Every finding on record at Good Samaritan Hospital of Suffern, Inc.

An on-site investigation for complaint NY00281624 was conducted at Good Samaritan Home Care at one Crossfield Avenue West Nyack, NY 10994 on 9/29/2021. The complaint investigation included a review of the agency's Complaint Log from 1/1/21 to present; policies; interviews; three (3) patient records identified as patients #1, #2 and #3; and three (3) employee records identified as employees #1, #2 and #3. Interviews were conducted with the Director of Patient Services and the Administrator. The complaint is Substantiated. The following deficiencies are being cited: G - 434 - Participate in Care; G - 590 - Promptly Alert Relevant Physician of Changes J - 1140 - Governing Authority

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on record reviews, policy review and interview, the governing authority failed to inform Patients of the services the Patient is to receive and the frequency for the services and any related charges. This was evident for three (3) of three (3) clinical records reviewed. (Patients #1, #2 and #3) Failure to ensure that patients are informed in writing of rights has the potential for patients to be unaware of rights which may prevent them from making informed decisions. The findings are: The agency's admission packet was requested on 9/29/21. The admission packet was reviewed and documents a form titled Charges (no date of development) documents the rates for the following services: Skilled Nursing, Physical Therapy, Occupational Therapy, Speech Therapy, Medical Social Worker and Home Health Aide. It also has spaces for entries for Co-payment and Deductible costs. A review of the clinical records for Patients #1, #2 and #3 lack documented evidence of the Standard Charge Rates For Medicare and Non-Medicare or other charges (if any) that the Patients would be liable for. Patient #1 has a start of care date of 2/25/21. The Patient submitted a complaint stating that the agency was charging the Patient 637.00. The record lacks documented evidence of signed financial responsibility prior to initiating services. During an interview with the Director of Patient Services (DPS) on 9/29/21 at 1:00 PM ,the DPS stated that the agency is aware of the problem and no other explanation was provided.

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 observation, clinical record reviews and interview, the agency failed to promptly notify the physician of changes in patients' status which may require alteration in Plans of Care. This was evident for three (3) of three (3) clinical records reviewed. (Patients #1 and #2) Failure to notify the physician of the patient's status has the potential for patients to not receive interventions which may result in negative outcomes. The findings are: 1. Patient #1 has a start of care date of 2/25/21 with diagnoses of Aftercare for Total Knee Replacement, Asthma and Hypertension as documented on the Home Health Certification and Plan of Care dated 2/25/21 through 4/25/21. The Home Health Certification and Plan of Care dated 2/25/21 through 4/25/21 documents: Skilled Nursing visit (SN) one visit for one week; Physical Therapy (PT) Three visits for one week then two visits for one week; assess pain and notify physician if pain exceeds patient goal of 6 on a scale of 0 to 10; Percocet one tablet every four hours as needed for pain. The PT notes document the following: 2/25/21 - Patient complained of pain all the time and rates the pain as an 7, notified physician through physician's nurse about increased medications; 2/26/21- the note documents the Patient took two Percocet tablets (more than prescribed); 2/27/21 - pain is an 8, Patient has been taking pain medication and icing but reports nothing is helping to manage her severe pain properly; 2/28/21 - pain is an 8, Patient is compliant with medication and icing but is finding that her pain is not decreased by measures, physician will be called, Patient requested to hold off on gait and strength training today due to her extreme pain levels, physician will be notified, pain is local to the lateral right distal hamstring ; 3/1/21 - (discharge visit)- pain is an 8, pain is located to the distal right lateral hamstring, physician notified of pain, Patient feels her knee has improved, but that the pain in the back of her thigh is still intense. There is no documented evidence of communication with the physician regarding the Patient's increased pain, the treatments (medication and icing) is not helping and the location of the pain located in the back of her thigh (not the knee). During an interview with the Director of Patient Services (DPS) on 9/29/21 at 2:00 PM, the DPS did not provide an explanation for the above. 2. Patient #2 has a start of care date of 4/15/21 with diagnoses of Aftercare for Total Knee Replacement and Asthma as documented on the Home Health Certification and Plan of Care dated 4/15/21 through 6/13/21. The Home Health Certification and Plan of Care dated 4/15/21 through 6/13/21 documents: SN two visits for two weeks; PT three times a week for one week then two times a week for two weeks then three times a week for one week; assess pain and notify physician if pain exceeds patient goal of 6 on a scale of 0 to 10; Hydromorphone 2 mg tablet one every 8 to 12 hours as needed for moderate to severe pain; Acetaminophen 250 mg/Aspirin 250 mg/Caffeine 65 mg (Excedrin) one and one half tablets two times a day. The PT notes document the following: 4/15/21 - pain is a 7, one Oxycodone tablet (Oxycodone is not documented on the Plan of Care), Physician notified; 4/16/21 - pain is a 5 and two Oxycodone tablets taken (Oxycodone is not listed on the Plan of Care); 4/17/21 - pain is a 6, one Oxycodone tablet taken, pain is outside the goal range for Patient, notified physician office; A communication note dated 4/20/21 documents the PT spoke to the physician and a "new" medication was given. There is no documented evidence as to what new medication was prescribed. A communication note dated 4/22/21 documents the PT "left a message for the physician about no relief from using Oxycodone which impacts functional status". A SN note dated 4/16/21 documents the Nurse made a call to the home to schedule a home visit and was told by the Patient's Significant Other (SO) that Patient is having a lot of pain, is taking Excedrin about two hours after pain medication and then taking Tylenol Arthritis (Tylenol is not listed on the Plan of Care), instructed SO to take plain Tylenol and plain ASA (Aspirin) and SO stated the Patient has a platelet problem; t/c (telephone call) made to physician. A SN note dated 4/19/21 documents the Patient's blood pressure was elevated (140/100) and Patient had pain of a 10 and went down to a 7. The Nurse documents the physician's office was called regarding the pain and elevated blood pressure. The note does not document the Nurse spoke with the physician, only the Nurse. The SN note lacks documented evidence of the date/time the physician was called, the information the Nurse communicated to the physician and the physician's response. The record lacks documented evidence of documented evidence of communication between the Nurse, the PT and the physician regarding the Patient's pain for possible revision to the Plan of Care. During an interview with the Director of Patient Services (DPS) on 9/29/21 at 2:00 PM, the DPS did not provide an explanation for the above.