Every finding on record at Health Services of Northern New York, Inc

This Statement of Deficiencies report includes the results of a review of the agency's compliance with emergency preparedness requirements completed during the recertification survey conducted 01/07/25-01/10/25 and 01/13/25-01/15/25. Pre-survey activities consisted of a review on 01/02/25 of the agency's Health Commerce System account. The following information was reviewed during the survey: the agency's emergency plan, emergency preparedness policies and procedures, the emergency patient roster, and the staff call down list. Interviews were conducted with the Administrator and Director of Patient Services. The following deficiencies are being cited as a result of the survey: State: J 1156 Personnel

The following statement of deficiencies represents the results of a partial extended recertification survey of Health Services of Northern New York Certified Home Health Agency conducted 01/07/25-01/10/25 and 01/13/25-01/15/25. A standard recertification survey was initiated on 01/07/25. Deficient practices were identified within Level 1 standards in the Conditions 484.60 Care Planning, Coordination of Services, and Quality of Care, 484.70 Infection Prevention and Control, and 484.80 Home Health Aide Services resulting in a partial extended survey. The survey included a review of 17 clinical records including 5 discharged patients, 7 home visits, 14 personnel records, pertinent policies and procedures, admissions packet, Quality Improvement Committee Meeting and Governing Body meeting minutes for the past 12 months, 2 contracts, Complaint Log, the Emergency Preparedness Plan, and the Home Health Aide Training Program. The patient census at the time of survey was 228. Pre-survey activities consisted of a review on 01/02/25 of the agency's Health Commerce System account, Home Care Worker Registry, Criminal History Record Check, review of the internet Quality Improvement and Evaluation System (iQIES) reports for the period 10/01/23 to 09/30/24, and the agency's compliance with report submissions for the most recent statistical report. The agency's Administrator, Director of Patient Services, Staffing Manager, and field staff were interviewed. Findings were reviewed at the exit conference on 01/15/25. The following deficiencies are being cited as a result of the survey: Federal: G 528 Comprehensive Assessment of Patients; G 574, G 576, and G 608 Care Planning, Coordination of Services, and Quality of Care; G 682 Infection Prevention and Control; G 798 and G 800 Home Health Aide Services State: J 1140, J 1156, J 1168, and J 1260 Governing Authority; J 1304 Contracts; J 1401, J 1424, J 1426, J 1456, and J 1476 Personnel

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: (1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on observational home visits and review of clinical records, it was determined in 3 of 17 records, (patients #4,16, and 17) comprehensive assessments were not of sufficient scope to ensure all patients' needs were identified. Patient #16 was admitted to the agency on 09/15/23 with diagnoses that included incomplete spinal lesion from fractures at T7-10, neuromuscular dysfunction of the bladder with urinary retention, hypertension, anxiety, and history of falling. This patient was selected from the internet Quality Improvement and Evaluation System (iQIES) potentially avoidable events report dated 10/01/23 through 09/30/24 for urinary tract infection. On 09/15/23, the registered nurse (RN) visited for the comprehensive assessment. The RN documented: - the patient “requires a urinary catheter.” - Someone must help the patient to maintain toileting hygiene The Plan of Care dated 09/15/23 included the following nursing intervention: - intermittent catheterization, client independent with procedure every 6 hours, 16 fr. There was no evidence in support of the care plan statment "client independent with procedure. There RN failed to assess the patient’s knowledge and ability via demonstration with actual or verbal re-demonstration to ensure the procedure of self-catheterization was completed using appropriate infection prevention technique. On 01/14/25, at 1:10 p.m., the findings were reviewed with the Administrator and Director of Patient Services who acknowledged the findings and provided no additional information. Patient #17 was admitted to the agency on 08/03/24 with diagnoses that included mitral valve replacement, type 2 diabetes, asthma, obesity and a history of falling. The patient was selected from the internet Quality Improvement and Evaluation System (iQIES) potentially avoidable events report dated 10/01/23 through 09/30/24 for urinary tract infection (UTI). On 08/05/24, the registered nurse visited for the initial assessment and documented the patient -had urge incontinence managed by incontinence pads -Someone must help the patient to maintain toileting hygiene -had friends and family “24/7” to assist the patient -ability to maintain perineal hygiene, needs partial/moderate assistance On 08/05/24, the RN completed a follow-up visit and documented: -urine dark with sediment and slight odor -right flank pain -notified primary care provider of client’s urinary complaints and ordered urine -urinalysis clean catch obtained The RN failed to assess the patient and caregivers’ ability to perform perineal and toileting hygiene, and to educate the patient on UTI prevention. On 08/06/24 the RN visited and documented: -urine amber, cloudy with sediment and slight odor -frequency, urgency -occasional flank pain and pressure The RN failed to document follow-up from the urinalysis obtained the day prior and to assess the patient and caregivers’ ability to perform perineal and toileting hygiene, and to educate the patient on UTI prevention. On 08/08/24, the RN visited and documented: -urine amber, cloudy, sediment and slight odor -urgency -clinical condition urinary tract infection. The patient’s medication profile included an 08/08/24 addition on nitrofurantoin macrocrystals, 100 mg capsule, take 1 capsule 4 times daily for UTI. On 08/13/24 the agency RN received a call from the patient’s primary care provider who stated the patient continues to have UTI symptoms. A new antibiotic was ordered. The note was sent to the RN. On 08/15/24, the RN visited and documented: -urine clear, yellow -urinary tract infection The medication profile included an 08/15/24 addition of cefpodoxime 200 mg tabs, take 0.5 tabs twice daily for UTI The RN failed to assess the patient and caregivers’ ability to perform perineal and toileting hygiene, and to educate the patient on UTI prevention. On 01/14/25, at 1:10 p.m., the findings were reviewed with the Administrator and Director of Patient Services who acknowledged the findings and provided no additional information. Home Visit Patient #4 was admitted to the agency on 11/21/24 with diagnoses of fractured femur, osteoarthritis, chronic kidney disease and type 2 diabetes. On 11/21/24 the registered nurse (RN) visited for the initial assessment and documented the client was “independent with Dexcom.” On 01/09/24 @ 2:30 p.m., the surveyor conducted an observational home visit with the physical therapist. After the visit, the surveyor interviewed the patient who stated [aide] puts the Dexcom on for me as it is difficult for me to reach. Upon further questioning, the aide was a private aide. There was no evidence the RN assessed the private aide’s ability to correctly apply the Dexcom and observe the aide’s technique. On 01/10/25 at 10:30 a.m. the record was reviewed with the Administrator and the Director of Patient Services who acknowledged the findings and provided no additional information. Home Visit Patient #5 was admitted to the agency on 10/25/24 with diagnoses of type 2 diabetes mellitus with other complications, acute osteomyelitis of the left ankle and foot, foot ulcer, and non-pressure chronic ulcer to left foot. Wound At the initial assessment on 10/25/24, the Registered Nurse (RN) documented the patient had three wounds on their left foot. On the 10/25/24-12/23/24 Plan of Care, the wounds were referred to as site #1, site #2, and site #3. On 12/12/24, the RN documented site #2 was healed. At the recertification assessment on 12/19/24, site #2 was not mentioned. However, the 12/24/24-02/21/25 Plan of Care still included wound care for site #2. The RN failed to update the plan of care based on the patient’s updated comprehensive assessment. Diabetes At the initial assessment on 10/25/24, the RN documented the patient used a Libre 3 continuous blood glucose meter and took NovoLog (rapid acting insulin) using a sliding scale at meals and Tresiba (long-acting insulin) 0.2 mL at bedtime. The RN also documented the patient’s caregiver demonstrated how to change and use the continuous meter and the patient could administer their insulin. The RN failed to assess: - if the patient had a back-up glucometer and test strips - the patient or caregiver’s ability to use the back-up glucometer The RN failed to complete a comprehensive assessment of the patient and failed to determine a plan for what the patient and caregiver would do in the event the continuous glucose meter failed. On 01/10/25 at 10:30 a.m. the record was reviewed with the Administrator and the Director of Patient Services who acknowledged the findings and provided no additional information. Patient #11 was admitted to the agency on 12/17/24 with diagnoses of facial weakness following cerebral infarction (stroke), dysphagia (trouble swallowing), stage 4 chronic kidney disease, and heart failure. The 12/17/24-2/14/25 Plan of Care included the diagnoses of dysphagia and facial weakness. On 12/17/24 the Registered Nurse (RN) visited the patient for an initial assessment. There is no evidence the RN assessed the patient’s ability to swallow and/or assessed the patient’s potential need for a speech therapy evaluation. On 01/10/25 at 10:30 a.m. the record was reviewed with the Administrator and the Director of Patient Services who acknowledged the findings and provided no additional information. Home Visit 1. Patient #5 was admitted to the agency on 10/25/24 with diagnoses of type 2 diabetes mellitus