Every finding on record at Warren Co Hlth Svs Chha

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to ensure in four of six records (Patient # 3, 4, 5, and 6) professional staff maintain an accurate, current and clearly documented clinical record related to the provision of the patient's care. Failure to maintain an accurate, current and clearly documented clinical record has the potential for staff to make clinical decisions based on inaccurate and/or missing information with the potential to result in negative patient outcomes. Findings: Patient #3 (start of care 05/27/2025) has diagnoses of Pressure Ulcer of Sacral Region, Stage 4 and Pressure Ulcer of Left Buttock, Stage 4. The clinical record contains POCs for certification periods 01/22/2026 through 03/22/2026, and 03/23/2026 through 05/21/22026 which list the following as DME: "ABD" pad, adhesive bandages, alcohol, catheter, catheter drainage bag, catheter insertion kit, cotton tipped applicators, "ROHO" wheelchair cushion, vitals signs equipment, oil emulsion dressing, gloves, irrigation saline, lab supplies, Mediset, skin protectant, staples/suture removal kit, syringe/needle, tape, towels and wound cleanser. The clinical record contains skilled nursing (SN) assessments dated 01/21/2026 and 03/19/2026 which do not identify "ABD" pad, adhesive bandages, alcohol, catheter, catheter drainage bag, catheter insertion kit, cotton tipped applicators, "ROHO" wheelchair cushion, vitals signs equipment, oil emulsion dressing, gloves, irrigation saline, lab supplies, Mediset, skin protectant, staples/suture removal kit, syringe/needle, tape, towels and wound cleanser under DME. The clinical record requires clarification regarding the ordered DME. Patient #4 (start of care 12/27/2014) has diagnoses of Quadriplegia and Multiple Sclerosis. The clinical record contains POCs for certification periods 02/27/2026 through 04/27/2026, and 04/28/2026 through 06/26/2026 which list the following DME: "ABD' bandage, ACE bandage, adhesive bandage, adhesive remover pads, alcohol, biohazard bags, biohazard containers, blue pads, brava protective sheet, catheter, catheter drain bad, catheter insertion kit, catheter supplies, cotton tipped applicator, diabetic supplies, scale, glucometer, rails/grab bars, vitals signs equipment, alginate dressing, hydrofera dressing, hydrogel dressing, antimicrobial dressing, compression dressing, foam dressing, hydrocolloid dressing, hydrosorb dressing, mesalt dressing, net dressing, oil dressing, sterile dressing, transparent film dressing, gauze, gloves, heel/elbow protector, iodine cleanser, skin prep protectant, stales/suture removal kit, syringe/needle, tape, towels, tracheostomy supplies, triple antibiotic, wound closure strips..". The clinical record contains SN assessments dated 02/24/2026 and 04/24/2026 which do not identify the following DME "ABD' bandage, ACE bandage, adhesive bandage, adhesive remover pads, alcohol, biohazard bags, biohazard containers, blue pads, brava protective sheet, catheter, catheter drain bad, catheter insertion kit, catheter supplies, cotton tipped applicator, diabetic supplies, scale, glucometer, rails/grab bars, vitals signs equipment, alginate dressing, hydrofera dressing, hydrogel dressing, antimicrobial dressing, compression dressing, foam dressing, hydrocolloid dressing, hydrosorb dressing, mesalt dressing, net dressing, oil dressing, sterile dressing, transparent film dressing, gauze, gloves, heel/elbow protector, iodine cleanser, skin prep protectant, stales/suture removal kit, syringe/needle, tape, towels, tracheostomy supplies, triple antibiotic, wound closure strips...". The clinical record requires clarification regarding the ordered DME. Patient #5 (start of