Every finding on record at Hudson Valley Care Partners, LLC

The following statement of deficiencies represents the results of a partial extended recertification survey of Hudson Valley Certified Home Health Agency, located at 266 Vineyard Avenue, Highland NY 12528, conducted on 06/7/2021 through 6/11/2021. A standard recertification survey was initiated on 06/7/2021. Deficient practices were identified with high priority standards in Plan Of Care resulting in a partial extended survey. The Agency has a total active census of seventy-eight (78) patients, including a Long Term Home Health Care Waiver Program with an active patient list of seventeen (17) patients. The survey consisted of a review of nine (9) clinical records. four (4) active patient records identified as Patients: #2,#3,#5, and #8; three (3) active patients with observational home visits identified as Patients: #1, # 4, and # 7; two (2) discharge records identified as Patients: #6 and # 9; ten (10) personnel records for professional and paraprofessional personnel: identified as Employees #1, #2, #3, #4,#5, #6, #7, #8 , #9 and # 10; Three contracts (3) contracts; Review of pertinent policies and procedures; Quality Improvement meeting minutes for the past 12 months; agency's admission packet; Patients Potentially Avoidable Events; the Emergency Preparedness Plan; Complaint Log; Pre-survey activities consisted of reviews on 5/28/2021 of the agency's Health Commerce System account, Home Care Registry, IQIES ( Internet Qualify Improvement and Evaluation System) Event Outcome Report for the period 05/1/2019 to 04/30/2020, and the agency's compliance with report submission for the 2019 statistical report and the Emergency drill conducted 6/11/19 through 11/13/2019. The Administrator/ Director of Patient Services was interviewed. Findings were reviewed at the exit conference on 06/11/2021. The following deficiencies are identified as a result of the survey: G- 0536- A Review Of All Current Medications G- 0574 - Plan Of Care Must Include The Following G- 0578 - Conformance With Physicians Orders G- 0580 - Only as ordered By A Physician G- 0754 - A Qualified Hh Aide Successfully Completed G - 1022- Discharge and Transfer Summaries J- 0744 - Clinical Records J - 1108 - Governing Authority J- 1156 - Governing Authority J- 1168 - Governing Authority J - 1260 - Governing Authority J - 1412 - Personnel J - 1426 - Personnel J - 1432 - Personnel J - 1476 - Personnel J - 1512 - Records and Reports L - 0001- Unacceptable Infection Ctl Procedure W - 0614 - Responsibilities of Home Care Svcs Entities R - 1020 - Responsibilities of Providers; Required Notification R - 1034 - Responsibilities of Providers; Required Notification

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record reviews and staff interview the agency failed to review all medications the Patient is currently using in order to reconcile all medications for duplicate therapy or missing medication orders . This was evident for five (5) of nine (9) patient care records reviewed.(Patients #1, #2, #3, # 4 and # 7). Failure to review all medications the patient is currently using in order to reconcile all medications for duplicate or missing medication orders have the potential for negative patient outcomes. The findings are: 1. Patient # 4 has a start of care date of 5/20/2021 with diagnosis that include Pressure Ulcer of Right buttock Stage 2, Chronic Pain due to Trauma, Generalized Anxiety Disorder as documented on the " Home Health Certification and Plan Of Care" for the certification period of 5/20/21 to 7/18/21. The " Home Health Certification and Plan Of Care" for the certification period of 5/20/21 to 7/18/21 document: "Orders for Discipline and Treatments: Skilled Nurse ( SN) once a week for one week, 3 as needed adjustments in Plan Of Care, twice a week for 8 weeks. Assess compliance with medication regimen. Medications: Aspirin Delayed release 325 mg via mouth ( PO) daily, Baclofen tablet 20 mg three times a day ( TID) PO, Lexapro 20 mg tablet PO daily, Lyrica 150 mg TID, PO, Macrodantin 50 mg at bedtime (HS), Methadone HCL 5 mg tablet as directed one tablet in the morning, one tablet at noon, two tablets HS, Omeprazole delayed release 20 mg PO daily, Oxycodone HCL 10 mg tablet every six hours as needed, Xanax 0.25 mg tablet as needed PO TID, Miralax Powder one to two capfull PO every morning, Senokot 8.6 mg two tablet PO every morning, Colace 100 mg capsule TID PO, Lasix 40 mg