with other complications, acute osteomyelitis of the left ankle and foot, foot ulcer, and non-pressure chronic ulcer to left foot. Wound At the initial assessment on 10/25/24, the Registered Nurse (RN) documented the patient had three wounds on their left foot. On the 10/25/24-12/23/24 Plan of Care, the wounds were referred to as site #1, site #2, and site #3. On 12/12/24, the RN documented site #2 was healed. At the recertification assessment on 12/19/24, site #2 was not mentioned. However, the 12/24/24-02/21/25 Plan of Care still included wound care for site #2. The RN failed to update the plan of care based on the patient’s updated comprehensive assessment. Diabetes At the initial assessment on 10/25/24, the RN documented the patient used a Libre 3 continuous blood glucose meter and took NovoLog (rapid acting insulin) using a sliding scale at meals and Tresiba (long-acting insulin) 0.2 mL at bedtime. The RN also documented the patient’s caregiver demonstrated how to change and use the continuous meter and the patient could administer their insulin. The RN failed to assess: - if the patient had a back-up glucometer and test strips - the patient or caregiver’s ability to use the back-up glucometer The RN failed to complete a comprehensive assessment of the patient and failed to determine a plan for what the patient and caregiver would do in the event the continuous glucose meter failed. On 01/10/25 at 10:30 a.m. the record was reviewed with the Administrator and the Director of Patient Services who acknowledged the findings and provided no additional information. 2. Patient #11 was admitted to the agency on 12/17/24 with diagnoses of facial weakness following cerebral infarction (stroke), dysphagia (trouble swallowing), stage 4 chronic kidney disease, and heart failure. The 12/17/24-2/14/25 Plan of Care included the diagnoses of dysphagia and facial weakness. On 12/17/24 the Registered Nurse (RN) visited the patient for an initial assessment. There is no evidence the RN assessed the patient’s ability to swallow and/or assessed the patient’s potential need for a speech therapy evaluation. On 01/10/25 at 10:30 a.m. the record was reviewed with the Administrator and the Director of Patient Services who acknowledged the findings and provided no additional information. 3. Patient #16 was admitted to the agency on 09/15/23 with diagnoses that included incomplete spinal lesion from fractures at T7-10, neuromuscular dysfunction of the bladder with urinary retention, hypertension, anxiety, and history of falling. This patient was selected from the internet Quality Improvement and Evaluation System (iQIES) potentially avoidable events report dated 10/01/23 through 09/30/24 for urinary tract infection. On 09/15/23, the registered nurse (RN) visited for the comprehensive assessment. The RN documented: - the patient “requires a urinary catheter” - someone must help the patient to maintain toileting hygiene The Plan of Care dated 09/15/23 included the following nursing intervention: - intermittent catheterization, client independent with procedure every 6 hours, size 16 fr. There was no evidence to support the Plan of Care statement "client independent with procedure. There RN failed to assess the patient’s knowledge and ability via demonstration with actual or verbal re-demonstration to ensure the procedure of self-catheterization was completed using appropriate infection prevention technique. On 01/14/25, at 1:10 p.m., the findings were reviewed with the Administrator and Director of Patient Services who acknowledged the findings and provided no additional information. 4. Patient #17 was admitted to the agency on 08/03/24 with diagnoses that included mitral valve replacement, type 2 diabetes, asthma, obesity and a history of falling. The patient was selected from the internet Quality Improvement and Evaluation System (iQIES) potentially avoidable events report dated 10/01/23 through 09/30/24 for urinary tract infection (UTI). On 08/05/24, the registered nurse visited for the initial assessment and documented the patient: - had urge incontinence managed by incontinence pads - someone must help the patient to maintain toileting hygiene - had friends and family “24/7” to assist the patient - ability to maintain perineal hygiene, needs partial/moderate assistance On 08/05/24, the RN completed a follow-up visit and documented: - urine dark with sediment and slight odor - right flank pain - notified primary care provider of client’s urinary complaints - urinalysis clean catch obtained On 08/06/24 the RN visited and documented: - urine amber, cloudy with sediment and slight odor - frequency, urgency - occasional flank pain and pressure The RN failed to document follow-up from the urinalysis obtained the day prior. On 08/08/24, the RN visited and documented: - urine amber, cloudy, sediment and slight odor - urgency - clinical condition, UTI The patient’s medication profile included an 08/08/24 addition on nitrofurantoin macrocrystals, 100 mg capsule, take 1 capsule 4 times daily for UTI. On 08/13/24 the agency RN received a call from the patient’s primary care provider who stated the patient continues to have UTI symptoms. A new antibiotic was ordered. On 08/15/24, the RN visited and documented: - urine clear, yellow - UTI The medication profile included an 08/15/24 addition of cefpodoxime 200 mg tabs, take 0.5 tabs twice daily for UTI At each visit above the RN failed to assess the patient and caregivers’ ability to perform perineal and toileting hygiene, and to educate the patient on UTI prevention. On 01/14/25, at 1:10 p.m., the findings were reviewed with the Administrator and Director of Patient Services who acknowledged the findings and provided no additional information. Home Visit 5. Patient #4 was admitted to the agency on 11/21/24 with diagnoses of fractured femur, osteoarthritis, chronic kidney disease and type 2 diabetes. On 11/21/24 the registered nurse (RN) visited for the initial assessment and documented the client was “independent with Dexcom.” On 01/09/24 at 2:30 p.m., the surveyor conducted an observational home visit with the physical therapist. After the visit, the surveyor interviewed the patient who stated [aide] puts the Dexcom on for me as it is difficult for me to reach. Upon further questioning, the aide was a private aide. There was no evidence the RN assessed the private aide’s ability to correctly apply the Dexcom. On 01/10/25 at 10:30 a.m. the record was reviewed with the Administrator and the Director of Patient Services who acknowledged the findings and provided no additional information. Failure to ensure complete and accurate comprehensive assessments are performed has the potential for unmet patient needs and possible negative patient outcomes.

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 interviews with an agency registered nurse, it was determined in 2 of 17 records (patients #8 and 9), the nurse failed to develop a complete and accurate plan of care. Evidence as follows: 1. Patient #9 was admitted to the agency on 10/24/24 with diagnoses of coronary artery disease, myocardial infarction (heart attack), congestive heart failure, diabetes type 2, and bilateral below the knee amputations (BKA). Wound Care The 10/24/24-12/22/24 Plan of Care included: perform wound care/dressing change 3 times/week, by caregiver. Using aseptic technique, remove dressing, cleanse wound with soap and water, and apply Aquacell Ag and mepilex. The Plan of Care failed to include the location of the wound that the wound care order applied to. Adaptive Equipment On 10/24/24 the registered nurse (RN) saw the patient for an initial visit and documented the patient had bilateral BKA’s and currently used bilateral prosthetics to ambulate. The 10/24/24 Plan of Care failed to include the use of bilateral prosthetics including frequency and duration for use. On 01/14/25 at 1:10 p.m. the above findings were reviewed with the Administrator and Director of Patient Services who acknowledged the findings and provided no additional information. 2. Patient #8 was admitted to the agency on 11/29/24 with diagnoses of renal (kidney) cell cancer, diabetes type 2, and adrenocortical insufficiency due to immunosuppressant drug therapy. The 11/29/24-01/27/25 Plan of Care included an order for a home health aide (HHA) 2-3 times/week for 8 weeks. On 11/29/24 the registered nurse (RN) saw the patient for an initial visit and documented “HHA requested for bathing assistance…” On 12/06/24 the RN visited the patient and documented no referral for a home health aide. On 01/08/25 the surveyor located an aide care plan in the patient’s electronic medical record (EMR) with both a start and resolved date of 12/03/24. On 01/10/25 the surveyor called and interviewed the RN regarding the HHA order, aide care plan, and conflicting information found in the 12/06/24 nursing visit note. The RN stated when the patient was called to set up the HHA, they had changed their mind and no longer wanted aide services. The RN failed to discontinue the order and update the Plan of Care once HHA services were no longer requested. On 01/10/25 at 10:30 a.m. the above findings were reviewed with the Administrator and Director of Patient Services who acknowledged the findings and provided no additional information. Failure to ensure the plan of care is complete, accurate, and updated as needed has the potential for unmet patient needs and possible negative patient outcomes.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on clinical record review it was determined in 4 of 17 records (patients #5, 9, 10, and 15), the nurse failed to update the plan of care to reflect all current/ongoing ordered treatment. Evidence as follows: Home Visit Patient #5 was admitted to the agency on 06/13/24 with diagnoses of chronic venous hypertension with ulcer of bilateral lower extremity, pressure ulcer of left buttock, stage 2, hypertensive heart disease with heart failure, and type 2 diabetes. On 7/31/24, the surveyor completed an observational home visit with the Registered Nurse (RN). The patient was wearing a brace on their right leg and foot. The patient’s 12/24/24-02/21/25 Plan of Care does not contain an order for any type of brace and does not list any type of brace under “Supplies”. The RN failed to obtain orders and update the plan of care to include the brace, how often it should be worn, and add it to the list of supplies based on the patient assessment. On 01/10/25 at 10:30 a.m. the record was reviewed with the Administrator and the Director of Patient Services who acknowledged the findings and provided no additional information. 