care 05/04/2026) has diagnoses of aftercare following surgery for Neoplasm and Malignant Neoplasm of Pelvis Bones, Sarum, and Coccyx. The clinical record contains a POC for certification period 05/04/2026 through 07/02/2026, and a resumption of care POC dated 05/15/2026 which list the following DME: ""ABD" pad, bedpan/urinal, blue pads, catheter, catheter drainage bag, catheter insertion kit, catheter supplies, cotton tipped applicators,...incentive spirometer,...vitals signs equipment, walker,...alginate dressing, foam dressing, oil emulsion dressing, sterile dressing, transparent film dressing, gait belt, gloves, saline irrigation, lab supplies, mediset, iodine skin cleanser, skin prep, sterilization pouches, surgical supplies, tape, towels,...". The clinical record contains SN assessments dated 05/04/2026 and 05/15/2026 which do not identify the following DME: ""ABD" pad, bedpan/urinal, blue pads, catheter, catheter drainage bag, catheter insertion kit, catheter supplies, cotton tipped applicators,...incentive spirometer,...vitals signs equipment, walker,...alginate dressing, foam dressing, oil emulsion dressing, sterile dressing, transparent film dressing, gait belt, gloves, saline irrigation, lab supplies, mediset, iodine skin cleanser, skin prep, sterilization pouches, surgical supplies, tape, towels,...". The clinical record requires clarification regarding the ordered DME. Patient #6 (start of care 03/05/2026) has diagnoses of Acute Cystitis without Hematuria and Unspecified Escherichia Coli as the diseases classified elsewhere. The clinical record contains a resumption of care POC dated 04/16/2026 which identifies the following DME: "Cane". The clinical record contains a Physical Therapy note dated 04/16/2026 which lacks DME documentation of "Cane". The clinical record requires clarification regarding the ordered DME. The findings were confirmed on 05/20/2026 at 12:40 PM with the Assistant Director of Patient Services, Supervising Public Health Nurse and Clinical Supervising Nurse; no additional evidence was provided.

The following statement of deficiencies represents the results of a re-certification survey of Warren County Health Services, a Certified Home Health Agency, conducted June 23 through June 26, 2024. A standard re-certification survey was initiated on June 23, 2025. Deficient practices were identified within Level 1 standards in: 484.55 Comprehensive Assessment of Patients and 484.60 Care Planning, Coordination and Quality of Care resulting in a partial extended survey. The survey consisted of a review of ten clinical records including three discharge records, five personnel records for professional personnel, 1 personal record for contracted para-professional personnel and four observational home visits. The survey included a review of pertinent policies and procedures, Quality Improvement Meeting Minutes for the past twelve months, agency's Admission Packet, the Emergency Preparedness Plan and the Complaint Log. The census at the time of the survey was fifty-one. Pre-survey activities consisted of review on June 10, 2025, of the agency's Health Commerce System account, Home Care Worker Registry, Criminal History Record Check, Certification and Survey Provider Enhanced Reports (CASPER) for the period 03/01/2024 through 02/28/2025, the Home Health Agency (HHA) Error Summary by Agency Report for the period 01/01/2024 through 12/31/2024 and the agency's compliance with report submissions for the 2023 statistical report. Findings were reviewed at the exit conference on June 26, 2025. The following deficiencies are identified as a result of the survey: Federal: G0372, G0514 and G0574. State: J1108, J1156, J1328, J1416, J1420, J1424, J1460, J1464, R0510 and W0407.

