name) who is a private hired aide. Patient request HHA placement. 1/31/2023: 1:50PM: Returning call from Patient’s daughter, stating patient needs wound care asap stating patient has been waiting for six days for a nurse visit. Message sent to IC. 2/1/2023: 4:09PM: pt’s daughter calling back IC ( Intake Coordinator) caller connected. 2/1/2023 COVID-19 Screening Coordination 2/2/2023: Note Type: Insurance Verification: OT Auth (Authorization) entered as requested. 2/2/2032: Note Type: CFM:(Clinical Field Manager) Review for SOC Scheduling: Note: Case reviewed and approved for (RDOE) assignment. Yes 2/2/2032: Note Type: Narrative: Note: RN emailed CFM (Name) and Branch Director with concerns after reading referral on this case. 2/2/2032: Note Type: Non-Admit Details: Last Update: 2/2/2023: 12:29:42PM Note: For all other No—Admit Reasons, Please specify details below: Per CFM case not safe in community, Branch Director (Name) had discussed this with intake. The VNS Health Fax Transmittal Physician Notification documents: “Date: 2/2/2023. To: Dr. Name : From: Employee #1 : Patient #1: Please be advised: Patient not taken under care because: needs cannot be met in the home, may require a higher level of care, home environment is not safe.” The clinical record lacks documented evidence of the additional e-mail note from RN with a date 2/2/23. There is no documented evidence that the fax transmittal was processed/ no confirmatory date/ time. There is no documented evidence that the physician's office was notified of the SOC date being changed to 2/2/2023. The patient information lacks documented evidence that the agency provided an initial assessment within 48 hours to determine if Patient #1 service needs could be safely met in the community. The clinical lacks documented evidence of coordination and collaboration of the agency’s intake, Skilled and Therapy Services and management teams for services to be provided to Patient#1. The clinical record lacks documented evidence of the agency's policy being followed. On 4/26/23 at 10:40AM the Senior Vice President Chief Quality Officer and the Associate Vice President Quality and Performance Improvement were interviewed , no additional information was provided.

This Statement of Deficiencies is a result of an on-site investigation of complaint 94665, conducted at VNS of NY Home Care CHHA, located at 220 E. 42nd Street, New York, NY 10017 from 12/19/2022 to 12/20/2022. The active patient census is 6,426. The investigation consisted of a review of three (3) clinical records (Patient #1, #2, and #3), three (3) personnel records (Employee #1, #2, and #3), the agency's complaint log, pertinent policies and procedures, and interviews with the Senior Vice President of Quality. Pre-survey activities consisted of review on 12/16/2022 of the agency's Health Commerce System account. Findings were reviewed at the exit conference. The allegation was determined substantiated. The following deficiencies are being cited as result of the survey: G0550 - At Discharge G0602 – Communication with all physicians

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on record review and staff interviews, the agency failed to ensure the Discharge OASIS Assessment reflects the patient’s wound condition/status at the time of discharge. This was evident for one (1) of three (3) clinical records reviewed (Patient: #1). Failure to ensure the Discharge OASIS Assessment reflects the patient’s wound condition/status, has the potential for negative patient outcomes. The findings are: Patient #1 has a Start of Care date of 08/10/2022, discharge date of 8/19/2022. with the diagnosis "Pressure Ulcer of Sacral Region, Stage 3” documented in the Home Health Certification and Plan of Care for the Certification Period 8/10/2022 to 10/08/2022. The Start of Care OASIS Assessment dated 8/10/2022 documents: “yes,” the patient has unhealed pressure ulcer at stage 2 or higher; and the patient’s current number of unhealed Pressure Ulcer at Stage 3, full thickness tissue loss, is one (1). The last SN Visit Note dated 8/19/2022 documents the patient one unhealed Pressure Ulcer at Stage 3, full thickness tissue loss. The Discharge OASIS Assessment dated 8/21/2022 documents: the patient was discharged from agency 8/19/2022; the patient currently has “No” unhealed pressure ulcer at stage 2 or higher; and the “stage of the most problematic unhealed pressure ulcer that is stageable” is “NA (Not Applicable) - Patient has no pressure ulcers.” The Discharge OASIS Assessment lacks documented evident of reflecting the patient’s wound condition/status at the time of discharge. On 12/20/2022 at 12:30pm the Associate Vice President of Quality was interviewed and did not provide an explanation for the findings.