1. Patient #15 was admitted to the agency on 04/14/24 with diagnoses of bilateral foot cellulitis, diabetes type 2, congestive heart failure, and coronary artery disease. The patient was discharged on 05/9/24 and was selected from the internet Quality Improvement and Evaluation System (iQIES) potentially avoidable events report, dated 10/01/23 through 09/30/24, for an increase in the number of pressure ulcers. Glucose Monitoring The 04/14/24-06/12/24 Plan of Care included an order that the patient does not check their blood sugar. On 04/14/24 the registered nurse (RN) saw the patient for an initial visit. The nurse documented in a start of care note, located in a communication note within the patient’s electronic medical record, the patient was not checking their blood sugar and they had no glucometer in the home. On 04/29/24 the RN saw the patient for a scheduled visit and documented: - the patient is to check blood sugar levels twice a day (before breakfast and dinner) - notify the physician if blood glucose levels were 300 - nurse to record blood sugar ranges every visit The RN failed to obtain a physician order and update the Plan of Care to include the following for blood glucose monitoring: frequency, ranges to report, and nurse assessment each visit. Wound Care The 04/14/24-06/12/24 Plan of Care included the following wound care orders: - wounds 1-6 right/left foot abrasions: allow water to run over scabs/open areas (while bathing), pat dry, apply betadine, apply meglisorb, apply gauze, wrap with kling, and secure - wounds 7-8 right/left knee cluster scabs: leave open to air, allow water to run over scabs (when bathing), pat dry On 05/06/24 the RN saw the patient for a routine visit and documented 3 new wounds: - wound 9: right foot great toe - wound 10: left outer foot great toe - wound 11: left foot top of great toe The following wound care was documented for all 3 new wounds: - wound care frequency: every Monday, Wednesday, Friday - cleanse with soap and water, pat dry, apply betadine, cover with aquacell, cover with gauze, wrap with kling, and secure The RN failed to obtain a physician order and update the Plan of Care to include the new wound care orders. On 01/14/25 at 1:10 p.m. the above findings were reviewed with the Administrator and Director of Patient Services who acknowledged the findings and provided no additional information. 2. Patient #9 was admitted to the agency on 10/24/24 with diagnoses of coronary artery disease, myocardial infarction (heart attack), congestive heart failure, diabetes type 2, and bilateral below the knee amputations (BKA). On 12/04/24 the registered nurse (RN) saw the patient for a scheduled visit and documented being instructed by the physician’s office to send the patient to the emergency room (ER) for increased redness and new blisters with peeling skin to the left lower leg. On 12/04/24 the patient was seen in the ER. Per the ER provider note, the patient was going to be treated with Augmentin (antibiotic) at home. On 12/05/24, in a patient communication note, the RN documented speaking with the patient and that the patient stated they obtained their antibiotic and had started taking it. The RN failed to update the patient’s Plan of Care to include the new antibiotic after confirming the patient had started taking it. On 01/14/25 at 1:10 p.m. the above findings were reviewed with the Administrator and Director of Patient Services who acknowledged the findings and provided no additional information. 3. Patient #10 was admitted to the agency on 11/19/24 with diagnoses of post procedural pneumothorax, solitary pulmonary nodule, Chronic obstructive pulmonary disease (COPD), hypertension, and nicotine dependence. The 11/19/24-01/17/25 Plan of Care ordered oxygen, “2 liters per minute, nasal canula, intermittent; wear with exertion/ambulation”. On 11/19/24 the registered nurse (RN) visited for an initial comprehensive assessment and documented: - use 2L of oxygen with exertion, off at rest On 11/26/24 the RN visited the patient and documented: - “no use of O2 (oxygen) per stress test will no longer need” There is no evidence in the record the RN updated the Plan of Care with the new oxygen orders. On 01/14/25 at 1:10 p.m. the above findings were reviewed with the Administrator and Director of Patient Services who acknowledged the findings and provided no additional information. Home Visit 4. Patient #5 was admitted to the agency on 10/25/24 with diagnoses of type 2 diabetes mellitus with other complications, acute osteomyelitis of the left ankle and foot, foot ulcer, and non-pressure chronic ulcer to left foot. Wound At the initial assessment on 10/25/24, the registered nurse (RN) documented the patient had three wounds on their left foot. On the 10/25/24-12/23/24 Plan of Care, the wounds were referred to as site #1, site #2, and site #3. On 12/12/24, the RN documented site #2 was healed. At the recertification assessment on 12/19/24, site #2 was not mentioned. However, the 12/24/24-02/21/25 Plan of Care still included wound care for site #2. The RN failed to update the Plan of Care based on the patient’s updated comprehensive assessment. On 01/10/25 at 10:30 a.m. the record was reviewed with the Administrator and Director of Patient Services who acknowledged the findings and provided no additional information. Failure to ensure the Plan of Care is complete, accurate, and updated has the potential for unmet patient needs and possible negative patient outcomes.

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 review of clinical records it was determined for 2 of 17 patients (patients #9 and 11), the agency failed to coordinate care to meet the needs of the patients. Evidence as follows: Patient #11 was admitted to the agency on 12/17/24 with diagnoses of facial weakness following cerebral infarction (stroke), dysphagia (trouble swallowing), stage 4 chronic kidney disease, and heart failure. The patient was discharged from the hospital on 12/16/24. On the discharge paperwork, it documents under “Discharge Instructions” a referral was made for a home health aide. During the initial assessment on 12/17/24, the Registered Nurse (RN) documented in the narrative note that the caregiver had applied to Medicaid to get extra help. The interdisciplinary group conference communication note from 1/7/25 documented that a social worker was assisting with the Medicaid application because the patient was seeking additional assistance. The RN failed to coordinate with the patient and the agency to refer in home health aide services while awaiting placement of long-term help. On 01/10/25 at 10:30 a.m. the record was reviewed with the Administrator and the Director of Patient Services who acknowledged the findings and provided no additional information. G 608 1. Patient #9 was admitted to the agency on 10/24/24 with diagnoses of coronary artery disease, myocardial infarction (heart attack), congestive heart failure, diabetes type 2, and bilateral below the knee amputations (BKA). On 10/24/24 the Registered Nurse (RN) saw the patient for an initial visit and the Physical Therapist (PT) saw the patient for an initial evaluation visit. The RN documented the patient: - has bilateral BKA’s and uses prosthetics to ambulate - has a wound on the left knee in which the prosthetic irritates The PT documented the patient: - has a wound on the left patella (knee) - has pain when weight bearing in the prosthetic due to the patella tendon bearing area of the prosthetic socket (area that amputation site goes into the prosthetic) pushes against the knee The patient was then seen by the RN on 10/30, 11/10, 11/11, 11/13, 11/20, 11/27, 12/4, 12/11, 12/18, 12/23, and 12/30/24. There was no evidence the nurse coordinated with the patient and/or physician to determine if the patient should be seen/evaluated by an orthopedist/prosthetist to ensure proper fitting of the prosthetic leg. On 01/14/25 at 1:10 p.m. the above findings were reviewed with the Administrator and Director of Patient Services who acknowledged the findings and provided no additional information. 2. Patient #11 was admitted to the agency on 12/17/24 with diagnoses of facial weakness following cerebral infarction (stroke), dysphagia (trouble swallowing), stage 4 chronic kidney disease, and heart failure. The patient was discharged from the hospital on 12/16/24. On the discharge paperwork, it documents under “Discharge Instructions” a referral was made for a home health aide. During the initial assessment on 12/17/24, the Registered Nurse (RN) documented in the narrative note that the caregiver had applied to Medicaid to get extra help. The interdisciplinary group conference communication note from 1/7/25 documented that a social worker was assisting with the Medicaid application because the patient was seeking additional assistance. The RN failed to coordinate with the patient and the agency to refer in home health aide services while awaiting placement of long-term help. On 01/10/25 at 10:30 a.m. the record was reviewed with the Administrator and the Director of Patient Services who acknowledged the findings and provided no additional information. Failure to coordinate patient care has the potential for unmet patient needs and possible negative patient outcomes.