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on Certification and Survey Provider Enhanced Reports (CASPER) review, the agency failed to encode and electronically transmit each completed Outcome and Assessment Information Set (OASIS), regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. Failure to encode and electronically transmit each completed OASIS assessment, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary has the potential for incorrect and incomplete reporting data. Finding: On 06/10/2025 the surveyors reviewed Certification and Survey Provider Enhanced Reports (CASPER) "Home Health Agency Error Summary Report by Agency" for the report period 01/01/2024 - 12/31/2024. The report contains a warning code -3330 "Record Submitted Late": The submission date is more than 30 days after M0090 "Date Assessment Completed" on this new record. The CASPER report states 5 (0.45%) out of 1121 assessments processed were submitted more than 30 days after M0090. The agency lacks documented evidence the agency submitted required documents timely for 5 out of 1121, or 0.45% of submissions. The finding was confirmed on 06/26/2025 at 8:25 AM with the Assistant Director of Patient Services; no additional evidence was provided

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, evidence is lacking in one of ten records (Patient # 4) the initial assessment visit was conducted within 48 hours of receiving the referral for services, within 48 hours of the patient's return home or on the physician ordered start of care date. Failure to conduct the initial assessment within the required time frame has the potential to result in unmet patient needs and negative patient outcomes. Finding: Patient # 4 (start of care 06/16/2025) has diagnoses of Congenital Deformity of Spine and Essential (Primary) Hypertension. The record contains a home care referral dated 06/12/2025 with no specific physician ordered start of care date. The Physical Therapist (PT) conducted the initial assessment on 06/16/2021. The record lacks documented evidence the physician was notified the initial assessment was conducted more than 48 hours after the referral was received. The finding was confirmed on 06/25/2025 at 11:45 AM with the Assistant Director of Patient Services; no additional evidence was provided.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record review, the agency failed to ensure a complete Plan of Care (POC) was developed to meet the individualized needs of the patient in nine of ten patient records reviewed (Patient # 1, 3. 4. 5. 6. 7. 8. 9 and 10). Failure to develop a comprehensive POC has the potential for unmet patient needs and places patients at risk for receiving incorrect and/or inappropriate care. Finding: Patient # 1 (start of care 06/08/2025) has diagnoses of Encounter for Orthopedic Aftercare Following Surgical Amputation and Type 2 Diabetes Mellitus with Other Specified Complication. The record contains a POC for certification period 06/08/2025 through 08/06/2025 states the patient has an allergy to Hydrocodone and contains an order for Hydrocodone 10 milligram (mg)-Acetaminophen 325 mg tablet oral 1 tablet every 8 hours as needed (prn) for severe pain (7-10) maximum (max) daily dose of 3 tablets (tabs) max daily dose of acetaminophen 4000 mg. The record is lacking documented evidence of clarification with the physician for the patient to take this medication Patient # 3 (start of care 06/13/2025) has diagnoses of Non-Pressure Chronic Ulcer of Back with Fat Layer Exposed and Hypertensive Chronic Kidney Disease with Stage 1-4/Unspecified Chronic Kidney Disease. The record contains a Skilled Nurse (SN) admission assessment conducted on 06/13/2025 that states the patient has hearing aids, urinary catheter, cane and rolling walker. The record does not contain physician's orders for this durable medical equipment (DME). Patient # 4 (start of care 06/16/2025) has diagnoses of Congenital Deformity of Spine and Essential (Primary) Hypertension. The record contains a Physical Therapist (PT) assessment conducted on 06/16/2025 that states the patient uses a multi-wheeled walker, wheelchair, hospital bed, Hoyer lift and tub transfer bench. The POC for certification period 06/16/2025 through 08/14/2025 is lacking an order for this DME. Also, the POC for certification period 06/16/2025 through 08/14/2025 contains the following orders that are lacking the reason to take the medication: · Ibuprofen 800 mg tablet oral 1 tablet 3 times daily/prn Take at least 6-8 hours apart not to exceed 3 tablets per day, take with food and · Ondansetron Hydrochloride (HCL) 4 mg