tablet PO daily, Wellbutrin SR extended release 150 mg every 12 hours PO, Metamucil Plus Calcium two capsules daily PO, Vitamin E 400 units daily PO, Flaxseed Oil 1200 units PO daily, Culturelle 10B cell one capsule twice a day PO, Fleet Enema rectal enema 7-19 gm/118 ml as needed per rectum daily, Bisacodyl EC delayed release 5 mg ,2-3 tablet PO every morning, Vitamin D3 1000 unit daily PO." On 6/10/21 at 9:30 AM, during an observational home visit, a review of the medications in the home identified the following discrepancies: A bottle labeled Methadone HCL with a date filled 5/24/21 document Methadone HCL 5 mg one tablet in the morning, one tablet at noon, one tablet at 9 PM, A bottle labeled Colace with a date filled on 4/19/21 document Colace 100 mg twice a day. A Bottle labeled Lactulose 30 ml twice a day PO was not on the Plan Of Care, a bottle labeled Oxycodone with a date filled on 4/23/21 document 10 mg one tablet every 12 hours as needed. The last documented Skilled Nursing visit was on 6/7/21. There is no documented evidence of an interim order for Lactulose on the Plan Of Care. There is no documented evidence the medications were reviewed and reconciled. On 6/10/21 at 1:30 PM, the Director Of Nursing was interviewed and did not provide an explanation for the above findings. 5. Patient #7 has a start of care date of 12/22/2020 with diagnosis that include Hypertension, Hyperlipidemia, Diabetes Mellitus, and chronic left heel wound documented on the " Home Certification and Plan of Care" for the Certification Period of 4/21/2021 to 6/19/2021. The " Home Health Certification and Plan of Care" for the Certification Period of 4/21/2021 to 6/19/2021 documents "Medication: Clopidogrel Bisulfate 75 mg by mouth daily, Voltaren gel 1% ointment 2 x daily; Skilled Nurse (SN) 2x week x 9 weeks, 3 PRN, adjustment to POC; Assess patients response to interventions for pain; Assess need for noninvasive methods of pain". During a home visit conducted on 6/8/2021 at 11:00 AM, Clopidogrel not present in the home; patient states that he is not on Clopidogrel. The record documents the following skilled nursing visits: 5/27/2021, 5/28/2021, 5/31/201 and 6/3/2021. There is no documented evidence skilled nursing perform a medication review or reconciliation during each visit. During an interview with the Administrator on 6/9/21 1:00 PM, the Administrator did not provide an explanation for the above findings. 2. Patient #1 has a start of care date of 4/21/21 with diagnoses of Acute Respiratory Failure and Cardiac Disease as documented on the "Home Health Certification and Plan of Care" dated 4/21/21 through 6/19/21. The "Home Health Certification and Plan of Care" dated 4/21/21 through 6/19/21 documents: "Skilled Nurse (SN) visits two (2) times a week for three (3) weeks than one (1) time a week for six (6) weeks and medications include: Oxycodone HCL 15 mg one tablet every six (6) hours as needed for pain, Diazepam 5 mg one tablet daily, Anoro Ellipta 62.5 mcg- 25 mcg one inhalation daily, Docusate Sodium 250 mg one capsule daily, Ventolin inhaler one (1) inhalation every four (4) hours." During a home visit conducted on 6/8/21, the Nurse reviewed the Patient's medications. The Patient's family member stated that she is the person who administers the medications to the Patient. The following was found during the medication review: Docusate Sodium bottle is 100 mg and the family member states the Patient takes this "as needed" not every day; There was no Anoro Ellipta in the home and the family member states "that was discontinued months ago; the Ventolin inhaler is being used every four hours as needed for shortness of breath. The family member states the patient is also taking Metamucil as needed and Stilolto Respimat inhaler one (1) inhalation daily as needed for shortness of breath. A request was made to view the bottle for the Oxycodone. The family member would not allow the Nurse to view the current bottle but provided an empty bottle and stated that the Patient is "taking it every four (4) hours". The SN note dated 4/26/21 documents the Patient took Immodium. A review of the record and Medication Profile with a printed date of 6/7/21, the Profile lacks documentation to include the Immodium, Stilolto Respimat. Metamucil and the frequency change for the Ventolin inhaler. During an interview with the Nurse on 6/8/21 at 12:00 PM, the Nurse did not provide an explanation for the above. 