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observational home visits, review of clinical records, and agency policies and procedures, it was determined in 3 of 7 visits (patients #1, 2, and 6), staff failed to adhere to accepted standards and practices to prevent the transmission of infection. Evidence as follows: Home Visit Patient #7 was admitted to the agency on 11/16/24 with diagnoses of deep disruption of operation wound, skin graft failure, displaced fracture of right tibia, fracture of right fibula, and hypertension. On 01/10/25 at 10:30 a.m. the surveyor completed an observational home visit with the RN and observed the following: Bag Technique Upon entry to the patient's home the Registered Nurse (RN) placed a barrier on the floor and the nursing supply bag on top of it. On 01/10/25 at 12:00 p.m., the surveyor requested the agency’s bag technique policy; the Director of Patient Services provided the surveyor with the “Nursing Bag Technique” policy dated 02/26/13. The policy stated the nursing bag was to be placed “on a clean surface in the car and never on the floor. In the home a barrier is to be placed under the bag”. The surveyor noted that there were other clean options for bag placement within the patient’s home. * According to the Home Care Association of New York State, nursing bags should not be placed on the floor. Per the Home Care “Bag Technique” and the Use of Surface Barriers. Home Healthcare Now 35(9):p 478-484, October 2017., floor surfaces can be a reservoir for pathogenic organisms. Wound Care The patient had showered prior to RN arrival and wound was left open to air. The RN set up wound care supplies on a barrier, donned clean gloves and cleansed the wound as ordered. The RN then removed their gloves, performed hand hygiene and donned a new set of clean gloves. With the new clean gloves on the RN picked up an unopened package of kerlix and abdominal pad thus contaminating the clean gloves. The RN proceeded to perform wound care without removing the now contaminated gloves. On 01/10/25 at 12:00 p.m., surveyor requested the agency’s policy for wound care. The Director of Patient Services provided the surveyor with the following policies: - “Wound Assessment” dated 08/11/09, the policy did not provide specific steps or guidance to practitioner when performing wound care. - "Aseptic Technique” dated 02/26/13, the policy defined aseptic as a clean [not sterile] technique, and did not provide specific instructions on the handling of pre-packaged equipment and supplies while wearing gloves. - “Standard Precautions” dated 02/22/13, the policy stated that staff “change gloves between tasks and procedures on the same client after contact with material that may contain a high concentration of microorganisms. Remove gloves promptly after use, before touching noncontaminated items and environmental surfaces”. On 01/14/25 at 1:10 p.m., the surveyor reviewed the findings from the visit and record with the Director of Patient Services and Administrator, they acknowledged the findings and no additional information was provided. Home Visit Patient #6 was admitted to the agency 07/20/2024 with diagnoses that included hip replacement surgery, chronic kidney disease, emphysema, osteoarthritis bilateral knees, coronary heart disease, and anxiety disorder. Wound Clinic physician orders dated 01/03/25 were included in the patient’s record for a stage 3 pressure ulcer at the coccyx (tailbone) as follows: - Primary dressing: Purachol Plus Ag+ collagen- Secondary dressing: (calcium alginate) DermaGinate dressing, 2x2 - 3 X per week/30 days - Secured with (bordered dressing) Proximel, 4 x 4 - 4x4 (gauze) and tape as back up if no Proximel On 01/08/25 at 11:30 a.m., the surveyor conducted an observational home visit with the registered nurse (RN) and Home Health Aide (HHA). Upon arrival, the HHA was assisting the patient in the bathroom after a shower. The surveyor and RN remained in the living room. The RN donned clean gloves, then retrieved a plastic bag of supplies “from the wound clinic,” and explained the wound clinic staff send the remaining portions of the Purachol Plus Ag with collagen, DermaGinate and scissors home with the patient. The RN contaminated the gloves handling the plastic bag. With the contaminated gloves, the RN took the scissors and dressings from the plastic bag. Without cleansing the scissors, the RN cut small pieces of each dressing. The RN and surveyor then went into the bathroom. The surveyor observed the RN, using the same contaminated gloved index finger press the small pieces of dressing material into the wound depth. With the same contaminated gloves, the RN then opened the sterile bordered dressing and grasped the sterile pad of the cover with the thumb and index finger of the right hand, thus contaminating the cover dressing which was then transferred to the left hand and secured over the coccyx wound. According to the Journal of Wound, Ostomy and Continence Nursing: Clean technique involves meticulous handwashing, maintaining a clean environment by preparing a clean field, using clean gloves and sterile instruments, and preventing direct contamination of materials and supplies. No “sterile to sterile” rules apply. This technique may also be referred to as non-sterile. Clean technique is considered most appropriate for long-term care, home care, and some clinic settings; for patients who are not at high risk for infection; and for patients receiving routine dressings for chronic wounds such as venous ulcers, or wounds healing by secondary intention with granulation tissue.1–7 Clean vs. Sterile Dressing Techniques for Management of Chronic Wounds: A Fact Sheet. Journal of Wound, Ostomy and Continence Nursing 39(2S): p S30-S34, March/April 2012. | DOI: 10.1097/WON.0b013e3182478e06 On 01/09/25, the surveyor reviewed the agency’s “Aseptic Technique” policy, updated 02/22/13 included, “remember that anything around the clean work area is considered dirty, including personal clothing.” On 01/10/25, at 10:30 a.m., the findings were reviewed with the Administrator and Director of Patient Services who acknowledged the findings and provided no additional information. Home Visit Patient #2 was admitted to the agency on 06/16/23 with diagnoses that included infection reaction to internal prosthetic device, subacute osteomyelitis right ankle and foot, end stage heart failure, chronic kidney disease and type 2 diabetes. On 01/09/25 at 8:30 a.m., the surveyor conducted an observational home visit with the registered nurse. The Plan of Care dated 12/076/24 included orders for central line site care as follows: - Skilled nurse to perform using sterile technique weekly and as needed if dislodged. - Remove old dressing secure with tape to prevent line migration, cleanse site with chlorhexidine x 1, allow to dry. Apply new sterile securement device, bio-disc and Tegaderm to secure. Remove old clave, cleanse with alcohol x 1, apply new clave. During the visit, the surveyor observed the RN perform the central line dressing change. The RN donned clean gloves and removed the old dressing and discarded, then doffed the soiled gloves. Without performing hand hygiene, the RN donned the sterile gloves from the kit and proceeded with the completion of the dressing change. The RN failed to perform hand hygiene after doffing contaminated gloves and donning the sterile gloves. The Core Infection Prevention and Control Practices for Safe Care Delivery in All Healthcare Settings recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) include the following strong recommendations for hand hygiene in healthcare settings. Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: - Immediately before touching a patient - Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices - Before moving from work on a soiled body site to a clean body site on the same patient - After touching a patient or the patient's immediate environment - After contact with blood, body fluids, or contaminated surfaces - Immediately after glove removal Reference: https://www.cdc.gov/handhygiene/providers/guideline.html On 01/10/25, at 10:30 a.m., the findings were reviewed with the Administrator and Director of Patient Services who acknowledged the findings and provided no additional information. Home Visit Patient #4 was admitted to the agency on 11/21/24 with diagnoses of fractured femur, osteoarthritis, chronic kidney disease and type 2 diabetes. On 01/09/25, the surveyor conducted an observational home visit with the physical therapist (PT). During the visit, the PT placed their computer on the kitchen counter atop a reusable barrier. After the visit, the PT folded the barrier and tucked it beneath their arm, thereby contaminating their coat. The PT failed to disinfect the barrier. On 01/10/25 at 10:30 a.m. the record was reviewed with the Administrator and the Director of Patient Services who acknowledged the findings and provided no additional information. Home Visit Patient #1 was admitted to the agency on 10/15/24 with diagnoses of type 2 diabetes of foot ulcer, non-pressure chronic ulcer of right heel and midfoot limited to breakdown of skin, and hypertensive chronic kidney disease. On 01/08/25, the surveyor completed an observational home visit with the Registered Nurse (RN). Bag Technique The RN took the patient’s vital signs using a stethoscope, blood pressure cuff, thermometer, and pulse oximeter. The RN placed the equipment on a barrier after they were finished using them and continued the assessment. At the end of the visit, the RN put the equipment directly back in their nursing bag without cleaning them. On 1/10/24 the agency provided the policy “Nursing Bag Techniques”, dated 02/26/13, which states “[w]hen the visit is completed, reusable equipment is cleaned using alcohol and disinfectant, hands are washed, and equipment is returned to the clean area of the bag”. The RN failed to follow agency policy and clean their equipment prior to returning it to their nursing bag. Blood Draw During the visit the nurse performed a blood draw on the patient’s right upper extremity using a butterfly needle. After the RN finished the blood draw, they returned to their bag and put the used needle in the outer pocket, then turned to the surveyor and stated that they would usually use a sharps container but forgot it. On 01/17/25, the surveyor reviewed the policy, “Blood Specimen Collection Via Venipuncture”, revised 03/09/15, which included, “[d}iscard used supplies in appropriate receptacles”. According to the National Institute for Occupation Safety and Health article “Preventing Needlestick Injuries in Health Care Settings” published on the Center for Disease Control