tablet oral 1 tablet 3 times daily/prn Take at least 6-8 hours apart not to exceed 3 tablets. Patient # 5 (start of care 11/03/2021) has diagnoses of Pompe Disease and Pre-Excitation Syndrome. The physician's POC for certification period 06/15/2025 through 08/13/2025 contains the following orders: Albuterol Sulfate 2.5 mg/3 milliliter (ml) (0.083%) solution for inhalation 3ml every 6 hours/prn. The order is lacking a route for delivery of the medication (oral or nasal) and the reason to take the medication;Boswella capsule unknown gastrostomy tube (g-tube) 1 supplement 2 times daily 8 AM and 8PM. The order is lacking instruction of how to administer the capsule via g-tube (i.e. open capsule) and direction of how much and what type of fluid to administer the medication with;Calcium 600 + D (3) 600 mg-5 micrograms (mcg) (200 unit) tablet g-tube 1 tablet every 12 hours crush then administer. The order is lacking direction of how much and what type of fluid to administer the medication with; Culturelle Digestive Health 10 billion cell- 200 mg sprinkle oral capsule 1 capsule daily 12 midnight (MN) administer into g-tube ok to open capsule. The order is lacking direction of how much and what type of fluid to administer the medication with; Folic Acid 800 mcg tablet g-tube 1 tablet every PM. Crush and administer via g-tube. The order is lacking direction of how much and what type of fluid to administer the medication with; Levocarnitine 1 gram (gm)/10ml oral solution g-tube 5 ml 4 times daily 8AM/12PM/4PM/8PM. The order is lacking flushing instruction for before/after the medication administration;Seacure g-tube 2 unknown 3 times daily 7:30AM/2PM/7:30PM. The order is lacking the medication form and dosage;Sodium Chloride 0.9% for nebulization inhalation per instructions as directed/prn every 4-6 hours not to exceed 4 times per day. The order is lacking a reason to take the medication and the route for delivery (oral or nasal);Sodium Chloride 0.9% irrigation solution irrigation 30 ml 4 times daily prn. The order is lacking direction of what is to be irrigated;Sulfasalazine oral 20 ml g-tube 1 supplement 3 times daily 12 MN, 8 AM, 4 PM. The order is lacking flushing instruction for before/after the medication administration andZyrtec 10 mg tablet g-tube 1 tablet daily/prn. Crush and administer via g-tube after mixing with 30-60 cubic centimeters (cc) of water. The order is lacking a reason to take the medication.Also, the recertification PT assessment conducted on 06/12/2025 states the patient is vent (ventilator) dependent, has a tracheostomy (trach) and states "no inhalant/mist medications prescribed. The physician's POC is lacking instruction for the use of and supplies for the ventilator, any care or supplies for the tracheostomy and contains orders for inhalation medications. Additionally, the PT assessment states "...is on a tube feeding or Total Parenteral Nutrition (TPN) regimen...". The POC states the patient is on a regular diet and is lacking any orders for tube feedings or a TPN regimen. Further, the PT assessment states the patient uses a power wheelchair, has a hospital bed, shower chair and Hoyer lift. The physician's POC does not contain orders for this DME. Patient # 6 (start of care 05/23/2025) has diagnoses of Dysphagia following Cerebral Infarction and Essential (Primary) Hypertension. The record contains a physician's POC for certification period 05/23/2025 through 07/21/2025 that contains the following orders lacking instruction to crush the medications and if to mix with a fluid (and amount of fluid) to deliver the medication via the g-tube: Acetaminophen 325 mg tablet g-tube 2 tablets every 6 hours/prn as needed for mild pain or fever;Aspirin Children's 81 mg chewable tablet g-tube 1 tablet daily 9 AM; bleeding risk;Atorvastatin 80 mg tablet g-tube 1 tablet bedtime 9AM; no grapefruit;Bupropion Hydrochloride (HCL) 75 mg tablet g-tube 1 tablet 9 AM and 9 PM;Cholecalciferol (Vitamin D3) 25 mcg (1,000 units) tablet g-tube 1 tablet daily 9 AM; Escitalopram 20 mg tablet g-tube 1 tablet daily 9 AM;Famotidine 20 mg tablet g-tube 1 tablet 2 times daily 9 AM and 9 PM;Losartan 100 mg tablet g-tube 1 tablet daily 9 AM.