COURT COUNTY OFDEPARTMENT OF HEALTH AND HUMAN SERVICESFORM APPROVEDCENTERS FOR MEDICARE & MEDICAID SERVICESOMB N0. 0938-0355. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.HOME HEALTH AGENCYAND DEFICIENCIESCalendar No.11. Provider No.: 1. Name of Facility:JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)2. Street Address:12. Type of Survey:Resurvey (G3)Initial (G2)3. City and/or County:4. State:1 = Standard4 = 1 and 22 = Partial Extended5 = 1 and 35. Zip Code:6. Telephone No. (G4)3 = Extended6 = 1, 2 and 37. State/County Code: (G5)8. State/Region Code: (G6)13. Eligibility: (G7). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9. Name of Administrator:1 = Medicare 2 = Medicaid 3 = Both14. Has there been a change of ownership since last survey?THE PEOPLE OF THE STATE OF NEW YORK TO(G9)1 = RN/LPN5 = Medical/License Social Worker9 = Other2 = Physician6 = Pub Adm/MBA/ACCTNo 10. Discipline of Administrator: (G8)Yes3 = PT/OT7 = Lawyer4 = Speech Path/Audiologist 8 = Proprietor15. A. Is this home health agency also a Medicare certified hospice? (G10)NoYesGREETINGS:If yes, give the hospice Medicare provider number: (G11)WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the HonorableB. Does this home health agency operate sub-units? (G12),NoYeslocated at County ofo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomIf yes, how many: (G13)C. Is this home health agency a sub-unit? (G14)NoYesIf yes, parent agency provider number: (G15)Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.D. Does this home health agency or sub-unit operate branch(es)? (G16)NoYes, one of the Justices of theIf yes, how many: (G17)Court in Witness, Honorableday of, 20 County,If yes, give official name and mailing address of each branch (include street, state and zip code):(Attorney must sign above and type name below)If more space is needed, check here, use a separate page and attach.Attorney(s) for16. Type of Agency: (G18)17. Type of Control: (G20)01 = VNAVoluntary Non-Profit02 = Combination Government Voluntary01 = Religious Affiliation03 = Official Health Agency02 = PrivateOffice and P.O. Address04 = Rehab based program*03 = Other05 = Hospital based program*For Profit06 = Skilled Nursing Facility/Nursing Facility04 = Proprietarybased program*Government05 = State/County 06 = Combination Govt. and Voluntary07 = OtherTelephone No.: Facsimile No.: E-Mail Address:*If Medicare/Medicaid certified give the provider number: (G19)07 = Local GovernmentMobile Tel. No.:Form CMS-1572(a) (08/90)American LegalNet, Inc. www.USCourtForms.comCOURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::HOME HEALTH AGENCY SURVEYIndex No.AND DEFICIENCIES REPORT( continued)Calendar No.18. Services Offered: (G21)19. Staffing (List full-time equivalent):1 = Provided by Agency Staff 2 = Under Arrangement 3 = CombinationJUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)Registered Nurse (G22)Licensed Practical Nurse (G23)Physical Therapist (G24)01 = Nursing Care 02 = Physical TherapyOccupational Therapist (G25)Speech Pathologist/Audiologist (G26)03 = Occupational TherapySocial Worker (G27). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Home Health Aide (G28)04 = Speech Therapy 05 = Medical Social WorkerPharmacist (G29)06 = Home Health AideDietitian (G30)07 = Intern/ResidentTHE PEOPLE OF THE STATE OF NEW YORK TOAll Others (G31)08 = Nutritional Guidance 09 = Pharmaceutical Services20. Home Health Agency provides directly: (G32)10 = Appliance and Equipment Service1 = Home Health aide training program11 = Vocational Guidance2 = Home Health aide competency evaluation programGREETINGS:12 = Laboratory Services3 = BothWE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable13 = Other4 = Neither,22. Patient census since last standard survey:located at County of21. Number records reviewed with home visits(G33)o'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomAdmissions:Number records reviewed, no home visits Number of home visits with no records review Total records reviewed Total home visits(G34)(G35)(G38) Unduplicated admissions (G39) Readmissions(G36) (G37)DischargesYour failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.(G40) Hospital discharges (G41) Nursing home discharges (G42) Goals met discharges (G43) Death discharges (G44) Total discharges, one of the Justices of theCourt in Witness, Honorableday of, 20 County,(Attorney must sign above and type name below)23. Surveyor summary: Based on the reviews of the patients from this home health agency including all information surveyedin the standard survey and using the Functional Assessment Instrument (FAI), this home health agency: (G45)1. Provides care that promotes a high potential for reaching the highest attainable levels of functioning for itsAttorney(s) forpatients. There is no evidence of need for a partial extended or extended survey.2. Provides care that promotes a moderate potential for reaching the highest level of functioning for some but notall of its patients. There are standard level deficiencies and need for a partial extended survey. If no conditions are out of compliance, a Plan of Correction will be requested for the standard level deficiencies.Office and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address:3. Provides substandard care. There are condition level deficiencies in one or more Conditions of Participation.There is an immediate need for an extended survey.Mobile Tel. No.:Form CMS-1572(b) (08/90)American LegalNet, Inc. www.USCourtForms.comCOURT COUN