website, health care workers should plan for disposal before using needles and dispose of used needles promptly in appropriate sharps disposal containers. On 01/10/25 at 10:30 a.m. the record was reviewed with the Administrator and the Director of Patient Services who acknowledged the findings and provided no additional information. Home Visit Patient #5 was admitted to the agency on 10/25/24 with diagnoses of type 2 diabetes mellitus with other complications, acute osteomyelitis of the left ankle and foot, foot ulcer, and non-pressure chronic ulcer to left foot. On 01/09/25, the surveyor completed and observational home visit with the Registered Nurse (RN). Upon entering the home, the RN removed a re-usable barrier from their bag and placed it on the living room table. They set their nursing bag and equipment on top of the re-usable barrier. Upon completing the visit, the RN picked up the barrier and (without cleaning it) placed it back in the pocket of their nursing bag. On 1/10/24 the agency provided the policy “Nursing Bag Techniques”, revised 02/26/13, which states “[i]n the home a barrier (i.e. waxed paper, paper towel, or newspaper) is to be placed under the bag” and “[w]hen the visit is completed, reusable equipment is cleaned using alcohol and disinfectant”. On 01/10/25 at 10:30 a.m. the record was reviewed with the Administrator and the Director of Patient Services who acknowledged the findings and provided no additional information. Home Visit 1. Patient #6 was admitted to the agency 07/20/2024 with diagnoses that included hip replacement surgery, chronic kidney disease, emphysema, osteoarthritis bilateral knees, coronary heart disease, and anxiety disorder. Wound Clinic physician orders dated 01/03/25 included in the patient’s record for a stage 3 pressure ulcer at the coccyx (tailbone) as follows: - primary dressing: Purachol Plus Ag+ collagen- Secondary dressing: (calcium alginate) DermaGinate dressing, 2x2 - 3 X per week/30 days - secured with (bordered dressing) Proximel, 4 x 4 - 4x4 (gauze) and tape as back up if no Proximel On 01/08/25 at 11:30 a.m., the surveyor conducted an observational home visit with the registered nurse (RN) and home health aide (HHA). Upon arrival, the HHA was assisting the patient in the bathroom after a shower. The surveyor and RN remained in the living room. The RN applied clean gloves, then retrieved a worn plastic bag of supplies located on the kitchen table, “from the wound clinic,” and explained the wound clinic staff sent the remaining portions of the Purachol Plus Ag with collagen, DermaGinate, and scissors home with the patient. The RN contaminated the gloves handling the plastic bag. With the contaminated gloves, the RN took the scissors and dressings from the plastic bag. Without cleansing the scissors, the RN cut small pieces of each dressing. The RN and surveyor then went into the bathroom. The surveyor observed the RN, using the same contaminated gloved index finger press the small pieces of dressing material into the wound depth. With the same contaminated gloves, the RN then opened the sterile bordered dressing and grasped the sterile pad of the cover with the thumb and index finger of the right hand, thus contaminating the cover dressing which was then transferred to the left hand and secured over the coccyx wound. On 01/09/25, the surveyor reviewed the agency’s “Aseptic Technique” policy, dated 02/22/13 which included, “remember that anything around the clean work area is considered dirty, including personal clothing.” On 01/10/25, at 10:30 a.m., the findings were reviewed with the Administrator and Director of Patient Services who acknowledged the findings and provided no additional information. Home Visit 2. Patient #2 was admitted to the agency on 06/16/23 with diagnoses that included infection reaction to internal prosthetic device, subacute osteomyelitis right ankle and foot, end stage heart failure, chronic kidney disease and type 2 diabetes. On 01/09/25 at 8:30 a.m., the surveyor conducted an observational home visit with the registered nurse (RN). The Plan of Care dated 12/07/24 included orders for central line site care as follows: - Skilled nurse to perform using sterile technique weekly and as needed if dislodged. - Remove old dressing, secure with tape to prevent line migration, cleanse site with chlorhexidine x 1, allow to dry. - Apply new sterile securement device, bio-disc and Tegaderm to secure. Remove old clave, cleanse with alcohol x 1, apply new clave. During the visit, the surveyor observed the RN perform the central line dressing change. The RN applied clean gloves and removed the old dressing and discarded, then removed the soiled gloves. Without performing hand hygiene, the RN applied the sterile gloves from the kit and proceeded with the completion of the dressing change. The RN failed to perform hand hygiene after removing the contaminated gloves and applying the sterile gloves. Per the agency's "Standard Precautions" policy, dated 02/22/13, handwashing should be done "immediately after gloves are removed." On 01/10/25, at 10:30 a.m., the findings were reviewed with the Administrator and Director of Patient Services who acknowledged the findings and provided no additional information. Home Visit 3. Patient #1 was admitted to the agency on 10/15/24 with diagnoses of type 2 diabetes of foot ulcer, non-pressure chronic ulcer of right heel and midfoot limited to breakdown of skin, and hypertensive chronic kidney disease. On 01/08/25, the surveyor completed an observational home visit with the registered nurse (RN). Bag Technique The RN took the patient’s vital signs using a stethoscope, blood pressure cuff, thermometer, and pulse oximeter. The RN placed the equipment on a barrier after they were finished using them and continued the assessment. At the end of the visit, the RN put the equipment directly back in their nursing bag without cleaning them. On 1/10/24 the agency provided the policy “Nursing Bag Techniques”, dated 02/26/13, which stated “[w]hen the visit is completed, reusable equipment is cleaned using alcohol and disinfectant, hands are washed, and equipment is returned to the clean area of the bag”. The RN failed to follow agency policy and clean their equipment prior to returning it to their nursing bag. Blood Draw During the visit the nurse performed a blood draw on the patient’s right upper extremity using a butterfly needle. After the RN finished the blood draw, they activated the needle safety (a piece that covers the sharp end of the needle), returned to their bag, and put the used needle in the outer pocket, then turned to the surveyor and stated they would usually use a sharps container but forgot it. On 01/17/25, the surveyor reviewed the policy, “Blood Specimen Collection Via Venipuncture”, revised 03/09/15, which included, “[d}iscard used supplies in appropriate receptacles”. According to the National Institute for Occupation Safety and Health article “Preventing Needlestick Injuries in Health Care Settings” published on the Center for Disease Control website, health care workers should plan for disposal before using needles and dispose of used needles promptly in appropriate sharps disposal containers. On 01/10/25 at 10:30 a.m. the record was reviewed with the Administrator and the Director of Patient Services who acknowledged the findings and provided no additional information. Failure to follow accepted standards of practice for infection control has the potential for unmet patient needs and possible negative patient outcomes. Home Visit 1. Patient #6 was admitted to the agency 07/20/2024 with diagnoses that included hip replacement surgery, chronic kidney disease, emphysema, osteoarthritis bilateral knees, coronary heart disease, and anxiety disorder. Wound Clinic physician orders dated 01/03/25 for a stage 3 pressure ulcer at the coccyx (tailbone) as follows: - primary dressing: Purachol Plus Ag+ collagen- Secondary dressing: (calcium alginate) DermaGinate dressing, 2x2 - 3 X per week/30 days - secured with (bordered dressing) Proximel, 4 x 4 - 4x4 (gauze) and tape as back up if no Proximel On 01/08/25 at 11:30 a.m., the surveyor conducted an observational home visit with the registered nurse (RN) and home health aide (HHA). Upon arrival, the HHA was assisting the patient in the bathroom after a shower. The surveyor and RN remained in the living room. The RN applied clean gloves, then retrieved a worn plastic bag of supplies located on the kitchen table, and explained the wound clinic staff sent the remaining supplies home with the patient. The RN contaminated the clean gloves by handling the plastic bag. With the contaminated gloves, the RN took the scissors and dressings from the plastic bag. Without cleansing the scissors, the RN cut small pieces of each dressing. The RN and surveyor then went into the bathroom. The surveyor observed the RN, using the same contaminated gloves, use thier index finger to press the small pieces of dressing material into the wound depth. With those same contaminated gloves, the RN then opened the sterile bordered dressing and grasped the sterile pad of the cover with the thumb and index finger of the right hand, thus contaminating the cover dressing, which was then transferred to the left hand and secured over the coccyx wound. On 01/09/25, the surveyor reviewed the agency’s “Aseptic Technique” policy, dated 02/22/13 which included, “remember that anything around the clean work area is considered dirty, including personal clothing.” On 01/10/25, at 10:30 a.m., the findings were reviewed with the Administrator and Director of Patient Services who acknowledged the findings and provided no additional information. Home Visit 2. Patient #2 was admitted to the agency on 06/16/23 with diagnoses that included infection reaction to internal prosthetic device, subacute osteomyelitis right ankle and foot, end stage heart failure, chronic kidney disease and type 2 diabetes. On 01/09/25 at 8:30 a.m., the surveyor conducted an observational home visit with the registered nurse (RN). The Plan of Care dated 12/07/24 included orders for central line site care as follows: - Skilled nurse to perform using sterile technique weekly and as