· Also, the record contains a SN admission assessment conducted on 05/23/3035 that states the patient uses the following DME: grab bars, gait belt, and brace on right lower leg. The POC is lacking orders for this DME. Additionally, the POC contains an order for Calmoseptine 0.44%-20.6% Topical Ointment topical per instructions 4 times daily/prn Apply to any skin irritations as needed. The order requires clarification as to what type of skin irritations the ointment should be used on. Patient # 7 (start of care 03/07/2025) has diagnoses of Parkinson’s Disease without Dyskinesia, Without Mention of Fluctuations and Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms. The POC for certification period 05/06/2025 through 07/04/2025 contains an order for Tylenol Extra Strength 500 mg tablet oral 2 tablets every 6 hours/prn Do not exceed 4000 mg per 24-hour period. The order is lacking the reason to take this medication prn. Also, the SN recertification conducted on 05/01/2025 states the patient has a bedside commode and multi wheeled walker. The physician’s POC does not contain an order for this DME. Patient # 8 (start of care 04/18/2025 discharged 06/06/2025) has diagnoses of Venous Insufficiency (Chronic) (Peripheral) and Non-Pressure (PRS) Chronic Ulcer Other Part Right Low Leg with Other Severity. The POC for certification period 04/18/2025 through 06/16/2025 contains an order for Albuterol Sulfate HFA 90 mcg/actuation aerosol inhaler inhalation 1-2 puff every 4 hours/prn wheezing. The order is lacking the route to take the medication (oral or nasal). Patient # 9 (start of care 12/21/2024 discharged 06/09/2025) has diagnoses of 04/20/3035 through 06/18/2025) contains an order for Piperacillin - Tazobactam 13.5 gm (gram) intravenous solution intravenous per instructions as directed Infuse Zosyn (Piperacillin - Tazobactam) 12.5 gm in 240 ml of normal saline (NS), continuous over 24 hours at 10 ml/hour (hr) using elastomeric pump. The order is lacking a frequency. Patient # 10 (start of care 03/19/2025 discharged 05/27/2025) has diagnoses of Encounter for Surgical Aftercare following Surgery on the Respiratory System and Pleural Effusion, Not Elsewhere Classified. The SN recertification assessment conducted 05/14/2025 states the patient has the following DME: cane, wheeled walker, wheelchair and hospital bed. The POC for certification period 05/18/2025 through 07/16/2025 is lacking and order for this DME. The findings were confirmed on 06/25/2025 at 11:45 AM and 06/26/2025 at 11:30 AM with the Assistant Director of Patient Services; no additional evidence was provided.

The following statement of deficiencies represents the results of a standard re-certification survey of Warren County Public Health Services, Certified Home Health Agency conducted September 06, 2022 through September 08, 2022. The survey consisted of a review of ten clinical records, including three discharge records, three observational home visits, one telephonic home visit and six personal records. The survey included a review of pertinent policies and procedures, Quality Improvement Meeting minutes for the past twelve months, the agency's admission packet, the Emergency Preparedness Plan and complaint log. A focused COVID-19 survey was conducted in conjunction with the re-certification survey and the vaccination records of 10 personnel were reviewed. Pre-survey activities consisted of a review on August 29, 2022 of the agency's Health Commerce System account, the Home Care Registry, Criminal History Record Check, and Certification and Survey Provider Enhanced Reports (CASPER) for the period June 01, 2021 through May 31, 2022. The agency's Assistant Director of Patient Services and Supervising Professional Health Nurse were interviewed. The following deficiencies are identified as a result of the survey: Federal: G 0544 G 0572 G 0574 G 0590 G 0592 G 1022 State: J 0404 J 1108 J 1148 J 1156 J 1272 J 1440 J 1504 L 0001 R 0510 W 0407

Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than- This STANDARD is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to ensure the comprehensive assessment was updated and revised, including the administration of the Outcome and Assessment Information Set (OASIS) as frequently as the patients condition warrants due to a major change in condition the patient's health status, but not less frequently than the last five days of every 60 days beginning with the start-of-care date in one of ten records reviewed (Patient # 5). Failure to revise and update the comprehensive assessment has the potential for unmet patient needs and places patients at risk for receiving incorrect and/or inappropriate care. Finding: Patient # 5 (start of care 08/21/2021) has diagnoses of Crohn's Disease and Adjustment and Management of Ventricular Assist Device. The record contains two comprehensive assessment's dated 06/20/2022 and 08/29/2022; and a progress note dated 08/26/2022 that states "Registered Nurse (RN) missed recertification (recert) date". The assessment dated 08/29/2022 is 10 days overdue. The record lacks documented evidence the comprehensive assessment was completed within 60 days. The finding was confirmed on 09/06/2022 at 3:30 PM with the Assistant Director of Patient Services; no additional evidence was provided.