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to ensure follow-up communication with the physician involved in the patient's plan of care. This was evident in one (1) of three (3) clinical records reviewed (Patient #1). Failure to ensure communication with patient physicians places all patients at risk for negative outcomes and potential for hospital admission. The findings are: Patient #1 has a Start of Care date of 08/10/2022, discharge date of 8/19/2022. with the diagnosis "Pressure Ulcer of Sacral Region, Stage 3” documented in the Home Health Certification and Plan of Care for the Certification Period 8/10/2022 to 10/08/2022. The Coordination “Intake Assessment” note dated 8/9/2022 documents: “Requested start of care: 8/10;” “Treatment orders special instructions: RN (Registered Nurse) for wound care. No specific wound care orders noted. VNS Health RN to use VNSNY Standard wound care protocol of soap and water, dry sterile dressing and establish evidence based findings with PMD (primary medical doctor).” The “Home Health Certification and Plan of Care (485)” for the Certification Period 8/10/2022 to 10/08/2022 and signed by the physician 9/9/2022 documents, the Skilled Nurse (SN) is to provide wound order as per the agency’s protocol, “pending wound care orders confirmation (with the physician).” The RN Start of Care Assessment dated 8/10/2022 documents: “Pressure Ulcer of Sacral Region Stage 3;” Wound care provided “cleanse with soap and water, cover with 4x4s (gauzes), pending wound care orders confirmation;” and “Unable to obtain wound care orders at this time. Primary RN to follow-up.” The RN Coordination Note – Physician Communication dated 8/12/2022 documents: “Name of physician/designee spoken with/to: VM (voicemail);” “Summary of information provided. Unable to confirm SOC visit completed and review plan of care. Will reattempt.” The subsequent SN Visits Notes dated 8/13/2022, 8/15/2022 and 8/17/2022 document the SN provided wound care using the agency’s wound care protocol. The SN visit notes lack documentation of a follow-up with the physician to discuss the plan and of care and obtain wound care specific orders. The SN Visit Note dated 8/19/2022 documents: “Patient with Stage III Sacral Ulcer, no orders confirmed yet. VN (Visiting Nurse) called Dr. (name) office and spoke to office staff/ coordinating manager (name) who stated that patient is not a patient of Dr. (name);” “CFM (Clinical Field Manager) notified via email. Wound care provided as per agency protocol.” The CFM email dated 8/19/2022 to the Intake Coordinator documents: “As per our clinician, she called Dr. (name) office to get wound care orders. Per Office Manager (name), they have no record of patient. Per (Office Manager) (Patient #1) is not a patient of Dr. (name). Please verify and advise MD (Medical Doctor), who will sign VNS orders. Please escalate; we need to release 485 today.” The Intake Coordinator email dated 8/19/2022 to the CFM documents: “I have obtained and updated location, Dr. (name)’s office at (name) (phone number).” The Fax transmittal dated 8/19/2022 documents the agency faxed the “Home Health Certification and Plan of Care (485)” that includes the agency’s wound care protocol for the physician to sign. The Coordination Note dated 8/20/2022 documents: “Authorization Justification needed: Skilled Nurse please confirm if patient was admitted to hospice. Hospice referral sent 8/18/22 and Dgt (Daughter) agreed to hospice. Skilled Nurse current WC (wound care) orders soap and water; if case is not with hospice, please confer w(with)/MD for updated WC. Please reach out to CFM to BD (Branch Director) for assistance if you are having difficulty contacting MD.” The clinical record documents that the last SN visit was on 8/19/2022. The RN Discharge OASIS Assessment dated 8/21/2022 documents the discharge date of 8/19/2022. The Coordination Note dated 8/22/2022 documents, “Pt admitted to (name) Hospice 8/21/22.” The clinical record lacks documented evidence the RN communicating with the physician to obtain wound care specific orders, or the RN escalating the problem with contacting the physician to supervisory staff prior to the patient’s discharge. On 12/20/2022 at 12:30pm the Associate Vice President of Quality was interviewed and did not provide an explanation for the findings.