3. Patient #2 has a start of care date of 12/10/20 with diagnoses of Congestive Heart Failure and Chronic Obstructive Pulmonary Disease as documented on the "Home Health Certification and Plan of Care" dated 4/9/21 through 6/7/21. The "Home Health Certification and Plan of Care" dated 4/9/21 through 6/7/21 documents" SN visits two (2) times a week for nine (9) weeks for assessment; Physical Therapy (PT) visits two (2) times a week for eight (8) weeks." The PT documents on 4/14/21 the Patient has "pain of a 9 throughout her body and is using Prednisone for pain relief." The SN note dated 4/23/21 documents the Patient is using Lidocaine patches to the shoulders to relieve pain. The SN note dated 4/30/21 documents the Patient is taking Tylenol for shoulder pain. The SN note dated 5/21/21 documents the Patient is taking Tramadol 50 mg three (3) times a day for pain. The record lacks documented evidence of interim orders for the Prednisone, Lidocaine patch, Tylenol and Tramadol. The Medication Profile printed 6/9/21 lacks documented evidence the Profile was revised to include the Prednisone, Lidocaine patch, Tylenol and Tramadol. During an interview with the Administrator on 6/9/21 at 1:00 PM, the Administrator did not provide an explanation for the above findings. 4. Patient #3 has a start of care date of 7/20/15 with diagnoses of Diabetes Mellitus Type Two, Hypertension and Cerebral Vascular Accident as per the "Home Health Certification and Plan of Care" dated 4/19/21 through 6/17/21. The "Home Health Certification and Plan of Care" dated 4/19/21 through 6/17/21 documents: "SN every two (2) weeks for for eight (8) weeks for assessment and to pre-pour medications." The SN note dated 4/29/21 documents the Patient "needs renewal of Ketoconazole". A review of the record and the Medication Profile with a printed date of 6/7/21 lacks documented evidence for the Ketoconazole with dosage, placement and frequency for use. During an interview with the Administrator on 6/9/21 1:00 PM, the Administrator did not provide an explanation for the above findings.

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 may choose to include. This ELEMENT is not met as evidenced by: 2. Patient #1 has a start of care date of 4/21/21 with diagnoses of Acute Respiratory Failure and Cardiac Disease as documented on the "Home Health Certification and Plan of Care" dated 4/21/21 through 6/19/21. The "Home Health Certification and Plan of Care" dated 4/21/21 through 6/19/21 documents: "SN visits two (2) times a week for three (3) weeks than one (1) time a week for six (6) weeks for assessment of vital signs, breath sounds, vital signs, complications with medications, exacerbation with Congestive Heart Failure- edema, shortness of breath and weight, pain....". Medications include: Oxycodone 15 mg every six (6) hours as needed for pain, Atenolol (antihypertensive) 100 mg daily, Lisinopril (antihypertensive) 10 mg two (2) times a day and Norvasc 5 mg two (2) times a day." The record documents a Licensed Practical Nurse (LPN) on 4/26/21, 5/4/21, 5/7/21, 5/18/21 and 5/25/21. During a home visit on 6/8/21, the nurse that conducted the visit was an LPN. The Home Health Certification and Plan of Care does not have any tasks the LPN is to perform. Assessments are outside of the scope of practice of LPN's. The Plan of Care lacks documentation to include parameters for physician notification for blood pressure, pulse, weights and pain. 3. Patient #2 has a start of care date of 12/10/20 with diagnoses of Congestive Heart Failure, Diabetes Mellitus Type Two and Chronic Obstructive Pulmonary Disease as documented on the "Home Health Certification and Plan of Care" dated 4/9/21 through 6/7/21. The "Home Health Certification and Plan of Care" dated 4/9/21 through 6/7/21 documents:" SN visits two (2) times a week for nine (9) weeks for assessment, assess vital signs, lung sounds, weight, diabetic status and pain. Patient to monitor blood sugars four (4) times a day. Medications include: Humalog Insulin 35 units three (3) times day, Lantus 10 mg at bedtime; Physical Therapy (PT) visits two (2) times a week for eight (8) weeks." The SN notes between 4/20/21 through 6/7/21 document the Patient has pain to the shoulders and the Patient is using Lidocaine Patches and Tylenol. The PT documents on 4/14/21 the Patient has "pain of a 9 throughout her body and is using Prednisone for pain relief. The Plan of Care lacks documented pain relieving modalities the Patient to use to alleviate