needed if dislodged. - Remove old dressing, secure with tape to prevent line migration, cleanse site with chlorhexidine x 1, allow to dry. - Apply new sterile securement device, bio-disc and Tegaderm to secure. Remove old clave, cleanse with alcohol x 1, apply new clave. During the visit, the surveyor observed the RN perform the central line dressing change. The RN applied clean gloves and removed the old dressing and discarded, then removed the soiled gloves. Without performing hand hygiene, the RN applied the sterile gloves from the kit and proceeded with the completion of the dressing change. The RN failed to perform hand hygiene after removing the contaminated gloves and applying the sterile gloves. Per the agency's "Standard Precautions" policy, dated 02/22/13, handwashing should be done "immediately after gloves are removed." On 01/10/25, at 10:30 a.m., the findings were reviewed with the Administrator and Director of Patient Services who acknowledged the findings and provided no additional information. Home Visit 3. Patient #1 was admitted to the agency on 10/15/24 with diagnoses of type 2 diabetes of foot ulcer, non-pressure chronic ulcer of right heel and midfoot limited to breakdown of skin, and hypertensive chronic kidney disease. On 01/08/25, the surveyor completed an observational home visit with the registered nurse (RN). Bag Technique The RN took the patient’s vital signs using a stethoscope, blood pressure cuff, thermometer, and pulse oximeter. The RN placed the equipment on a barrier after they were finished using them and continued the assessment. At the end of the visit, the RN put the equipment directly back in their nursing bag without cleaning them. On 1/10/24 the agency provided the policy “Nursing Bag Techniques”, dated 02/26/13, which stated “[w]hen the visit is completed, reusable equipment is cleaned using alcohol and disinfectant, hands are washed, and equipment is returned to the clean area of the bag”. The RN failed to follow agency policy and clean their equipment prior to returning it to their nursing bag. Blood Draw During the visit the nurse performed a blood draw on the patient’s right upper extremity using a butterfly needle. After the RN finished the blood draw, they activated the needle safety (a piece that covers the sharp end of the needle), returned to their bag, and put the used needle in the outer pocket, then turned to the surveyor and stated they would usually use a sharps container but forgot it. On 01/17/25, the surveyor reviewed the policy, “Blood Specimen Collection Via Venipuncture”, revised 03/09/15, which included, “[d}iscard used supplies in appropriate receptacles”. According to the National Institute for Occupation Safety and Health article “Preventing Needlestick Injuries in Health Care Settings” published on the Center for Disease Control website, health care workers should plan for disposal before using needles and dispose of used needles promptly in appropriate sharps disposal containers. On 01/10/25 at 10:30 a.m. the record was reviewed with the Administrator and the Director of Patient Services who acknowledged the findings and provided no additional information. Failure to follow accepted standards of practice for infection control has the potential for unmet patient needs and possible negative patient outcomes.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on observational home visits, review of clinical records, and interviews with the Administrator and Director of Patient Services, it was determined in 1 of 1 records for patients receiving home health aide services (patient #6) the nurse failed to develop complete and accurate aide written instructions. Evidence as follows: Home Visit 1. Patient #6 was admitted to the agency 07/20/2024 with diagnoses that included fall with hip fracture and hip replacement surgery, chronic kidney disease, emphysema, osteoarthritis bilateral knees, coronary heart disease, and anxiety disorder. The Plan of Care (POC) dated 11/17/24 included: - aide visits 5 times per week for 8 weeks and PRN (as needed) - aspirin, enteric coated 81 mg daily for blood thinner - follow nutritious diet, high protein diet (meat, fish, eggs, cheese, cottage cheese, milk, beans, nuts, and peanut butter The aide written instructions included: - prepare meals, regular diet: start date 07/20/24 - standard precautions: start date 07/20/24 The aide written instructions failed to include: - high protein diet - bleeding precautions On 01/10/25, at 10:30 a.m., the findings were reviewed with the Administrator and Director of Patient Services who acknowledged the findings and provided no additional information. Failure to ensure home health aide care plans are complete and contain all pertinent information has the potential for unmet patient needs and negative patient outcomes.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on observational home visits, review of clinical records, and interviews with the patient, registered nurse, and home health aide, it was determined in 1 of 1 record for patients receiving home health aide services (patient #6) the nurse failed to ensure the aide performed duties permitted under state law and consistent with home health aide training. Evidence as follows: Home Visit 1. Patient #6 was admitted to the agency 07/20/2024 with diagnoses that included fall with hip fracture and replacement surgery, chronic kidney disease, emphysema, osteoarthritis bilateral knees, coronary heart disease, and anxiety disorder. Wound Clinic physician orders dated 01/03/25 for a stage 3 pressure ulcer at the coccyx (tailbone) were as follows: - May shower with protection but do not get wound dressing(s) wet. Protect with water repellant cover (for example, large plastic bag). - May shower without wound dressing if the dressing is being changed. - Primary dressing: Purachol Plus Ag+ collagen. - Secondary dressing: (calcium alginate) DermaGinate dressing, 2x2. - 3 X per week/30 days. - Secured with (bordered dressing) Proximel, 4 x 4. - 4x4 (gauze) and tape as back up if no Proximel. On 01/08/25 at 11:30 a.m., the surveyor conducted an observational home visit with the registered nurse (RN) and home health aide (HHA). After the visit, the surveyor interviewed the patient who stated it was the aide who applied the dressing to the coccyx wound after showering on the days the RN did not have a visit scheduled (Tuesdays and Thursdays). The patient visited the Wound Clinic on Fridays. On 01/09/25 at 12:12 p.m., the surveyor conducted a phone interview with the HHA who confirmed they applied a new dressing after the daily shower and did not ever need to cover an existing dressing as the patient removed it prior to showering. The surveyor inquired if wound care training had occurred, and the HHA replied training had occurred via “[RN] and the Wound Care Clinic,” and confirmed they had never accompanied the patient to the Clinic. A printed copy of the wound care clinic orders was reviewed in the patient’s home. On 01/09/25 at 11:10 a.m., the surveyor conducted a phone interview with the RN who stated they had trained [HHA] on wound dressing management. The RN stated the HHA was taught to apply the bordered dressing “until I can get there.” Instructing a HHA to apply a bandage to a wound is non-permissible per the "Home Health Aide Scope of Tasks, Permissible and Non-Permissible Activities, New York State Department of Health, March 2009, which only allows HHAs to change dressings involving clean procedure for stable surface wounds.” On 01/10/25, at 10:30 a.m., the findings were reviewed with the Administrator and Director of Patient Services who acknowledged the findings and provided no additional information. Failure to ensure that home health aides perform duties within their scope of practice has the potential for negative patient outcomes.

This Statement of Deficiencies report is the result of a recertification survey conducted 01/25/22 - 02/07/22. The following information was reviewed on 01/19/22, during the pre-survey preparation: participation in the required emergency drills, and accuracy of contact information in the Health Commerce System. The following information was reviewed during the survey: the agency's emergency preparedness policies and procedures, the emergency patient roster and staff call down list. Interviews were conducted with the Administrator and Director of Patient Services. No federal deficiencies were cited. State Deficiency J 1156 Governing Authority was cited.

The following statement of deficiencies report represents the results of a standard recertification survey of Health Services of Northern New York, Inc. Certified Home Health Agency conducted 01/25/22 through 02/07/22. On 01/26/22, deficiencies were identified in level 1 standards G 574 Plan of care must include the following and G 798 Home health aide assignments and duties. As a result, the survey was expanded to partial extended survey. The survey consisted of a review of 17 clinical records including 5 discharge records, 10 personnel records for professional and paraprofessional personnel, 2 contracts, and 7 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 Log. Pre-survey activities consisted of review 01/19-01/24/2022 of the agency's Health Commerce System account, Home Care Worker Registry, Criminal History Record Check, Certification and Survey Provider Enhanced Reports (CASPER) for the period 11/01/20 to 10/31/21, and the agency's compliance with report submissions for the 2019 statistical report and emergency drill conducted June 11-13, 2019. The Administrator, Director of Patient Services and nursing staff were interviewed. Findings were reviewed at the exit conference on 02/07/22. Federal Standard Level deficiencies cited: G 528 Comprehensive assessment must include the patient's current health, psychosocial, functional and cognitive status; G 574 Plan of care must include the following; and G 798 Home health aide assignments and duties. State deficiencies cited: J 1156, 1260 and 1276 Governing Authority; J 1412, 1426 and 1428 Personnel. Criminal History Background Check deficiencies cited: R 610 General Requirements; R 1022 Responsibilities of Providers Required Notification.