This Statement of Deficiencies is a result of an on-site investigation of complaint 71808, conducted at VNS of NY Home Care CHHA, located at 220 E 42nd St, New York, NY10017 on 09/15/2022. The active patient census is 6,351. The investigation consisted of a review of three (3) clinical records (identified as Patients #1, #2, and #3), four (4) personnel records (Employees #1, #2, #3, and #4), the agency's complaint, accident/incident log and interviews with the Senior Vice President of Quality, the Assistant Vice President of Quality, the Branch Director, the Regional Vice President, the Vice President People Support, and the Health Services Specialist. Pre-survey activities consisted of review on 9/14/2022 of the agency's Health Commerce System account. Findings were reviewed at the exit conference. The allegations are substantiated. A Statement of Deficiencies will be issued. The following deficiencies are being cited as result of the survey: G0434 - Participate in Care G0528 - Health, Psychosocial, Functional, Cognition G0572 - Plan of Care G0574 - Plan of Care Must Include the Following G0580 - Only as Ordered by a Physician G0590 - Promptly Alert Relevant Physician of Changes G0706 - Interdisciplinary Assessment of the Patient

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview the governing authority failed to ensure that patient and the representative be informed about any changes in the care to be furnished. This was evident for one (1) of three (3) patient care records reviewed (Patient #1). Failure to ensure that patient and the representative be informed about any changes in the care to be furnished has the potential for negative patient outcomes. The findings are: 1. Patient #1 has a Start of Care date of 09/03/2022 with the following diagnoses "Stage 2 Pressure Ulcer of Right Buttock, Stage 2 Pressure Ulcer of Left Buttock, Hemiplegia following Cerebral Infract Affecting Left Nondominant Side, Essential Hypertension” documented in the Home Health Certification and Plan of Care dated 09/03/2022 to 11/01/2022. The Home Health Certification and Plan of Care dated 09/03/2022 to 11/01/2022 documents: “hha (home health aide) effective 9/4/2022 1WK1, 3WK1, 2WK1 (once a week for one week, three times a week for one week, twice a week for one week.” The clinical record lacks documented evidence of the patient receiving aide services from 9/4/2022 to the present. There is no documented evidence of the patient or family being informed that agency is unable to provide aide services since 9/3/2022. On 09/15/2022 at 3:18pm, the Assistant Vice President of Quality and the Regional Vice President were interviewed and did not provide an explanation for the findings.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview the governing authority failed to ensure that comprehensive assessment accurately documents the patient’s current status including wounds. This was evident for three (3) of three (3) patient care records reviewed (Patient's #1, #2, and #3). Failure to ensure an accurate and complete comprehensive assessment that reflects the patient’s current status including wounds has the potential for negative patient outcomes. The findings are: The Agency’s Policy and Procedure documents: “Assessment Wounds” “Wounds and patients change therefore wounds need to be re-assessed regularly and treated according to the changing needs of the patient and the wound: a. Reassessment of wounds on each visit. b. Reassessment and documentation of the wound should include: 1) Wound measurements.” 1. Patient #1 has a Start of Care date of 09/03/2022 with the following diagnoses "Stage 2 Pressure Ulcer of Right Buttock, Stage 2 Pressure Ulcer of Left Buttock, Hemiplegia following Cerebral Infract Affecting Left Nondominant Side, Essential Hypertension” documented in the Home Health Certification and Plan of Care dated 09/03/2022 to 11/01/2022. The Visit Note Report – RN (registered nurse) OASIS (Outcome and Assessment Information Set) Admission dated 9/3/2022 documents: “Wound Assessment: #16 Up Buttock Left Pressure Ulcer Stage II, Measurement taken: no; #17 Up Buttock Right Pressure Ulcer Stage II, Measurement taken: no.” The visit note lacks documented evidence of a wound assessment that includes the measurement. On 09/15/2022 at 3:18pm, the Assistant Vice President of Quality, and the Regional Vice President were interviewed and did not provide an explanation for the findings. 