pain. The record documents a LPN made visits on 4/20/21, 4/26/21, 5/18/21, 5/24/216/1/21 and 6/7/21. The Home Health Certification and Plan of Care does not document the tasks the LPN is to perform. Assessments are outside of the scope of practice of LPN's. The Plan of Care lacks documentation to include parameters for physician notification for blood pressure, pulse, blood sugar, weight and pain. 4. Patient #3 has a start of care date of 7/20/15 with diagnoses of Diabetes Mellitus Type Two, Hypertension and Cerebral Vascular Accident as per the "Home Health Certification and Plan of Care" dated 4/19/21 through 6/17/21. The" Home Health Certification and Plan of Care" dated 4/19/21 through 6/17/21 documents: "SN every two (2) weeks for for eight (8) weeks for assessment, observe/assess vital signs, assess pain medication effectiveness and instruct in signs and symptoms of hyper/hypo glycemia and daily weights; PCW (Personal Care Worker/Personal Care Aide) for assistance with personal care." The Plan of Care does not document a frequency (hours/days) the PCA is to go to the home. The SN note dated 4/15/21 documents Patient "checks his blood sugar sometimes". The Plan of Care lacks documentation to include parameters for physician notification for pulse, pain, blood sugar and weights. The Plan of Care documents: "report blood pressure to physician for systolic reading greater than 150 and less than 90". There is no parameters for diastolic readings. During an interview with the Administrator on 6/9/21 at 1:00 PM, the Administrator did not provide an explanation for the above findings. Based on clinical record reviews and interview, the agency failed to develop/revise complete and comprehensive Plans of Care. This was evident for seven (7) of nine (9) clinical records reviewed. (Patients # 1, #2, #3, #5, #7, #8 and #9). Failure to develop complete and comprehensive Plans Of Care has the potential for negative patient outcomes. The findings are: 1. Patient # 5 has a start of care date of 10/23/20 with Diagnosis that include Seizures, Ataxia, Paroxysmal Atrial Fibrillation, Essential Primary Hypertension, Chronic Combined systolic congestive and diastolic congestive Heart Failure as documented on the " Home Health Certification and Plan Of Care" for the certification period of 4/21/21 to 6/19/21. The " Home Health Certification and Plan Of Care" for the certification period of 4/21/21 to 6/19/21 document:" Orders for Discipline and Treatments: Skilled Nursing ( SN) once a week for nine weeks, three as needed for change in plan of care, assess compliance with medication regimen. Assess compliance with sodium restricted diet. Nutritional Requirement: Regular diet. Medications: Artificial Tears Ophthalmic Solution 2 drops as needed OP dry eyes, Eliquis 2.5 mg one tablet twice a day via mouth ( PO), Epi Pen 2-Pak injection device 0.3 mg/0.3 ml one injection as needed, Erythromycin Ophthalmic ointment 5 mg/ mg one ointment at bedtime, OP, Levetiracetam 250 mg one tablet every 12 hours PO, Pro Air Inhaler Aerosol solution 10B 90 Base) two puffs every four hours, Metoprolol Succinate Extended release 50 mg, one tablet daily PO. There is no documented evidence of Blood Pressure parameters for physician notification. There is no documented evidence of an order for sodium restricted diet. There is no documented evidence the Plan of Care is complete. On 6/9/21 at 12:45 PM , the Administrator was interviewed and did not provide an explanation for the above findings. 5. Patient #7 has a start of care date of 12/22/2020 with diagnosis that include Hypertension, Hyperlipidemia, Diabetes Mellitus, and chronic left heel wound documented on the " Home Health Certification and Plan of Care" for the Certification Period of 4/21/2021 to 6/19/2021. The " Home Health Certification and Plan of Care" for the Certification Period of 4/21/2021 to 6/19/2021 documents "Medication: Clopidogrel Bisulfate 75 mg by mouth daily, Voltaren gel 1% ointment 2 x daily; SN 2x week x 9 weeks, 3 PRN, adjustment to POC; Assess patients response to interventions for pain; Assess need for noninvasive methods of pain" The Plan of Care lack documented evidence of pain parameters for monitoring and when to notify the physician. During an interview with the Administrator on 6/9/21 at 12:30 PM, the Administrator/DPS did not provide an explanation for the above findings. 