Every finding on record at Alpine Home Health Care, LLC

A Re-certification Survey was conducted at Centers Home Health Revival (Bronx) CHHA located at4770 White Plains Road, Bronx, NY 10470 on 09/11/2023 through 09/14/2023. The following Statement of Deficiencies represents the results of a partial extended re-certification survey of Centers Home Health Revival (Bronx) CHHA conducted on 09/11/2023 through 09/14/2023 . A Standard Re-Certification Survey was initiated on 09/11/2023. Deficient practices were identified within Level 1 standards in 484.505 Comprehensive Assessment of Patients , 484.60 Care Planning, Coordination, Quality of Care, and 484.75 Skilled Professional Services resulting in a partial extended survey. The survey consisted of a review of eight (8) clinical records including two (2) discharge records, nine (9) personnel records for professional and paraprofessional personnel three (3) contracts, and three (3) observational home visits. The survey included a review of pertinent policies and procedures, Quality Improvement Meeting minutes for the past 12 months, agency’s Admission Packet, the Emergency Preparedness Plan, and Complaint Logs. Pre-Survey activities consisted of review on 9/7/23 and 9/8/23 of the agency’s Health Commerce System Account, Home Care Registry, Criminal History Record Check, Internet Quality Improvement and Evaluation System (iQIES), for the period 06/2022 – 05/2023, the agency’s compliance with report submissions for the 2021 Statistical Report and the most recent Emergency Drill. The Administrator and the Director of Patient Services were interviewed throughout the survey. Findings were reviewed at the exit conference on 9/14/2023. The following deficiencies are identified as a result of the survey: G0536: A review of all current medications G0544: Update of the comprehensive assessment G0572: Plan of care G0574: Plan of care must include the following G0590: Promptly alert relevant physician of changes G0716: Preparing clinical notes

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 review and staff interview the agency failed to ensure an accurate and comprehensive review of each patient's medications. This was evident for one (1) of eight (8) clinical records reviewed (Patient: #3). Failure to ensure review of all patients' current medications are complete, accurate and are reflected in the patient's plan of care has the potential for negative patient outcomes. The findings are: 1.Patient #3 (HV- Physical Therapy visit) has a Start of Care Date of 07/27/2023 with the following diagnoses "Orthostatic Hypotension, Unspecified Protein-Calorie Malnutrition, Bipolar Disorder" documented on the Home Health Certification and Plan of Care dated 07/27/2023 to 09/24/2023. The Clinical Comment - Intake Note dated 07/25/2023 documents: "Ritalin 20 mg PO (by mouth) Q8H (every 8 hours) as needed for ADD (Attention Deficit Disorder) for 14 days; stop on 08/05/2023." The RN Subsequent Visit dated 08/02/2023 documents: "Narrative: Meds regimen reviewed with patient, no concerns, reinforced teaching on compliance indication and side effects." The RN (Registered Nurse) - DC SN (Skilled Nursing) Services (not from agency) dated 08/18/2023 documents:" Medications Was Medication Management Assessed? Yes Narrative: All meds are in home, verbalized understanding of compliance indications and side effects, instructed on filling prescription timely to prevent outage." On 09/12/2023, a home visit was conducted, and the following medication was observed: "Methylphenidate HCL 20 mg 1 tablet by mouth four times a day." The label documents: Filled 07/28/2023. The patient was interviewed and stated:" I take this medication as needed." The Home Health Certification and Plan of Care for the Certification Period 07/27/2023 to 09/04/2023 and the Client Medical Report lacks documented evidence of the Methylphenidate/Ritalin. There is no documented evidence of all patient's #3 medications being reviewed and reconciled. On 09/13/2023 at 3:30pm, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the findings.