2. Patient #2 has a Start of Care date of 08/03/2022 with the following diagnoses "Unspecified Malignant Neoplasm of Bladder, Essential Hypertension, Anxiety Disorder” documented in the Home Health Certification and Plan of Care dated 08/03/2022 to 10/01/2022. The Visit Note Report – RN OASIS Admission dated 8/3/2022 documents: "Integumentary - Indicate integumentary assessment findings: no problem identified.” “Patient had urostomy (redirects urine away from the bladder) for 20 years. Granuloma (inflammation) noted at three o’clock.” The Visit Note (RN) Report dated 8/24/2022 and 9/8/2022 documents: “Integumentary Indicate Integumentary Assessment findings: Wound.” “Wound Assessment #1 Granuloma left abdominal right lower quadrant.” “Wound Assessed: No.” The visit notes dated 8/3/2022, 8/10/2022, and 8/17/2022 lacks documented evidence of the assessment for the granuloma. On 09/15/2022 at 4:18pm, the Assistant Vice President of Quality and the Branch Director were interviewed and did not provide an explanation for the findings. 3. Patient #3 has a Start of Care date of 08/09/2022 with the following diagnoses "Venous Insufficiency, Non-Pressure Chronic Ulcer other Part Left Foot, Pressure Ulcer of Left Heel Stage 3, Lymphedema” documented in the Home Health Certification and Plan of Care dated 08/09/2022 to 10/07/2022. The Visit Note Report – RN OASIS Admission dated 8/9/2022 documents: “Does the patient have at least one unhealed pressure ulcer/injury at stage 1 or higher or designated as unstageable? NO" "Stage of most problematic unhealed pressure ulcer/injury that is unstageable: NA (not applicable) patient has no pressure ulcers/injuries or no stageable pressure ulcers/injuries" "Current number of stasis ulcers that are observed: two" "Wound Assessment #2 Lateral Dorsum Mid-lateral venous stasis ulcer" "#4 Multiple scattered mid-pretibial left Lymphedema" "#5 Multiple scattered mid-pretibial right Lymphedema" "#3 left heel pressure ulcer stage 3." “Patient also has pressure ulcer to left heel.” The Visit Note (RN) dated 8/9/2022 lacks documented evidence of a wound assessment – how many stasis ulcers 1 or 2, and the presence of a pressure ulcer. On 09/15/2022 at 4:18pm, the Assistant Vice President of Quality and the Branch Director were interviewed and did not provide an explanation for the findings.

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 governing authority failed to ensure that each patient must receive the home health services that are written in an individualized plan of care. This was evident for two (2) of three (3) patient care records reviewed (Patient's #1 and #3). Failure to ensure that each patient must receive the home health services that are written in an individualized plan of care has the potential for negative patient outcomes. The findings are: 1. Patient #1 has a Start of Care date of 09/03/2022 with the following diagnoses "Stage 2 Pressure Ulcer of Right Buttock, Stage 2 Pressure Ulcer of Left Buttock, Hemiplegia following Cerebral Infract Affecting Left Nondominant Side, Essential Hypertension” documented in the Home Health Certification and Plan of Care dated 09/03/2022 to 11/01/2022. The Home Health Certification and Plan of Care dated 09/03/2022 to 11/01/2022 documents: “hha (home health aide) effective 9/4/2022 1WK1, 3WK1, 2WK1 (once a week for one week, three times a week for one week, twice a week for one week.” The clinical record lacks documented evidence of the patient receiving aide services from 9/4/2022 to the present. There is no documented evidence of the physician being notified of the problems - placing hha service at home. There is no documented evidence of the patient receiving aide services as ordered on the plan of care. On 09/15/2022 at 3:18pm, the Assistant Vice President of Quality and the Regional Vice President were interviewed and did not provide an explanation for the findings. 2. Patient #3 has a Start of Care date of 08/09/2022 with the following diagnoses "Venous Insufficiency, Non-Pressure Chronic Ulcer Other Part Left Foot, Pressure Ulcer of Left Heel Stage3, Lymphedema” documented in the Home Health Certification and Plan of Care dated 08/09/2022 to 10/07/2022. The Verbal Order dated 08/29/2022 documents: “hha effective 8/28/2022 2WK1, 3WK4 (twice a week for one week, three time a week for four weeks).” The clinical record lacks documented evidence of the patient receiving aide services from 8/28/2022 to the present. There is no documented evidence of the patient receiving aide services as ordered on the plan of care. On 09/15/2022 at 4:18pm, the Assistant Vice President of Quality and the Branch Director were interviewed and did not provide an explanation for 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 review and staff interview the governing authority failed to ensure that a plan of care includes treatment, patient-specific interventions, measurable outcomes and goals. This was evident for two (2) of three (3) patient care records reviewed (Patient's #1 and #2). Failure to ensure that a plan of care includes treatment, patient-specific interventions, measurable outcomes and goals has the potential for negative patient outcomes. The findings are: The Agency’s Policy and Procedure documents: “Assessment Wounds” “Wounds and patients change therefore wounds need to be re-assessed regularly and treated according to the changing needs of the patient and the wound: a. Reassessment of wounds on each visit. b. Reassessment and documentation of the wound should include: 1) Wound measurements.” 