6. Patient #8 has a start of care date of 1/23/2020 with diagnosis that include Schizoaffective Disorder Depressive Type, and Tachycardia as documented on the " Home Health Certification and Plan of Care" for the Certification Period of 5/17/2021 to 7/15/2021. The " Home Health Certification and Plan of Care" for the Certification Period of 5/17/2021 to 7/15/2021 documents "Medication: Metoprolol 50 mg orally 1 time daily; assess for response to prescribed medications" The Plan of Care lack documented evidence of Heart Rate (pulse)parameters and when to notify the physician. During an interview with the Administrator/Director of Patient on 6/9/21 at 12:30 PM, the Administrator/DPS did not provide an explanation for the above findings. 7. Patient #9 has a start of care date of 2/27/20 and a discharge date of 4/24/2020; has a "Home Health Care Certification and Plan of Care" dated " 2/27/2020 to 4/26/2020" with diagnosis of Dysphagia following Cerebral Infarction. The "Home Health Care Certification and Plan of Care" dated 2/27/2020 to 4/26/2020 documents "Medications: Keppra 500mg per Peg tube 2 times daily, Nitroglycerin Sublingual Ta 0.4 mg PRN every 5 minutes as needed for chest pain; notify physician if systolic (Blood Pressure) B/P is greater than 160 or diastolic B/P greater than 90" The Home Health Care Certification and Plan of Care lacks documented evidence of treatment or intervention for elevated B/P . During an interview with the Administrator/Director of Patient Services on 6/9/2021 at 12:40 PM, the Administrator/DPS did not provide an explanation for the above findings.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician orders. This STANDARD is not met as evidenced by: 3. Patient #1 has a start of care date of 4/21/21 with diagnoses of Acute Respiratory Failure and Cardiac Disease as documented on the "Home Health Certification and Plan of Care" dated 4/21/21 through 6/19/21. The "Home Health Certification and Plan of Care" dated 4/21/21 through 6/19/21 documents: SN( Skilled Nurse) visits two (2) times a week for three (3) weeks than one (1) time a week for six (6) weeks; assess fro exacerbation of CHF (Congestive Heart Failure) - edema, weight gain, shortness of breath; assess for clinical status- pain and functional level; Oxycodone 15 mg every six (6) hours as needed for pain." The SN notes document: 4/23/21 - back pain rated an 8 on a scale of 0 to 10; 4/26/21 - pain is a 7; 4/29/21 - back pain (not rated); 5/4/21 - back pain 8; 5/18/21 - back and leg pain is a 6. The SN notes lack documented evidence of complete pain assessments and the amount, frequency and effectiveness of the Oxycodone. The SN notes document: the Patient has edema on 4/21/21, 4/23/21, 4/26/21, 5/4/21 and 5/7/21. The notes lack documented evidence of complete assessment to include measure and whether it is pitting. The SN notes lack documented evidence on Oxygen saturation rates on 4/21/21, 4/29/21, 5/4/21 and 5/31/21. The SN notes dated 4/21/21, 4/23/21 and 5/31/21 lack documented evidence the Patient was weighted. 4. Patient #2 has a start of care date of 12/10/20 with diagnoses of Congestive Heart Failure and Chronic Obstructive Pulmonary Disease as documented on "the Home Health Certification and Plan of Care "dated 4/9/21 through 6/7/21. The" Home Health Certification and Plan of Care" dated 4/9/21 through 6/7/21 documents SN visits two (2) times a week for nine (9) weeks for assessment; assess pain levels. The SN notes dated 4/8/21, 4/20/21 and 5/27/21 lack documented evidence the Patient's pain was assessed. 5. Patient #3 has a start of care date of 7/20/15 with diagnoses of Diabetes Mellitus Type Two, Hypertension and Cerebral Vascular Accident as per the "Home Health Certification and Plan of Care" dated 4/19/21 through 6/17/21. The "Home Health Certification and Plan of Care" dated 4/19/21 through 6/17/21 documents: SN every once every two (2) weeks for eight (8) weeks for assessment; report blood pressure systolic readings greater than 150 or less than 90; pre-pour medications, weigh each visit and instruct Patient in daily weights; PCW )Personal Care Worker/Personal Care Aide) to assist with personal care, ambulation and remind Patient to take medications. The SN note dated 5/22/21 lacks documented evidence of vital signs to include blood pressure. A review of the aide activity sheets for the months of April and May 2021 lack documented evidence the aide assisted with ambulation and reminded the Patient to take medications. The aide activity sheets dated 4/8/21, 4/10/21, 4/15/21, 