Every finding on record at A & T Certified Home Care, LLC

A standard re-certification survey and focused COVID-19 Infection Control of A&T Home Care located at 339 North Main Street, Suite 9A, New City, NY 10956 was initiated on 10/24/2022 and exited 10/27/2022. Deficient practices were identified within Level 1 standards in 484.60 condition resulting in a Partial Extended survey. The active census reported on 10/24/2022 is 24. Seven (7) clinical records were reviewed and are identified as Patients #1, #2, #3, #4, #5, #6,and #7. Three (3) Home Visit observations were conducted with patients #1, #5 and #6. Seven (7) personnel records were reviewed and are identified as Employees #1, #2, #3, #4, #5, #6 and #7. . Policies and procedures for Emergency Preparedness Plan, Health Commerce System, Home Care Registry, Criminal History Record Check, COVID-19 Infection Control, and Influenza Vaccination policy were reviewed. The agency's Patient Admission Packet and Patient Complaint log for the years 10/24/2021 through 10/24//2022 were reviewed. The agency's Quality Improvement meeting minutes were reviewed from 10/24/2021 thru 10/24/2022. Pre-survey activities consisted of review on 10/18/2022 of the agency’s Health Commerce System account, Home Care Worker Registry, Criminal History Record Check. The Agency's OBQI Adverse Event Outcome Reports were reviewed for the period of 7/1/2021 through 7/29/2022. The following Federal deficiencies are cited: G0574 - Plan of Care must include the following G0590 Promptly alert relevant Physician The following State deficiencies are cited: L -0002 Acceptable Infection Ctrl Procedure

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record reviews and interview, the agency failed to develop/revise complete and comprehensive Plans of Care. This was evident for four (4) of seven (7) clinical records reviewed (patients : #1, #3 , #4 and #7). Failure to develop complete and comprehensive Plans of Care places patients at risk for not having needs met and negative patient outcomes. The findings are: 2. Patient #1 has a start of care date of 9/13/2022 with diagnosis that include Type II Diabetes Mellitus with Foot Ulcer, Unspecified Atrial Fibrillation, Acquired Absence of Left Great Toe, Other Chronic Osteomyelitis Right Ankle and Foot as documented on the " Home Health Certification and Plan of Care" for the Certification Period of 9/13/2022 to 11/11 2022. The " Home Health Certification and Plan of Care" for the Certification Period of 9/13/2022 to 11/11/2022 document: "Orders for Discipline and Treatments: Skilled Nurse twice a week for one week, three times a week for eight weeks, two as needed for change in condition". Notify Physician for fasting blood sugar greater than 300 or less than 50. Skilled nurse to instruct patient/ caregiver on all aspects of diabetic management to include disease process, foot assessment, signs and symptoms of hypo/ hyperglycemia, glucometer use, and preparation and administration of diabetic medications ordered by physician". There is no documented evidence of an order for the frequency of glucose testing (fingersticks) in the Plan of Care. There is no documented evidence the Plan of Care is complete. The clinical record document:" Physical Therapy notes: 9/19/22 (Physical Therapy Evaluation), and physical therapy notes on the following dates: 9/21/22,9/29/22, 10/4/22, 10/6/22, 10/11/22. There is no documented evidence of a Medical Order for Physical Therapy evaluation and treatment in the Plan of Care. There is no documented evidence the Plan of Care is complete. 3. Patient #3 has a start of care date of 1/23/2022 and a discharge date of 5/11/2022 with diagnosis that include Hypertensive Transplanted Tissue Rejection, Type I Diabetes Mellitus with Diabetic Chronic Kidney Disease, Type I Diabetes Mellitus with Diabetic Polyneuropathy as documented on the " Home Health Certification and Plan of Care" for the Certification Period of 3/24/22 to 5/22/22. The " Home Health Certification and Plan of Care" for the Certification Period of 3/24/22 to 5/22/22 document: "Medications: Basaglar KwikPen subcutaneous 100 unit/ ml 10 units daily in the afternoon, Novolog Flexpen subcutaneous 100 unit/ml - 6 units before meals three times a day sliding scale add additional 150-200 2 units, 200-250 4 units, 250-300 6 units, 200-350 8 units, 350-400 10 units, greater than 400 give 12 units. Orders and Treatments: Skilled nursing twice a week for one week, once a week for three weeks, 2 as needed for change in condition. Notify physician for blood sugar greater than 600 or less than 50. Skilled nurse to instruct patient/ caregiver on all aspects of diabetic management to include disease process, signs and symptoms of hypo/ hyperglycemia, glucometer use, and preparation and administration of diabetic medications ordered by physician. Skilled nurse to review signs and symptoms of Diabetes Mellitus and management". There is no documented of an order for the frequency of Blood Glucose testing in the Plan of Care. The Plan of Care lacks documented evidence of clarity of the sliding scale. There is no documented evidence the Plan of Care is complete. 