1. Patient #1 has a Start of Care date of 09/03/2022 with the following diagnoses "Stage 2 Pressure Ulcer of Right Buttock, Stage 2 Pressure Ulcer of Left Buttock, Hemiplegia following Cerebral Infract Affecting Left Nondominant Side, Essential Hypertension” documented in the Home Health Certification and Plan of Care dated 09/03/2022 to 11/01/2022. The Home Health Certification and Plan of Care dated 09/03/2022 to 11/01/2022 documents: “Skilled nurse to perform/teach pressure ulcer care to stage 2 pressure injury to bilateral buttocks. Cleanse with soap and water, apply skin protectant cream, and cover with DSD (dry sterile dressing), every other day using clean/aseptic technique.” There is no documented evidence of the treatment order including the name of the skin protectant. The Visit Notes (RN) dated 9/3/2022 and 9/6/2022 documents: “Urostomy.” “Wound Assessment: #16 Up Buttock Left Pressure Ulcer Stage II, Measurement taken: no. #17 Up Buttock Right Pressure Ulcer Stage II, Measurement taken: no.” The Home Health Certification and Plan of Care dated 09/03/2022 to 11/01/2022 lacks documented evidence of duties to be performed by a SN (skilled nurse) including: an assessment, monitoring, treatment/intervention, measurable outcomes or goals for the urostomy and for the monitoring of the progress, measurable outcomes or goals for the pressure ulcers. On 09/15/2022 at 3:18pm, the Assistant Vice President of Quality and the Regional Vice President were interviewed and did not provide an explanation for the findings. 2. Patient #2 has a Start of Care date of 08/03/2022 with the following diagnoses "Unspecified Malignant Neoplasm of Bladder, Essential Hypertension, Anxiety Disorder” documented in the Home Health Certification and Plan of Care dated 08/03/2022 to 10/01/2022. The Visit Note (RN) Report dated 8/10/2022 documents: “Patient reported changing urostomy bag BID (twice a day). Last bag changed 2 days ago. Patient reported bag leaked a little, dried up and remained intact. Patient refused to remove current ostomy.” The Visit Note (RN) Report dated 8/17/2022 documents: “crusting times two around peristomal area, applied barrier strips around perimeter including over the granulomas and placed appliance over barrier strips.” The Client Episode Coordination Notes Report dated 9/1/2022 documents: “Stoma cleansed with warm water, patted dry, applied powder to peristoma skin, with barrier wipe time 2 in crusting procedure. Applied piece of Brava Elastic barrier strip to granuloma to cover and seal 1 piece deep convex Coloplast urostomy pouch applied. Remainder of Brava strip applied at 6:00 to reinforce. MIO belt applied.” The Home Health Certification and Plan of Care dated 08/03/2022 to 10/01/2022 lacks documented evidence of duties to be performed by a SN (skilled nurse) including: an assessment/monitoring, treatment, measurable outcomes or goals of the granuloma and the urostomy – site, bag and tubing frequency change. On 09/15/2022 at 4:18pm, the Assistant Vice President of Quality and the Branch Director were interviewed and did not provide an explanation for the findings.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview the governing authority failed to ensure that treatments are administered only as ordered by a physician or allowed practitioner. This was evident for two (2) of three (3) patient care records reviewed (Patient's #2 and #3). Failure to ensure that treatments are administered only as ordered by a physician or allowed practitioner has the potential for negative patient outcomes. The findings are: 1. Patient #2 has a Start of Care date of 08/03/2022 with the following diagnoses "Unspecified Malignant Neoplasm of Bladder, Essential Hypertension, Anxiety Disorder” documented in the Home Health Certification and Plan of Care dated 08/03/2022 to 10/01/2022. The Visit Note (RN) Report dated 8/17/2022 documents: “crusting times two around peristomal area, applied barrier strips around perimeter including over the granulomas and placed