4/17/21, 4/24/21, 4/30/21, 5/1/21, 5/8/21, 5/15/21 and 5/29/21 lack documented evidence the aide assisted with personal care. During an interview with the Administrator on 6/9/21 at 2:30 PM, the Administrator did not provide an explanation for the above findings. Based on observations, record reviews and interviews, the agency failed to ensure that services are provided in accordance with the Plans of Care . This was evident for five (5) of nine (9) clinical records reviewed. (Patients #1, #2, #3, #4, and #6,). Failure to ensure that patient care is provided in accordance with the Plans of Care has the potential for negative patient outcomes. The findings are: 1. Patient #4 has a start of care date of 5/20/2021 with diagnosis that include Pressure Ulcer of Right buttock Stage 2, Chronic Pain due to Trauma, Generalized Anxiety Disorder as documented on the " Home Health Certification and Plan Of Care" for the certification period of 5/20/21 to 7/18/21. The " Home Health Certification and Plan Of Care" for the certification period of 5/20/21 to 7/18/21 document: "Orders for Discipline and Treatments: Skilled Nurse ( SN) once a week for one week, 3 as needed adjustments in Plan Of Care, twice a week for 8 weeks. Assess wound for changes every visit. Perform wound care site and treatment. Assess exudate, odor, pain, tissue color, redness of wound Cleanse wound with Allevyn Ag ( Adhesive Absorbent Silver Barrier dressing) Apply every 72 hours or as needed if soiled/wet." On 5/31/21,the " SN" visit note document: " Dressing is removed. there is small amount of serosanguinous drainage noted. Area cleansed with Normal Saline and new dressing applied. area measure 10 x 10 cm at this time." On 6/3/21, the SN visit note document" Wound is none healing and measurements has not improved, call placed to physician to discuss changing orders, awaiting for a return phone call." On 6/8/21 at 10:30 AM, a request was made for the new interim order. This information was not provided. On 6/10/21 at 9:30 AM, during an observational home visit, the nurse performed the dressing and applied "Optifoam Gentle Foam wound dressing" on the wound. There is no documented evidence of an interim order for new wound dressing. There is no documented evidence the services were provided in accordance with the Plan Of Care. The record document the following SN visits: 5/31/21 conducted by an RN ( Registered Nurse) The SN visits document on 6/3/21, 6/7/21 nursing visits done by a Licensed Practical Nurse ( LPN). Assessments are outside of the scope of practice of LPN's. There is no documented evidence of assessment of the wound. There is no documented evidence the services were provided in accordance with the Plan Of Care. On 6/10/21 at 1:30 PM, the Administrator was interviewed and did not provide an explanation for the above findings. 2. Patient # 6 has a start of care date of 8/31/20 and a discharge date of 11/23/20 with diagnosis that include Essential Primary Hypertension, End Stage renal Disease, Peripheral Vascular Disease, Heart Failure, Telecasts as documented on the " Home Health Certification and Plan Of Care" for the certification period of of 10/30/20 to 12/28/20. The " Home Health Certification and Plan Of Care" for the certification period of 10/30/20 to 12/28/20 document:" Orders for discipline and treatment: Skilled Nurse (SN) once a week for one week, three as needed for changes in patient's status, twice a weeks for eight weeks, once a week for one week. Assess respiratory status/ identify complications. Pulse Oximetry, report to physician if Sp 02 ( Oxygen saturation) < 90%." A review of the "clinical notes" and the nursing visits indicated there is no pulse oximetry documentation on the following dates: 10/30/20, 11/2/20, 11/9/20, 11/16/20. There is no documented evidence the services were provided in accordance with the Plans Of Care. On 6/9/21 at 1:30 PM, the Administrator was interviewed and did not provide an explanation for above findings.