Every finding on record at Fsnr Chha, LLC

This Statement of Deficiencies is a result of an on-site investigation of complaint 100573 and 103767 conducted at Four Seasons Nursing & Rehabilitation CHHA, located at 1535 Rockaway Parkway, Brooklyn, NY 11236 on 02/06/2025. The active patient census is 211. The investigation consisted of a review of five (5) clinical records (identified as Patients #1, #2, #3, #4, and #5), the agency's occurrence and complaint binder, discharges, and interviews with the Administrator, the Director of Patient Services, the Director of Intake, and the Operations Manager. Pre-survey activities consisted of review on 02/05/2025 of the agency's Health Commerce System account. Findings were reviewed at the exit conference on 02/06/2025. The allegations in Complaint 100573 were determined to be Substantiated. The allegation in Complaint 103767 was determined to be Substantiated. A Statement of Deficiencies will be issued. The following deficiencies are being cited as result of the survey: G – 0608 - Coordinate care delivery G - 0984 - In accordance with current clinical practice

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on clinical care record review and staff interviews, the governing authority failed to coordinate care delivery to the patient or caregivers. This was evident for one (1) of five (5) patient care records reviewed (Patient #1). Failure to coordinate care delivery to the patient or caregivers has the potential for negative patient outcomes. The findings are: 1. Patient #1 has a Start of Care date of 07/12/2023 and a discharge date of 09/26/2023 with the following diagnoses "Bilateral Primary Osteoarthritis of Knee, Hypertension, Dementia" documented in the Home Health Certification and Plan of Care for the Certification Period 07/12/2023 to 09/09/2023. The Home Health Certification and Plan of Care for the Certification Period 07/12/2023 to 09/09/2023 documents: “Aid 07-16-23 2 x week x 4 weeks, 3h (twice a week for four weeks, three hours) duration; 08-12-23 5 x week x 4 weeks, 4h (five times a week for four weeks, four hour) duration.” The Duty Sheet documents aide services being provided with time in of 07:45am from 08/01/2023 to 08/11/2023, 8:00am on 08/14/2023, 12:15pm on 08/15/2023, and 1:45pm on 08/16/2023. The clinical record lacks documented evidence of the coordination of the delivery of care (aide services late time in) to the family on 08/15/2023 and 08/16/2023. On 02/06/2025 at 4:30PM, the Administrator, the Director of Patient Services, the Director of Intake, and the Operations Manager were interviewed and stated, “No notes were found on these dates”, and no further explanation for the findings.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on clinical care record review and staff interviews, the governing authority failed to ensure that services must be provided in accordance with HHA own policies and procedure. This was evident for one (1) of five (5) patient care records reviewed (Patient #4). Failure to ensure that services must be provided in accordance with HHA own policies and procedure has the potential for negative patient outcomes. The findings are: 1. Patient #4 has a referral date 12/19/2023. The Email Print-out documents: 12/20/2023 “Pt (patient) with uncontrolled DM (Diabetes Mellitus), diabetic foot ulcer, with recent hospitalization for infected wound/ OM (Osteomyelitis). NTUC (not taken under care) d/t (due to) poor wound healing potential.” The Administrative Policy and Procedure Manual for Intake/Referral documents: “All NTUC’ed (not taken under care) referrals after discussion with the DPS/Designee must be communicated via email, phone call, facsimile machine or the referral source reasons why agency could not take case under their care (NTUC) and document such communication in the intake tracking log and patient medical record. The clinical record lacks documented evidence of the communication in the intake tracking log and patient medical record of not accepting/admitting patient with the referral agency. On 02/06/2025 at 4:30PM, the Director of Patient Services was interviewed and stated, "I don’t see no notes, and I asked the staff, they could not answer my question too.”