appliance over barrier strips.” The Client Episode Coordination Notes Report dated 9/1/2022 documents: “Stoma cleansed with warm water, patted dry, applied powder to peristoma skin, with barrier wipe times 2 in crusting procedure. Applied piece of Brava Elastic barrier strip to granuloma to cover and seal 1 piece deep convex Coloplast urostomy pouch applied. Remainder of Brava strip applied at 6:00 to reinforce. MIO belt applied.” There is no documented evidence of an order for the treatment to granuloma and urostomy; and no documented evidence that treatments are administered only as ordered by a physician or authorized practitioner. On 09/15/2022 at 4:18pm, the Assistant Vice President of Quality and the Branch Director were interviewed and did not provide an explanation for the findings. 2. Patient #3 has a Start of Care date of 08/09/2022 with the following diagnoses "Venous Insufficiency, Non-Pressure Chronic Ulcer Other Part Left Foot, Pressure Ulcer of Left Heel Stage3, Lymphedema” documented in the Home Health Certification and Plan of Care dated 08/09/2022 to 10/07/2022. The Verbal Order dated 8/17/2022 documents: “DC (discontinue) wound vac to LLE (left lower extremity). LLE ulcer: cleanse with NS, apply Primapore dressing BIW (biweekly/twice a week), if Primapore is not available, use Aquacel Ag.” “RLE (right lower extremity) edema: apply tubigrip stocking, DC Unna boot dressing.” There is no documented evidence of the verbal order for LLE – is for lymphedema or for stasis ulcer. There is no documented evidence of a frequency of the treatment for RLE wound. The Visit Note (RN) Report documents: “8/17/2022 Wound Assessment #3 Left Heel Pressure Ulcer Stage 3, inactivate wound – completely epithelialized.” “8/25/2022 Wound Assessment #5 Multiple/Scattered Mid Pretibial Left Lymphedema, inactivate wound healed.” There is no documented evidence of the discontinuation order for the treatment of healed: 8/17/2022 pressure ulcer stage 3 left heel and 8/25/2022 left lymphedema. On 09/15/2022 at 4:18pm, the Assistant Vice President of Quality and the Branch Director were interviewed and did not provide an explanation for the findings.

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 the governing authority failed to promptly alert the physician to any changes in the patient’s condition that suggest that outcome is not being achieved and/or to alter the plan of care. This was evident for one (1) of three (3) patient care records reviewed (Patient #1). Failure to ensure to promptly alert the physician to any changes in patient’s condition to alter the plan of care has the potential for negative patient outcomes. The findings are: 1. Patient #1 has a Start of Care date of 09/03/2022 with the following diagnoses "Stage 2 Pressure Ulcer of Right Buttock, Stage 2 Pressure Ulcer of Left Buttock, Hemiplegia following Cerebral Infract Affecting Left Nondominant Side, Essential Hypertension” documented in the Home Health Certification and Plan of Care dated 09/03/2022 to 11/01/2022. The Home Health Certification and Plan of Care dated 09/03/2022 to 11/01/2022 documents: "Skilled nurse to perform/teach pressure ulcer care to Stage 2 pressure injury to bil (bilateral) buttocks. Cleanse with soap and water, apply skin protectant cream, and cover with DSD (dry sterile dressing), every other day using clean/aseptic technique." The Visit Note Report (RN AOSIS Admission) dated 9/3/2022 documents: “Wound Assessment #17 Up Buttock, right pressure stage II, Total necrotic tissue slough: 0-25%.” (No measurement of wounds). “Patient is chairbound and spends most time in bed as spouse is unable to lift him.” The Visit Note (RN) dated 9/6/2022 documents: “Wound Assessment #17 Up Buttock, right pressure stage II, Total necrotic tissue slough: 26-50%.” (No measurement of wounds). “Care coordination. Indicate if you communicated with others involved in this case: no.” There is no documented evidence of the physician being notified of the changes/worsening (from 0-25% to 26-50% of slough) of the right buttocks pressure ulcer to alter/change treatment and plan of care. The Visit Note (RN) dated 9/9/2022 documents: “Visiting nurse unable to provide wound care this time because he needs two people to complete the procedure. Patient is unable to turn in his hospital bed.” The Client episode Coordination Notes Report dated 9/9/2022 documents: “Physician Communication. Explained to office about visiting nurse unable to provide wound care for patient today, because it will put patient in a risk of falling. Patient with medical diagnose of Hemiparalysis. He needs two people to complete the procedure to ganranty (guarantee) his