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 a review of clinical records, observational home visits, and interviews with the Director of Patient Services (DPS), it was determined in 5 out of 17 records, (patients # 2, 4, 6, 13 and 14) comprehensive assessments were not of sufficient scope to ensure that all patients' needs were identified. Evidence was as follows: Patient #13 was admitted to the agency on 05/12/21 with diagnoses of cerebral palsy, seizure disorder with Dilantin toxicity, and hypertension. The 04/20/21 hospital history and physical revealed the patient had a history of repeated falls, the patient felt it was due to Dilantin (anti-seizure medication) and didn’t want to take it. The Dilantin level was noted to be 26.5 ug/ml (10-20 ug/ml), above the therapeutic range. The neurologist had decreased Dilantin from 100 mg three times daily to two times and did not want to make an abrupt change in medication due to the risk of recurrent seizures. The patient was discharged from a skilled nursing facility on 05/11/21 following a rehabilitation stay. On 05/12/21 the registered nurse (RN) visited the patient for the initial assessment and erroneously documented the patient had digoxin toxicity. The patient was not and had not been prescribed this cardiac medication. The RN failed to assess the patient’s history of seizures, including the date of the last seizure and signs and symptoms the patient experienced. On 01/28/22 at 12:30 pm the surveyor reviewed the record with the Administrator and DPS. They acknowledged the findings and provided no additional information. HV Patient # 2 was admitted to the agency 01/21/22 with diagnoses of chronic venous hypertension with ulcer of lower extremity, type 2 diabetes, hypertension, morbid obesity, and recent cerebral infarction. The 01/21/22 certification and plan of care included full cardiopulmonary (CP) assessment to be done once per week; all other visits temperature and dressing change only. On 01/21/22 the registered nurse (RN) visited the patient for the initial comprehensive assessment. The patient was experiencing mild slurred speech, blood pressure was 165/122 and 181/129, the RN called 911. Upon response Emergency Medical Services (EMS) determined not to transport patient to hospital. The RN continued assessment, patient’s speech became slurred with right sided facial droop, right arm weakness and drop. The RN again called 911 and patient was transported and admitted to the hospital. On 01/25/22 the RN visited the patient for a resumption of care assessment. The patient’s blood pressure was 169/95. The RN documented the patient would be seen twice weekly for wound vac dressing changes, CP assessments and monitoring. Review of agency policy “Cardiopulmonary Assessment” dated 01/24/13 included: - a comprehensive cardiopulmonary assessment will be completed at the time of the initial nursing assessment and each assessment visit subsequently - the physical assessment will include an assessment of cardiac and respiratory symptoms: vital signs including temperature, blood pressure, apical/peripheral pulses, and respirations; and auscultating lung sounds On 01/26/22 the surveyor completed an observational visit with the RN. The RN failed to assess the patient’s blood pressure, apical pulse, and respirations/lung sounds. On 01/28/22 at 1 p.m. the medical record was reviewed with the Administrator and DPS. They acknowledged the findings and provided no additional information. HV Patient # 4 was admitted to the agency 10/28/21 with diagnoses of hypertension, acute kidney failure and cerebral palsy. On 01/06/22 the RN visited the patient for a resumption of care following hospitalization for a urinary tract infection and sepsis. The patient was discharged from the hospital 01/05/22 with a peripherally inserted central catheter (PICC) for IV antibiotics through 01/13/22. Hospital discharge paperwork documented the total length of the PICC was 15 cm. On 01/07/22 the RN visited the patient and documented the PICC line came out and the patient was returning to the hospital for reinsertion. There was no evidence the RN assessed the catheter site or measured the length of the removed/expelled PICC. The hospital documented the total length of the PICC inserted on 01/07/22 was 15 cm. On 01/13/22, upon completion of antibiotic therapy, the RN removed the PICC line. There was no evidence the RN assessed the catheter site or measured the length of the PICC upon removal. On 01/28/22 at 1 p.m. the medical record was reviewed with the Administrator and DPS. The DPS stated she spoke to the RN who said she did measure the PICC line upon removal but failed to document it. No additional information was provided. Patient # 6 was admitted to the agency 01/19/22 with diagnoses of type 2 diabetes, chronic kidney disease, chronic obstructive pulmonary disease, and peripheral vascular angioplasty with implants and graphs. The registered nurse (RN) failed to perform a comprehensive assessment of the patient’s wounds and blood glucose readings. The 01/19/22 certification and plan of care included: - skilled nursing visits 3 times per week to provide wound care - weekly wound measurements - patient to test blood sugar twice daily and RN to assess blood sugar at visits On 01/19/22 the registered nurse (RN) visited the patient to complete an initial comprehensive assessment and documented the patient had 5 wounds / surgical incisions. The RN documented wound measurements of wound # 1, and the number of staples or sutures present on wounds # 2, 3, 4 and 5, however the RN failed to measure wounds # 2 - 5. On 01/26/22 the RN documented wound measurements for wounds # 1, 4 and 5, and documented the number of staples or steri-strips on wounds # 2 and 3, however the RN failed to measure wounds # 2 - 3. There was no evidence the RN assessed the blood sugars during visits on 01/21/22 or 01/26/22. On 01/28/22 at 1 p.m. the medical record was reviewed with the Administrator and DPS. They acknowledged the findings and provided no additional information. Patient # 14 was admitted to the agency 06/19/21 with diagnoses of cholecystitis, gastroparesis, type 1 diabetes and chronic kidney disease. On 06/19/21 the registered nurse (RN) visited the patient for an initial comprehensive assessment and documented the patient had a diabetic foot score of zero. On 06/25/21 the RN visited and documented the patient had a wound on left heel which was present for several months and being treated by the wound care clinic. On 06/19/21 the RN failed to perform a complete foot assessment adequate to identify the patient’s wound. On 02/01/22 at 3 p.m. the medical record was reviewed with the Administrator and DPS. They acknowledged the findings and provided no additional information. Failure to perform complete and accurate comprehensive assessments has the potential for unmet patient needs and possible negative patient outcomes.