4. Patient # 4 has a start of care date of 8/23/22 with diagnosis that include Type II Diabetes Mellitus with diabetic chronic kidney disease, long term (current) use of insulin as documented on the " Home Health Certification and Plan of Care" for the Certification Period of 8/23/22 to 10/21/22. The " Home Health Certification and Plan of Care" for the Certification Period of 8/23/22 to 10/21/22 document: " Medications: Metformin HCL ER oral (PO) 500 mg one tablet (Tab) twice a day, Metformin HCL ER 500 mg 2 tabs daily, Lantus Solostar Subcutaneous100 unit/ml 50 units inject 50 units subcutaneous in the morning. Orders and Treatments: Skilled Nursing once a week for one week, 2 as needed for change in condition. Skilled Nurse Skilled nurse to instruct patient/ caregiver on all aspects of diabetic management to include disease process, signs and symptoms of hypo/ hyperglycemia, glucometer use, and preparation and administration of diabetic medications ordered by physician". There is no documented evidence of an order for glucose testing frequency. There is no documented evidence of Blood Glucose parameters for physician notification. On 10/27/22 at 10:35 AM, the Regional Director was interviewed and did not provide an explanation for the above findings. 1. Patient #7 has a start of care date of 10/30/2020 and discharge date of 5/17/22 with the following diagnoses Infarct following a procedure, organ and space surgical site, Malignant neoplasm of unspecified site of left female Breast, Anemia in Neoplastic Disease, Type 2 Diabetes Mellitus without complications, Essential (primary) Hypertension, Major Depressive Disorder, Anxiety, Osteoarthritis of Knee, Other Nonspecific abnormal finding of Lung, Hyperlipidemia, Long term use of oral hypoglycemic drugs, and History of falling documented on the Home Health Certification and Plan of Care for Certification Period 4/23/2022 to 6/21/2022. The Home Health Certification and Plan of Care for Certification Period 4/23/2022 to 6/21/2022 documents " SN (Skilled Nursing) 1x week x 9 weeks (one time per week times 9 weeks); 2 PRN (as needed) visits for change in patient condition; SN to assess pain level and effectiveness of pain medications and current pain management therapy every visit; notify physician of temperature greater than 100 or less than 97". On 4/29/2022 the skilled nursing (SN) visit documents, "blood sugar 333, reviewed diabetic care and complications to monitor for". The Plan of Care lacks intervention for elevated blood glucose, and parameters for when to notify the physician. There is no documented evidence the Plan of Care is complete. On 10/27/22 at 10:35 AM, the Regional Director was interviewed and did not provide an explanation for the above 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 record reviews and interviews, the agency failed to promptly notify the physician of changes in patients' status which may require alteration in the Plans Of Care. This was evident for three(3) of seven (7) patient records reviewed. ( Patients #1, #3 and #7). Failure to promptly notify the physician of changes in patients' status, has the potential for negative patient outcomes. The findings are: 2. Patient #1 has a start of care date of 9/13/2022 with diagnosis that include Type II Diabetes Mellitus with Foot Ulcer, Unspecified Atrial Fibrillation, Acquired Absence of Left Great Toe, Other Chronic Osteomyelitis Right Ankle and Foot, Hyperlipidemia as documented on the " Home Health Certification and Plan of Care" for the Certification Period of 9/13/2022 to 11/11 2022. The " Home Health Certification and Plan of Care" for the Certification Period of 9/13/2022 to 11/11/2022 document: "Orders for Discipline and Treatments: Skilled Nurse twice a week for one week, three times a week for eight weeks, two as needed for change in condition". Notify Physician for fasting blood sugar greater than 300 or less than 50. Skilled nurse to instruct patient/ caregiver on all aspects of diabetic management to include disease process, foot assessment, signs and symptoms of hypo/ hyperglycemia, glucometer use, and preparation and administration of diabetic medications ordered by physician. Medications: Lipitor 40 mg one tablet daily oral (PO), Vitamin D3 PO 25 mcg (1000 UT) one capsule daily, Multivitamin PO one tablet PO daily, Eliquis PO 5 mg one table twice a day, Doxycyline Monohydrate PO one tablet twice a day, Ammonium Lactate External 12% -ml topically to bilateral feet daily as needed for dry skin, Jardiance PO 10 mg one tablet daily, Lipitor oral 40 mg one tablet PO daily, Carvedilol PO 3.125 mg one tablet PO twice a day, Aspirin PO 81 mg one tablet daily. On 10/26/22 at 12:30 PM, during an observational home visit, a review of the medication. There is no documented evidence of Lipitor among the medications reviewed. The record document the following skilled nursing visits: 10/3/22, 10/5/22, 10/7/22, 10/10/22, 10/12/22, 10/14/22, 10/17/22, 10/19/22, 10/21/22. There is no documented evidence of medication reconciliation during the nursing visits. There is no documented evidence the physician was alerted about the medication Lipitor in the orders. 