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 all information documented in the comprehensive assessment including the OASIS (Outcome and Assessment Information Set) is accurate. This was evident for one (1) of eight (8) clinical records reviewed. (Patient #2). Failure to ensure all information documented in the comprehensive assessment (including the OASIS) is accurate has the potential for negative patient outcome. The findings are: 1.Patient #2 (PAE) has a Start of Care (SOC) date of 09/17/2021, a Discharge Date of 12/14/2022, with the diagnoses "Pressure Ulcer of Sacral Region Stage 4, Pressure Ulcer of Left Buttock Stage 2, and Pressure Ulcer of Right Buttock Stage 2" documented in Home Health Certification and Plan of Care dated 11/11/2022 to 01/09/2023. The RN (Registered Nurse) 60-Day update of the comprehensive assessment dated 11/10/2022 documents the following wound assessment: Wound #1: Mid – Coccyx (Sacral) PU (Pressure Ulcer) Stage IV, Onset Date 09/17/2021; Wound #2: Left upper buttock PU Stage II, Onset Date 10/25/2022; Wound #3 Left upper buttock PU Stage II, Onset Date 10/25/2022; ICD 10 Diagnoses – Pressure Ulcer of Sacral Region Stage 4, Pressure Ulcer of Left Buttock Stage 2, and Pressure Ulcer of Right Buttock Stage 2. The RN update of the comprehensive assessment documents the patient has two stage 2 pressure ulcers on the left buttock. There is no documented evidence the patient has a pressure ulcer on the right buttock. The clinical record lacks documented evidence of the RN updating the comprehensive assessment with the correct wound diagnosis. The SN visit note dated 11/24//2022 documents the presence of left buttock pressure ulcer Stage 4,. and two Stage 2 Pressure ulcers (Wound #2 and #3) “healed.” The SN visit note dated 12/14/2022 documents one wound present, Wound #1: Mid – Coccyx (Sacral) PU (Pressure Ulcer) Stage IV. The RN discharge update of the comprehensive assessment/OASIS dated 12/14/2022 documents: “(M1307) the oldest stage 2 pressure ulcer that is present at discharge (excludes healed stage 2 pressure ulcers) – Was present at the most recent SOC/ROC (Resumption of Care) assessment;” The clinical record documents two stage 2 pressure ulcers were present on 10/25/2022 (after the SOC), were healed and not present at discharge. The clinical record lacks documented evidence of the RN updating the comprehensive assessment for the correct status of stage 2 pressure ulcers at the time of discharge. There is no documented evidence that OASIS M1307 information is accurate and that an update to the comprehensive assessment was made to correct information of the pressure ulcers. On 09/14/2023 at 12:20PM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the finding.

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 all patients receive the care that is written in the individualized plan of care. This was evident for one (1) of eight (8) clinical records reviewed. (Patient (#1). Failure to ensure all patients receive the care that is written in the individualized plan of care, has the potential for negative patient outcomes. The findings are: 1.Patient #1 has a Start of Care date of 07/27/2023 with diagnoses "Type 2 Diabetes Mellitus with Diabetic Peripheral Angiopathy without Gangrene, Spinal Stenosis, Acquired Absence of Left Leg Below Knee" documented in the Home Health Certification and Plan of Care dated 07/27/2023 to 09/24/2023. The Supplemental Order dated 08/08/2023 documents: "PT (Physical Therapy) effective week of 08/06/2023/, 2WK1(two visits per week for one week), 1WK2 (one visit per week for two weeks);” and “Goals: A Physical Therapy evaluation will be completed, and a plan of care developed to maximize functional capacity. All goals to be met by 3 weeks; Patient will demonstrate improved function in response to specific exercise(s) as evidenced by increased muscle strength and improvement in activities of daily living by 3 weeks; Patient/caregiver will demonstrate safe transfers using appropriate body mechanics and equipment by 3 weeks; Patient to demonstrate reduced fall risk and improved safe functional mobility by 3 weeks; Patient will demonstrate safe gait technique with assistive devices as needed to minimize risk of injury by 3 weeks." The Physical Therapist “Visit Note Report” dated 8/17/2023 (week two) documents: “Continued skilled physical therapy required for gait training, transfer training, balance training, and functional LE (lower extremities) strengthening;” and twelve (12) “Goals Not Met;” “Additional time required to meet intervention/goal.” The PT “Missed Visit Notification” note dated 08/25/2023 documents: “Date of visit: 8/24 (week three); Reason for missed visit: no answer; Was