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 a review of clinical records, observational home visits, and interviews with the Director of Patient Services (DPS), it was determined in 6 out of 17 records (patients # 2, 4, 5, 7, 9 and 13) the registered nurse failed to develop individualized plans of care that were complete, accurate, and addressed the total needs of the patients. Evidence was as follows: HV Patient #5 was admitted to the agency on 11/11/21 with diagnoses of stroke with left side hemiplegia (paralysis), difficulty swallowing with gastrostomy (stomach) feeding tube (G-tube), type 2 diabetes, hypertension, and heart disease. The 11/10/21 skilled nursing facility (SNF) discharge instructions included the following: -crush medications and give in pudding -Jevity 1.5 calorie/ml liquid, 360 cc at bedtime, flush feeding tube with 50 cc of water in the morning and at bedtime, check residual prior to feeding and hold if 250 cc or greater. -level 4 diet (pureed) with thin liquids -keep the head of the bed up 45 degrees The 11/11/21 Plan of Care failed to include aspiration precautions and keeping head of bed 45 degrees, crushing of medications and method of administration. The plan of care listed the diet as no concentrated sweets with no modification to pureed diet. On 01/05/22 the RN documented in a communication note the patient had plans to have the G-tube removed, however, required a swallow test done prior and the RN was awaiting a return call from the office. On 01/27/22 at 11:30 am the surveyor conducted an observational home visit with the physical therapy assistant (PTA). Following the visit, the surveyor interviewed the caregiver who stated the patient had a history of aspiration pneumonia two times, had a swallow evaluation the previous week and was now on nectar thickened liquids. The caregiver stated medications were crushed and administered in apple sauce. The clinical record included an RN visit note from 01/27/22 at 9:45am. There was no documentation of the stated swallowing evaluation and the new recommendation for nectar thick liquid and the RN failed to update the plan of care. On 01/28/22 at 12:30 pm the surveyor reviewed the record with the Administrator and DPS. They acknowledged the findings and provided no additional information. Patient #7 was admitted to the agency on 09/24/21 with diagnoses of foot ulcer and diabetes. The 09/23/21 referral from the wound care center included the patient was taking Lantus (long-acting insulin) 34 units at bedtime and Admelog (short-acting insulin) 8-20 units as directed. On 09/24/21 the RN visited the patient for the initial assessment and documented the patient was taking only the Lantus insulin. There was no evidence the medications were clarified with the primary care provider (PCP) or wound care center. The record included 01/10/22 orders for Admelog 8-20 units 3 times a day as needed for blood sugars above 200 and Trulicity Pen 1.5mg/O.5 ml once a week. The revised order included Admelog 6 units for blood sugar of 110-120 and 9 units for blood sugar of greater than 120. On 01/28/22 the surveyor conducted an observational home visit with an RN. The patient’s plan of care medication list in the home included the Admelog with instructions to take 6 units for blood sugar of 110-120 and 9 units for blood sugar of greater than 120, and Trulicity. During the visit the patient observed a 12/27/21 written home health aide care plan in the home, the patient stated he wanted an aide but was told he was on a wait list. On 02/01/22 at 10:40 am the surveyor interviewed the RN regarding when the medications were implemented, and the RN stated she was newly assigned the patient and during a visit discovered them on the counter in the patient’s home while using the kitchen sink for handwashing. The RN then asked the patient about the medications and called the PCP to verify them. On 02/01/22 11:15 am the surveyor interviewed the patient who stated he had been taking Admelog for a long time although lately has required less. The patient also stated he had been taking Trulicity for 3-4 years. On 02/01/22 at 3:30 pm the surveyor reviewed the record with the Administrator and DPS. They acknowledged the findings and provided no additional information. Patient #9 was admitted to the agency on 12/03/21 for physical therapy (PT) and home health aide (HHA) services following surgical repair of the right shoulder. On 12/03/21 the RN performed the start of care assessment and documented the patient had a non-removable dressing to the shoulder which was to be removed by the RN on 12/04/21. The patient was having difficulties with performing activities of daily living (ADLs) due to the right shoulder being immobile. On 12/03/21 the PT performed an evaluation visit and documented the patient had the right arm in a sling. On 12/06/21 the PT documented in a communication note a telephone call to the physician’s office. The physician gave verbal orders for pendulum exercises with the sling on for 6 weeks, the patient was allowed to take the sling off for showers as long as the patient did not raise the arm sideways away from the body, and to cover the incision with a Band-Aid. The 12/03/21 Plan of Care did not include any orders regarding the use of the sling and there were no additional verbal orders. On 02/01/22 at 3:30 pm the surveyor reviewed the record with the Administrator and DPS. They acknowledged the findings and provided no additional information. Patient #13 was admitted to the agency on 05/12/21 with diagnoses of cerebral palsy, seizure disorder with Dilantin toxicity, and hypertension. The 04/20/21 hospital history and physical revealed the patient had a history of repeated falls and the patient felt it was due to Dilantin and didn’t want to take it. The neurologist had decreased Dilantin from 100 mg three times daily to two times and did not want to make an abrupt change in medication due to the risk of recurrent seizures. On 05/12/21 the RN visited the patient for the initial assessment and documented the patient had digoxin toxicity. The patient was not and had not been prescribed this cardiac medication. The 05/12/21 Plan of Care failed to include a plan to monitor for seizures and seizure precautions. On 01/28/22 at 12:30 pm the surveyor reviewed the record with the Administrator and DPS. They acknowledged the findings and provided no additional information. Patient # 2 was admitted to the agency 01/21/22 with diagnoses of chronic venous hypertension with ulcer of lower extremity, type 2 diabetes, hypertension, morbid obesity, and recent cerebral infarction. The 01/21/22 certification and plan of care included: -wound care / wound vac dressing changes twice weekly by agency nurse and once weekly at wound care clinic -full cardiopulmonary (CP) assessment to be done once per week; all other visits temperature and dressing change only -client monitors blood sugars as needed (PRN); notify out of range 80-100 On 01/21/22 the registered nurse (RN) visited the patient for the initial comprehensive assessment. The patient was demonstrating signs/symptoms of a cerebral vascular event and his blood pressure, checked twice, was 165/122 and 181/129. The RN called 911 and the patient was transported and admitted to the hospital. On 01/25/22 the RN visited the patient for a resumption of care assessment. The patient’s blood pressure at that visit was 169/95. The RN documented the patient would be seen twice weekly for wound vac dressing changes, CP assessments and monitoring. The RN failed to update the plan of care to include CP assessments at every visit, and to include what would necessitate the patient to monitor blood sugar PRN. On 01/28/22 at 1 p.m. the medical record was reviewed with the Administrator and DPS. They acknowledged the findings and provided no additional information. HV Patient # 4 was admitted to the agency 10/28/21 with diagnoses of hypertension, acute kidney failure and cerebral palsy. The 10/20/21 certification and plan of care included registered nursing visits once weekly for nephrostomy tube dressing changes and assessment. The plan of care was incomplete as follows: Nephrostomy Dressing Site On 10/28/21 the registered nurse (RN) visited the patient for the initial comprehensive assessment and documented the patient was educated to keep the nephrostomy dressing sites dry. The RN failed to include an intervention in the plan of care regarding how the patient was to keep the sites dry including whether the patient was to shower or sponge bathe. On 01/27/22 the surveyor completed an observational visit with the RN. The surveyor observed that the dressing had come loose at the top. The patient stated that he had just showered and it must’ve gotten wet. Retinal Surgery / Eye Drops On 11/24/21 the RN documented the patient was scheduled for retinal detachment surgery 11/30/21. The RN failed to communicate with the physician to update the plan of care with interventions related to the eye surgery such as bending/lifting precautions or prescribed eye drops. During the observational home visit the RN reviewed the patient’s medications and noted 2 bottles of eye drops (brimonidine and dorzolamide). The RN called the ophthalmologist during the visit to obtain orders and update the plan of care. Following the visit, the surveyor interviewed the patient who stated the eye drops were initially ordered immediately following surgery, then reordered again just a few days prior to the visit. COVID-19 Precautions On 12/16/21 the RN documented the patient was diagnosed with COVID-19. The RN failed to update the plan of care to include COVID-19 precautions (e.g. droplet precautions and required personal protective equipment). On 01/28/22 at 1 p.m. the medical record was reviewed with the Administrator and DPS. They acknowledged the findings and provided no additional information. Failure to ensure that a comprehensive individualized plan of care is developed has the potential for unmet patient needs.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on review of clinical records for 5 patients receiving home health aide services (patients # 5, 8, 9, 11 and 13) and interviews with the Director of Patient Services (DPS), it was determined for 3 out of 5 patients (# 5, 8 and 9) the registered nurse failed to develop complete and accurate aide written instructions. Evidence was as follows: Patient #5 was admitted to the agency on 11/11/21 with diagnoses of stroke with left side hemiplegia (paralysis), difficulty swallowing with gastrostomy (stomach) feeding tube (G-tube), type 2 diabetes, hypertension, and heart disease. The 11/11/21 Plan of Care included Home Health Aide (HHA) services twice weekly. The patient received G-tube feedings, Jevity 360 ml nightly. The 11/11/21 Home Health Aide (HHA) care plan failed to include instructions regarding aspiration precautions, positioning to prevent aspiration and alert the HHA of the presence of the gastrostomy tube. The medication list included aspirin 81 mg daily and the HHA care plan failed to include bleeding precautions. On 01/28/22 at 12:30 pm the surveyor reviewed the record with the Administrator and DPS. They acknowledged the findings and provided no additional information. Patient #9 was admitted to the agency on 12/03/21 for physical therapy (PT) and home health aide (HHA) services following surgical repair of the right shoulder. On 12/03/21 the registered nurse (RN) performed the start of care assessment and documented the patient had a non-removable dressing to the shoulder which was to be removed by the RN on 12/04/21. The patient was having difficulties with performing activities of daily living (ADLs) due to the right shoulder being immobile. The 12/03/21 Plan of Care included HHA services twice weekly to assist with showers and shampoo hair. On 12/06/21 the PT documented in a communication note a telephone call to the physician’s office. The physician gave verbal orders the patient was allowed to take the sling off for showers as long as the patient did not raise the arm sideways away from the body, and to cover the incision with a Band-Aid. The 12/03/21 HHA care plan instructed the aide to assist the patient with a shower every visit and failed to include any instructions regarding the sling including removal for showers and the presence of the incision. On 02/01/22 at 3:30 pm the surveyor reviewed the record with the Administrator and DPS. They acknowledged the findings and provided no additional information. Patient # 8 was admitted to the agency 12/01/21 with diagnoses of acute respiratory failure, encephalopathy, type 2 diabetes, and oxygen dependence. The 12/01/21 plan of care included: - home health aide (HHA) twice weekly - aspirin 81 mg (blood thinner) for clot prevention On 12/01/21 the physical therapist (PT) documented in the initial PT assessment that the patient needed assistance to put on bilateral ankle foot orthotics (AFOs). The aide care plan failed to include: - diabetic precautions - bleeding precautions - assistance with AFOs On 02/01/22 at 3 p.m. the medical record was reviewed with the Administrator and DPS. They acknowledged the findings and provided no additional information. Failure to ensure that home health aide care plans are complete has the potential for unmet patient needs and possible negative patient outcomes.