Every finding on record at Emerest Certified Home Health Care of Ny LLC

A post certification visit (PCV) for Emerest Certified Home Health Care of NY LLC d/b/a Royal Care Certified Home Health of NY, a CHHA (Certified Home Health Agency), located at 798 Southern Boulevard, Bronx, NY 10455 was conducted on 01/17/2025 as a follow up to the initial certification survey that was conducted on 12/18/2023 to 12/21/2023. The PCV survey included a review of 4 clinical records, 2 personnel, plan of correction documentations, discharges, active patient roster, and interview with the Director of Patient Services. The current patient census is 138. The following deficiencies has been corrected: Federal tags: G0374 – Accuracy of Encoded OASIS Data G0574 – Plan of Care must include the following G0580 – Only as Ordered by a Physician G0706 – Interdisciplinary Assessment of the Patient G0718 – Communication with Physicians G0798 – Home Health Aide Assignments and Duties G0806 – Supervision of Home Health Aides G0808 – Onsite Supervisory Visit every 14 days State tags: J1260 – Governing Authority J1426 – Personnel The following deficiencies remains uncorrected: Federal tag: G0528 – Health, Psychosocial, Functional, Cognition G0590 – Promptly Alert relevant Physician of Changes G0818 – HH Aide Supervision Elements

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 agency failed to ensure that all patients assessments are complete and accurate. This was evident for three (3) of four (4) patient care records reviewed (Patient’s #1, #2, and #3). Failure to ensure that all patients assessments are complete and accurate has the potential for negative patient outcomes. The findings are: 1. Patient #1 has a Start of Care date of 06/26/2023 with the following diagnoses "Pressure Ulcer of Sacral Region, Stage 3; Type 2 Diabetes Mellitus with Diabetic Polyneuropathy" documented in the Home Health Certification and Plan of Care for the certification period 12/17/2024 to 02/14/2025. The Visit Note Report dated 12/13/2024, 12/20/2024, 12/23/2024, 12/30/2024, 01/03/2025, 01/06/2025, 01/10/2025, and 01/13/2025 documents: Coccyx, PU (pressure ulcer) Stage III; ; Indicate type: Susp (suspected) DTI (deep tissue injury); Epithelialization: <25%; Necrotic Tissue Amount: None; Edge / Surrounding tissue – Maceration: Absent; Undermining: None; Tunneling: No. The OASIS Manual dated 01/01/2023 documents: Deep Tissue Injury A purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. The Comprehensive Assessments lacks documented evidence of an accurate and complete assessment– stage III with suspected deep tissue injury, the description does not include deep tissue injury (no purple discoloration, no undermining/tunneling, no necrosis), and only <25% epithelialization, missing other 75% of the wound description. There is no documented evidence of a complete and accurate wound assessment that reflects the patient’s status. On 01/17/2025 at 3:00PM, the Director of Patient Services was interviewed and stated, according to the nurse presents with suspected DTI (deep tissue injury) due to the fact that it is close to the anus, and it was impossible close surgically, no further explanation for the findings. 2. Patient #2 has a Start of Care date of 09/26/2024 with the following diagnoses "Type 2 Diabetes Mellitus Foot Ulcer, Non-Pressure Chronic Ulcer Left Foot" documented in the Home Health Certification and Plan of Care for the certification period 11/25/2024 to 01/23/2025. The Visit Note Report documents: Dorsum, Distal Left Diabetic Ulcer on 11/29/2024 Granulation: None; Epithelialization: <25%. 12/04/2024, 12/11/2024, 12/13/2024 Granulation: None; Epithelialization: 25-<50%. 12/16/2024, 12/18/2024, 12/23/2024 Granulation Tissue: 75-100%; Epithelialization: 75-<100%. The Comprehensive Assessments lacks documented evidence of an accurate and complete assessment– only <25% and 25-50% epithelialization, missing other 75% and 50-75% of the wound description; and 75-100% granulation and 75-100% epithelialization on one wound. There is no documented evidence of a complete and accurate wound assessment that reflects the patient’s status. On 01/17/2025 at 3:00PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings. 3. Patient #3 has a Start of Care date of 12/10/2024 with the following diagnoses "Pressure Ulcer of Sacral Region, Stage 4; Osteomyelitis of Vertebra, Sacral and Sacrococcygeal Region" documented in the Home Health Certification and Plan of Care for the certification period 12/10/2024 to 02/07/2025. The Visit Note Report dated 12/13/2024 documents: Sacral Pressure Ulcer Stage IV; Granulation Tissue: Intact; Epithelialization: <25%; Necrotic Tissue Type: Yellow; Necrotic Tissue Amount: <25%. The Comprehensive Assessments lacks documented evidence of an accurate and complete assessment– only <25% epithelialization and <25% necrosis, missing 50% of the wound description; and granulation is intact. There is no documented evidence of a complete and accurate wound assessment that reflects the patient’s status. On 01/17/2025 at 3:00 PM, the Director of Patient Services was 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 the physician is promptly alerted to any changes in patient’s condition. This was evident for three (3) of four (4) patient care records reviewed (Patient’s #1, #2, and #3). Failure to ensure the physician is promptly alerted to any changes in patient’s condition has the potential for negative patient outcomes. The findings are: 1. Patient #1 has a Start of Care date of 06/26/2023 with the following diagnoses "Pressure Ulcer of Sacral Region, Stage 3; Type 2 Diabetes Mellitus with Diabetic Polyneuropathy" documented in the Home Health Certification and Plan of Care for the certification period 12/17/2024 to 02/14/2025. The Visit Note Report dated 12/13/2024, 12/20/2024, and 12/23/2024 documents: Coccyx, PU (pressure ulcer) Stage III; Epithelialization: 25%; Epithelialization: <25%. 12/13/2024 Measurement Taken: 4 X 7 X 2; Epithelialization: <25%; Necrotic Tissue Type: Yellow; Necrotic Tissue Amount: <25%. There is no documented evidence of the physician being promptly alerted about the development of necrotic tissue and increasing in size of the wound. On 01/17/2025 at 3:00PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings.

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 review and staff interview, the agency failed to ensure the supervisory visits of the home health aide includes an evaluation of the elements in the plan of care. This was evident for one (1) of four (4) patient care records reviewed (Patient #4). Failure to ensure the supervisory visits of the home health aide includes an evaluation of the elements 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 11/25/2024 with the following diagnoses "Acute Embolism and Thrombosis of Left Iliac Vein, Paroxysmal Atrial Fibrillation" documented in the Home Health Certification and Plan of Care for the certification period 11/25/2024 to 01/23/2025. The Care Log (duty sheet) documents aide services being provided on 12/03/2024, 12/04/2024, 12/06/2024, 12/09/2024, 12/11/2024, 12/13/2024, 01/03/2025, 01/06/2025, and 01/08/2025. The Client Coordination Note Report documents: 12/03/2024 hha (home health aide) oriented to hha (home health aide) plan of care; aide instructed to report changes in patient condition. 12/11/2024 Her aid and the daughter were present during the therapy session. 01/03/2025 hha (home health aide) supervision done during the visit. Reviewed HEP (home exercise program), transfer and ambulation with aide and patient. Patient report satisfaction with aide services. There is no documented evidence of how the aide was supervised. There is no documented evidence of the elements of aide supervision. On 01/17/2025 at 3:00PM, the Director of Patient Services was interviewed and did not provide an explanation for the findings.