MD notified (yes/no): Y.” The physical therapy did not conduct the last PT visit for week three as ordered in the plan of care. The clinical record lacks documented evidence of the PT making another attempt to reschedule the PT visit missed visit during week three. The clinical record lacks documented evidence of PT goals being met by three weeks as specified in the individualized plan of care. The PT missed visit notification lacks documented evidence of the PT consulting with the physician to request additional PT visit(s) to achieve the goals in the plan of care or to discharge patient from PT services with goals not met. There is not documented evidence the physician agreeing to modify the plan of care for PT services. The clinical record lacks documented evidence of the patient receiving PT services as written in the Plan of Care, including achieving PT goals. On 09/13/2023 at 2:35 PM, the Administrator and the Director of Patient Services were interviewed and did not provide an explanation for the finding.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview the agency failed to ensure each patient's individualized plan of care is complete, accurate and includes all the required information. This was evident for two of eight (8) clinical records reviewed. (Patients #6 and #7). Failure to ensure the development of a complete, accurate, and individualized plan of care for all patients has the potential for negative patient outcomes. The findings are: 1.Patient #6 has a Start of Care date of 01/10/2023 with the following diagnoses "Encounter for Change or Removal of Nonsurgical Wound Dressing, Type 2 Diabetes with Diabetic Peripheral Angiopathy, Chronic Peripheral Venous Insufficiency" documented in the Home Health Certification and Plan of Care dated 07/09/2023 to 09/06/2023. The Home Health Certification and Plan of Care dated 07/09/2023 to 09/06/2023 documents: “Skilled Nurse for instructions / reinforcement of diabetic care to include diet, skin care, blood glucose testing, medication regimen and reinforce medication teaching.” “Skilled nurse may perform finger stick blood sugar as needed for signs and symptoms of hyper/hypoglycemia.” The plan of care lacks documented evidence of the fingerstick frequency and parameters when to notify the physician. On 09/13/2023 at 2:35pm, the Administrator and Director of Patient Services were interviewed and did not provide an explanation for the findings. 2.Patient #7 has a Start of Care date of 07/29/2023 with the following diagnoses "Type 2 Diabetes with Diabetic Peripheral Angiopathy, Chronic Peripheral Venous Insufficiency" documented in the Home Health Certification and Plan of Care dated 07/29/2023 to 09/26/2023. The Home Health Certification and Plan of Care dated 07/29/2023 to 09/26/2023 documents: “Skilled Nurse for instructions / reinforcement of diabetic care to include diet, skin care, blood glucose testing, and diabetic foot care; skilled nurse may perform finger stick blood sugar as needed for signs and symptoms of hyper/hypoglycemia.” The Visit Note Report dated 08/04/2023 documents: “Self-perform BGL X TIW (blood glucose level times three times a week), parameter 70/400mg/dl (milligram per deciliter).” The plan of care lacks documented evidence of the fingerstick frequency and parameters when to notify the physician or an interim/supplemental order. On 09/13/2023 at 2:35pm, the Administrator and Director of Patient Services 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 agency failed to ensure all physicians are notified of changes in the patient's condition that require a change in the plan of care. This was evident for two (2) of eight (8) clinical records reviewed. (Patient #6 and #8). Failure to ensure each patient's physician(s) is notified of changes in the patient's condition and the need to revise the plan of care has the potential for negative patient outcome. The findings are: 1.Patient #6 has a Start of Care date of 01/10/2023 with the following diagnoses "Encounter for Change or Removal of Nonsurgical Wound Dressing, Type 2 Diabetes with Diabetic Peripheral Angiopathy, Chronic Peripheral Venous Insufficiency" documented in the Home Health Certification and Plan of Care dated 07/09/2023 to 09/06/2023. The Home Health Certification and Plan of Care dated 07/09/2023 to 09/06/2023 documents: “Wound status will improve as evidence by a decrease in size, drainage, absence of infection, and decrease in pain.” “Changes in skin integrity status will be identified and reported to the physician.” The Visit Note Report (Recertification) documents: 07/05/2023 “Care Coordination Indicate if you communicated with other disciplines involved in this case: NO.” Wound Assessment Mid-calf left venous stasis ulcer; measurement taken: 20 x 11 x 0.5cm. 09/05/2023 “Care Coordination Indicate if you communicated with other disciplines involved in this case: NO.” Wound Assessment Mid-calf left venous stasis ulcer; measurement taken: 20 x 14 x 0.3. The Visit Note Report documents: 07/12/2023 “Care Coordination Indicate if you communicated with other disciplines involved in this case: NO.” Wound Assessment Mid-calf left venous stasis ulcer; measurement taken: 20 x 12 x 0.5. 