safety. No wound care provided, needs doctor to follow-up in the community.” The Current Summary (complaint) dated 9/13/2022 documents: “Patient has been bed bound for several years and both arms and legs contracted. To perform skin care for bilateral buttock stage pressure ulcer, nurse needed an assistance from wife. Wife refused to assist nurse because of her bad shoulders.” There is no documented evidence of a follow up to the physician on how the wound care will be met – wife and nurse unable to turn or lift patient during wound care and personal care. There is no documented evidence that the physician was promptly alerted to the changes in the patient’s condition and plan of care. On 09/15/2022 at 3:18pm, the Assistant Vice President of Quality and the Regional Vice President were interviewed and did not provide an explanation for the findings.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview the governing authority failed to ensure an ongoing interdisciplinary assessment of the patient. This was evident for two (2) of three (3) patient care records reviewed (Patient's #1 and #2). Failure to ensure an ongoing interdisciplinary assessment of the patient has the potential for negative patient outcomes. The findings are: The Agency’s Policy and Procedure documents: “Assessment Wounds” “Wounds and patients change therefore wounds need to be re-assessed regularly and treated according to the changing needs of the patient and the wound: a. Reassessment of wounds on each visit. b. Reassessment and documentation of the wound should include: 1) Wound measurements.” 1. Patient #1 has a Start of Care date of 09/03/2022 with the following diagnoses "Stage 2 Pressure Ulcer of Right Buttock, Stage 2 Pressure Ulcer of Left Buttock, Hemiplegia following Cerebral Infract Affecting Left Nondominant Side, Essential Hypertension” documented in the Home Health Certification and Plan of Care dated 09/03/2022 to 11/01/2022. The Visit Note Report – RN (registered nurse) OASIS (Outcome and Assessment Information Set) Admission dated 9/3/2022 documents: “Wound Assessment #16 Up Buttock Left Pressure Ulcer Stage II, Measurement taken: no. #17 Up Buttock Right Pressure Ulcer Stage II, Measurement taken: no.” The Visit Note (RN) dated 9/3/2022 documents: “Wound Assessment #17 Up Buttock, right pressure stage II, Total necrotic tissue slough: 0-25%.” (No measurement of wounds). “Patient is chairbound and spends most time in bed as spouse is unable to lift him.” The Visit Note (RN) dated 9/6/2022 documents: “Wound Assessment #17 Up Buttock, right pressure stage II, Total necrotic tissue slough:26-50%.” (No measurement of wounds). The Visit Note (RN) dated 9/9/2022 documents: “Visiting nurse unable to provide wound care this time because he needs two people to complete the procedure. Patient is unable to turn in his hospital bed.” The Current Summary (complaint) dated 9/13/2022 documents: “Patient and wife have unrealistic expectation from visiting nurse. Patient has been bed bound for several years and both arms and legs contracted. To perform skin care for bilateral buttock stage pressure ulcer, nurse needed an assistance from wife. Wife refused to assist nurse because of her bad shoulders.” The Verbal Order dated 9/14/2022 documents: “No further nursing service needed non-skilled nursing pressure ulcer care and wife is competent to change simple dressing daily.” There is no documented evidence of an ongoing assessment – measurement of wound since 9/3/2022; for the caregiver’s ability to provide care - how will the wife going to do the treatment if patient needs 2 persons assist, wife with bad shoulder and the compliance; monitoring of the pressure ulcer after the discontinuation of nursing services. On 09/15/2022 at 3:18pm, the Assistant Vice President of Quality, and the Regional Vice President were interviewed and did not provide an explanation for the findings. 2. Patient #2 has a Start of Care date of 08/03/2022 with the following diagnoses "Unspecified Malignant Neoplasm of Bladder, Essential Hypertension, Anxiety Disorder” documented in the Home Health Certification and Plan of Care dated 08/03/2022 to 10/01/2022. The Visit Note (RN) Report dated 8/24/2022 and 9/8/2022 documents: “Integumentary Indicate Integumentary Assessment findings: Wound.” “Wound Assessment #1 Granuloma left abdominal right lower quadrant.” “Wound Assessed: No.” The visit notes dated 8/3/2022, 8/10/2022, and 8/17/2022 lacks documented evidence of an ongoing assessment for the granuloma. On 09/15/2022 at 4:18pm, the Assistant Vice President of Quality and the Branch Director were interviewed and did not provide an explanation for the findings.