3. Patient #3 has a start of care date of 1/23/2022 and a discharge date of 5/11/2022 with diagnosis that include Hypertensive Transplanted Tissue Rejection, Type I Diabetes Mellitus with Diabetic Chronic Kidney Disease, Type I Diabetes Mellitus with Diabetic Polyneuropathy as documented on the " Home Health Certification and Plan of Care" for the Certification Period of 3/24/22 to 5/22/22. The " Home Health Certification and Plan of Care" for the Certification Period of 3/24/22 to 5/22/22 document: "Medications: Basaglar KwikPen subcutaneous 100 unit/ ml 10 units daily in the afternoon, Novolog Flexpen subcutaneous 100 unit/ml - 6 units before meals three times a day sliding scale add additional 150-200 2 units, 200-250 4 units, 250-300 6 units, 200-350 8 units, 350-400 10 units, greater than 400 give 12 units. Orders and Treatments: Skilled nursing twice a week for one week, once a week for three weeks, 2 as needed for change in condition. Notify physician for blood sugar greater than 600 or less than 50. Skilled nurse to instruct patient/ caregiver on all aspects of diabetic management to include disease process, signs and symptoms of hypo/ hyperglycemia, glucometer use, and preparation and administration of diabetic medications ordered by physician. Skilled nurse to review signs and symptoms of Diabetes Mellitus and management". There is no documented of an order for the frequency of glucose testing in the Plan of Care. The Plan of Care lacks documented evidence of clarity of the sliding scale. There is no documented evidence the physician was notified for clarification of the sliding scale order for insulin administration and the frequency of glucose testing. 4. Patient # 4 has a start of care date of 8/23/22 with diagnosis that include Type II Diabetes Mellitus with diabetic chronic kidney disease, long term (current) use of insulin as documented on the " Home Health Certification and Plan of Care" for the Certification Period of 8/23/22 to 10/21/22. The " Home Health Certification and Plan of Care" for the Certification Period of 8/23/22 to 10/21/22 document: " Medications: Metformin HCL ER oral (PO) 500 mg one tablet (Tab) twice a day, Metformin HCL ER 500 mg 2 tabs daily, Lantus Solostar Subcutaneous100 unit/ml 50 units inject 50 units subcutaneous in the morning. Orders and Treatments: Skilled Nursing once a week for one week, 2 as needed for change in condition. Skilled Nurse Skilled nurse to instruct patient/ caregiver on all aspects of diabetic management to include disease process, signs and symptoms of hypo/ hyperglycemia, glucometer use, and preparation and administration of diabetic medications ordered by physician". There is no documented evidence of an order for glucose testing frequency. There is no documented evidence of Blood Glucose parameters for physician notification. There is no documented evidence the physician was notified about the glucose testing order and the order for blood glucose parameters. On 10/27/22 at 10:35 AM, the Regional Director was interviewed and did not provide an explanation for the above findings. 1. Patient #7 has a start of care date of 10/30/2020 and discharge date of 5/17/22 with the following diagnoses Infarct following a procedure, organ and space surgical site, Malignant neoplasm of unspecified site of left female Breast, Anemia in Neoplastic Disease, Type 2 Diabetes Mellitus without complications, Essential (primary) Hypertension, Major Depressive Disorder, Anxiety, Osteoarthritis of Knee, Other Nonspecific abnormal finding of Lung, Hyperlipidemia, Long term use of oral hypoglycemic drugs, and History of falling documented on the Home Health Certification and Plan of Care for Certification Period 4/23/2022 to 6/21/2022. The Home Health Certification and Plan of Care for Certification Period 4/23/2022 to 6/21/2022 documents " SN (Skilled Nursing) 1x week x 9 weeks (one time per week times nine weeks); 2 PRN (two as needed) visits for change in patient condition; SN to assess pain level and effectiveness of pain medications and current pain management therapy every visit; notify physician of temperature greater than 100 or less than 97" On 4/29/2022 the skilled nursing (SN) visit documents, "blood sugar 333, reviewed diabetic care and complications to monitor for; pain intensity 7; wound pain :10; wound protruding out more, wound is widening under left arm; On 5//6/2022 SN visit documents, "temp 100.2; pain intensity 9; wound pain 10, stated neuropathy is worse in hands from chemo". There is no documented evidence the physician was notified of the intensity of the pain, elevated blood sugar reading of 333, and the worsening wound. There is no documented evidence the Plan of Care was revised to meet the patient care needs. On 10/27/22 at 10:35 AM, the Regional Director was interviewed and did not provide an explanation for the above findings.