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on clinical record review and staff interview the agency failed to ensure services are provided in accordance with the physician's Plan of Care (POC) in one of ten patient records (Patient # 3). Failure to follow the POC has the potential for patients to receive care that is inconsistent with the physician's orders resulting in unmet patient needs and possible negative patient outcomes. Finding: Patient # 3 (start of care 02/03/2022) has diagnoses of Postsurgical Malabsorption and Adjustment and Management of Venous Access Device (VAD). The POC's for certification periods 06/03/2022 through 08/01/2022 and 08/02/2022 through 09/30/2022 both contain the following order: Use agency standard parameters and notify physician if systolic blood pressure (BP) > 160 or 100 or 100 or The finding was confirmed on 09/07/2022 at 1:45 PM with the Assistant Director of Patient Services and Supervising Public Heath Nurse; no additional evidence was provided.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Besed on clinical record review and staff interview the agency failed to ensure a complete Plan of Care (POC) was developed to meet the individulaized neeeds of the patient in five of ten patient records (Patient # 1, 2, 5, 6 and 8). Failure to develp a comprehensive POC has the potential for unmet patient needs and places patients at risk for receiving incorrect and/or inappropriate care. Findings: Patient # 1 (start of care 11/03/2021) has diagnoses of Pompe Disease and Neuromuscular scoliosis, Cervicothoracic Region. The POC for certification periods 07/01/2022 through 08/29/2022 and 08/30/2022 through 10/28/2022 contains orders for: Benefiber Oral Powder, 1 Tablespoon, Gastrostomy tube, daily. 12 noon. The order is incomplete as it lacks reconstitution instructions. Clindamycin Phos & Cleanser External Kit 1% Application, External, 2 times per day managed by Patient. The order is incomplete as it is lacking where to apply the treatment. Patient # 2 (start of care 08/19/2022) has diagnoses of Emphysema and Long Term Use of Inhaled Steroids. The POC for certification period 08/19/2022 through 10/17/2022 contains an order for: Glycolax Oral Powder 17 GM (grams)/Scoop, 17 Gram, Oral, Daily as need for contstipation. The order is incomplete as it lacks resonstitution instructions. Patient # 5 (start of care 08/27/2021) has diagnoses of Crohn's Disease and Encounter for Adjustment and Management of Venous Access Device (VAD). The POC for certification periods 06/23/2022 through 08/21/2022 and 08/22/2022 through 10/20/2022. The POC's contain orders for: The following medications are all ordered to be injectable: Cyanocobalamin, Cathflo Activase, Famotidine, Heparin Lock Flush, Infuvite, Normal Saline, Sodium Chloride, Stelera, Total Parenteral Nutrition (TPN) Electrolytes. The POC is incomplete as it lacks sharps precautions. Patient # 6 (start of care 08/08/2022) has diagnoses Chronic Obstructive Pulmonary Disease with Acute Exacerbation and Hypertensive Heart Disease with Heart Failure. The POC for certification period 08/08/2022 through 10/06/2022 contains orders for: Oxygen, 2 Liters/Minute, Inhalation, Continuous. The order is incomplete as it is lacking the route for the oxygen to be delivered. Patient # 8 (start of care 07/16/2022, discharged 08/10/2022) has diagnoses of Parainfluenza Virus Pneumonia and Pneumonitis due to Inhalation of Food and Vomit. The POC for certification period 07/16/2022 through 09/13/2022 contains an order for: Hydroxyzine Hydrocloride (HCL) Oral Tablet 23 milligrams (MG) 3 times per day as needed for itching. The order is incomplete as it is lacking an interval between doses. The findings were confimred on 09/06/2022 at 1:45 PM and 3:30 PM and 09/07/2022 at 1:50 PM with the Assistant Director of Patient Services and Supervising Registered Nurse; no additional evidence was provided.