07/19/2023, 07/26/2023, 08/02/2023, 08/09/2023, 08/16/2023, 08/23/2023, and 08/30/2023 “Care Coordination Indicate if you communicated with other disciplines involved in this case: NO.” Wound Assessment Mid-calf, left venous stasis ulcer; measurement taken: 20 x 14 x 0.3. There is no documented evidence that the RN (registered nurse) communicated with the physician regarding no changes with wound status – not healing during the 9 weeks period. On 09/13/2023 at 2:35pm, the Administrator and Director of Patient Services were interviewed and did not provide an explanation for the findings. 2.Patient #8 has a Start of Care date of 07/27/2023 with the following diagnoses "Cellulitis of Right Lower Limb; Essential Hypertension" documented in the Home Health Certification and Plan of Care dated 07/27/2023 to 09/24/2023. The Home Health Certification and Plan of Care dated 07/27/2023 to 09/24/2023 documents: “Skilled nurse to perform/teach wound care to right lower extremity cellulitis, cleanse with NSS apply Silver Hydrofibr, abd (abdominal) pad/gauze, secure with Kling wrap. Using clean technique every 2-3 days.” “Wound status will improve as evidence by a decrease in size, drainage, absence of infection, and decrease in pain.” “Changes in skin integrity status will be identified and reported to the physician.” The Visit Note Report (Recertification) documents: 07/27/2023 Wound Assessment Distal Mid Distal Pretibial, right, venous stasis ulcer; Measurement: 1.1 x 1.4 x 0; Granulation tissue: <24%; Exudate Type: serosanguinous; Epithelialization: <25%. The Visit Note Report documents: 08/07/2023 “Care Coordination Indicate if you communicated with other disciplines involved in this case: NO.” Wound Assessment Distal Mid Distal Pretibial, right, cellulitis; measurement taken: NO; Granulation tissue: intact; Epithelialization: 75-<100%; RLE (right lower extremity) open areas closed.” 08/11/2023 “Care Coordination Indicate if you communicated with other disciplines involved in this case: NO.” Wound Assessment Distal Mid Distal Pretibial, right, cellulitis; measurement taken: NO; Granulation tissue: intact; Epithelialization: 100%; Wound care per MD orders. No open areas observed. 08/15/2023 “Care Coordination Indicate if you communicated with other disciplines involved in this case: NO.” Wound Assessment Distal Mid Distal Pretibial, right, cellulitis; measurement taken: NO; Granulation tissue: intact; Epithelialization: 100%; Wound care per MD orders. No open areas, resolved. The Verbal Order dated 08/24/2023 documents: Order for MD notification. Wounds to bilateral lower legs healed. Patient requires no further skilled services.” There is no documented evidence that the RN communicated with the physician regarding changes with wound status – closed since 08/07/2023, continued treatment. On 09/13/2023 at 2:35pm, the Administrator and Director of Patient Services were interviewed and did not provide an explanation 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 record review and staff interview the agency failed to ensure all clinical notes are complete and accurately document the care provided . This was evident for one (1) of eight (8) clinical records reviewed. (Patient #1 ). The findings are: 1.Patient #1 has a Start of Care date of 07/27/2023 with diagnoses "Type 2 Diabetes Mellitus with Diabetic Peripheral Angiopathy without Gangrene, Spinal Stenosis, Acquired Absence of Left Leg Below Knee" documented in the Home Health Certification and Plan of Care dated 07/27/2023 to 09/24/2023. The SN (Skilled Nurse) “Visit Note Report” dated 08/02/2023 documents: “Indicate integumentary assessment/findings: No problems identified;” “Narrative: “RN performed wound care as per MD (Medical Doctor) order. Patient tolerated procedure well. RN reinforced education on adequate hydration and protein rich meal to improve wound healing.” The clinical record lacks documented evidence the patient has a wound and orders for wound care. The SN visit note documentation is inconsistent with the patient’s assessment and needs. On 09/13/2023 at 2:35PM, the Administrator and the Director of Patient Services (DPS) were interviewed. The DPS stated “there’s no wound;” the SN documentation “was an error.”