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview evidence is lacking in two of ten records (Patient # 1 and 6) the physician was contacted regarding changes that alter or suggest the need to alter the Plan of Care (POC). Failure to consult with the physician when changes occur in the patient's condition has the potential for unmet patient needs and/or negative patient outcomes. Findings: Patient # 1 (start of care 11/03/20210) has diagnoses of Pompe Disease and Neuromuscular Scoliosis. The POC for certification period 07/01/2022 through 08/29/2022 contains an order for: Physical Therapy 1-2 Encounters Every Week for 9 Weeks. The record lacks documentation of any visits the week of 08/14/2022 through 08/20/2022. The record also lacks any documentation the physician was notified of the missed visit(s). Patient # 6 (start of care 08/08/2022) has diagnoses of Chronic Obstructive Pulmonary Disease with Acute Exacerbation and Hypertenisve Heart Disease with Heart Failure. The POC for certification period contains orders for: Skilled Nursing: Use agency standard parameters and notify physician if systolic Blood Pressure (BP) >160 or 100 or 100 or Occupational Therapy: Obtain vital signs (VS): Notify physician (MD) for a Systolic BP > 160 or 100 or 100 or Physical Therapy (PT): 1-2 Enounters Every Week for 9 Weeks: 08/12/2022 -10/06/2022. The record lacks evidence of a PT visit the week of 08/28/2022 - 09/03/2022; the record lacks documented evidence the physician was notified of a PT missed visit. Skilled Nursing: 1-2 Encounters Every Week for 5 Weeks: 08/08/2022 - 09/10/2022. The record lacks evidence of a skilled nurse visit the week of 08/28/2022 - 09/03/2022; the record lacks documented evidence the physician was notified of a skilled nurse missed visit. The findings were confirmed on 09/06/2022 at 3:55 PM and 09/07/2022 at 1:45 PM with the Assistant Director of Patient Services; no additional evidence was provided.

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interivew, the agency failed to ensure a physician's plan of care (POC) reflects and/or is based on current information from the patient's updated comprehensive assessment in one of ten records reviewed (Patient #5). Failure to ensure the physician's POC reflects and is based on current information from the patient's updated comprehensive assessment has the potential for unmet paitent needs and places patients at risk for receiving incorrect and/or inapppriate care. Finding: Patient #5 (start of care 08/27/2022) has diagnoses of Crohn's Disease and Adjustment and Management of Ventricular Assist Device. The record contains a physician's POC for certification period 08/22/2022 through 10/20/2022 and a comprehensive assessment dated 08/29/2022. The record lacks documented evidence the physician's POC reflects and is based on information from the patients updated comprehensive assessment. The finding was confirmed on 09/06/2022 at 3:30 PM with the Assistant Director of Patient Services; no additional evidence was provided.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on clincal record review and staff interview, the agency failed to ensure in three of three records of patients that have been discharged (Patient # 8, 9 and 10) that a comprehensive discharge summary was prepared and sent to the physician. Failure to prepare a comprehensive discharge summary and notifying the physician of the discharge places patients at risk for poor coordination of patient services and unmet patient needs upon discharge from the agency. Findings: Patient # 8 (start of care 07/16/2022, discharged 08/10/2022) has diagnoses of Parainfluenza Virus Pneumonia and Pneumonitis due to Inhalation of Food and Vomit. The record contains a Transfer Summary dated 08/10/2022 stating "Patient fell at Dialysis", "Discharge/transfer to short-term general hosptial" and a progress note dated 08/11/2022 stating "Medical Doctor (MD) office notified that Warren County Health Services (WCHS) discharged patient to Glens Fall Hospital (GFH) as she will need rehab therapy". The record lacks documented evidence a discharge summary was completed and sent to the heatlh care facility/hospital or physician. Patient # 9 (start of care 07/12/2022, discharged 08/09/2022) has diagnoses of Infection following a Procedure, Other Surgical Site and Methicillin Susceptable Staphlococcal Infection. The record contains a discharge summary with a discharge date of 08/09/2022 and evidence of faxed notification to the physician dated 08/23/2022. The record lacks documented evidence the discharge summary was sent to the patient's physician within 5 business days of the discharge. Patient # 10 (start of care 07/27/2022, discharged 08/22/2022) has diagnoses of Hodgkin Lymphoma and Chronic Pancreatits. The record contains a Physical Therapy (PT) discharge summary dated 08/22/2022. The record lacks documented evidence the discharge summary was sent to the patient's physician. The findings were confirmed on 09/07/2022 at 1:50 PM with the Assistant Director of Patient Services and the Supervising Public Health Nurse; no additional evidence was provided.