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician. This ELEMENT is not met as evidenced by: Based on record review and staff interview, the agency failed to ensure that drugs and treatments are administered only as ordered by a physician. This was evident for one (1) of nine (9) clinical records reviewed. (Patient #4). Failure to ensure that drugs and treatments are administered only as ordered by a physician have the potential for negative patient outcomes. The findings are: Patient # 4 has a start of care date of 5/20/2021 with diagnosis that include Pressure Ulcer of Right buttock Stage 2, Chronic Pain due to Trauma, Generalized Anxiety Disorder as documented on the " Home Health Certification and Plan Of Care" for the certification period of 5/20/21 to 7/18/21. The " Home Health Certification and Plan Of Care" for the certification period of 5/20/21 to 7/18/21 document: "Orders for Discipline and Treatments: Skilled Nurse ( SN) once a week for one week, 3 as needed adjustments in Plan Of Care, twice a week for 8 weeks. Assess compliance with medication regimen. Medications: Aspirin Delayed release 325 mg via mouth ( PO) daily, Baclofen tablet 20 mg three times a day ( TID) PO, Lexapro 20 mg tablet PO daily, Lyrica 150 mg TID, PO, Macrodantin 50 mg at bedtime (HS), Methadone HCL 5 mg tablet as directed one tablet in the morning, one tablet at noon, two tablets HS, Omeprazole delayed release 20 mg PO daily, Oxycodone HCL 10 mg tablet every six hours as needed, Xanax 0.25 mg tablet as needed PO TID, Miralax Powder one to two capfull PO every morning, Senokot 8.6 mg two tablet PO every morning, Colace 100 mg capsule TID PO, Lasix 40 mg tablet PO daily, Wellbutrin SR extended release 150 mg every 12 hours PO, Metamucil Plus Calcium two capsules daily PO, Vitamin E 400 units daily PO, Flaxseed Oil 1200 units PO daily, Culturelle 10B cell one capsule twice a day PO, Fleet Enema rectal enema 7-19 gm/118 ml as needed per rectum daily, Bisacodyl EC delayed release 5 mg ,2-3 tablet PO every morning, Vitamin D3 1000 unit daily PO." On 6/10/21 at 9:30 AM, during an observational home visit, a review of the medications in the home identified the following discrepancies: A bottle labeled Methadone HCL with a date filled 5/24/21 document Methadone HCL 5 mg one tablet in the morning, one tablet at noon, one tablet at 9 PM, A bottle labeled Colace with a date filled on 4/19/21 document Colace 100 mg twice a day. A Bottle labeled Lactulose 30 ml twice a day PO was not on the Plan Of Care, a bottle labeled Oxycodone with a date filled on 4/23/21 document 10 mg one tablet every 12 hours as needed. Assess wound for changes every visit. Perform wound care site and treatment. Assess exudate, odor, pain, tissue color, redness of wound Cleanse wound with Allevyn Ag ( Adhesive Absorbent Silver Barrier dressing) Apply every 72 hours or as needed if soiled/wet." There is no documented evidence of an interim order for Lactulose. There is no documented evidence of an interim order change for Colace and Methadone. There is no documented evidence of communication with the physician for a new interim order for the above medications changes. On 6/3/21, the SN visit note document" Wound is none healing and measurements has not improved, call placed to physician to discuss changing orders, awaiting for a return phone call." On 6/8/21 at 10:30 AM, a request was made for the new interim order. This information was not provided. On 6/10/21 at 9:30 AM, during an observational home visit, the nurse performed the dressing and applied "Optifoam Gentle Foam wound dressing" on the wound. There is no documented evidence of communication with the physician for an interim order for a new dressing. There is no documented evidence of an interim order for Optifoam Gentle Foam wound dressing. On 6/10/21 at 1:30 PM, the Administrator was interviewed and did not have an explanation for the above findings.

A qualified HH aide successfully completed: CFR(s): 484.80(a)(1)(i-iv) A qualified home health aide is a person who has successfully completed: (i) A training and competency evaluation program as specified in paragraphs (b) and (c) respectively of this section; or (ii) A competency evaluation program that meets the requirements of paragraph (c) of this section; or (iii) A nurse aide training and competency evaluation program approved by the state as meeting the requirements of §483.151 through §483.154 of this chapter, and is currently listed in good standing on the state nurse aide registry; or (iv) The requirements of a state licensure program that meets the provisions of paragraphs (b) and (c) of this section. This ELEMENT is not met as evidenced by: Based on personnel record reviews and interview, the agency failed to ensure that all Aides have completed an approved NYS Home Health Aide training program. This was evident for one (1) of two (2) Aide records reviewed. (Employee #6). Failure to ensure that all aides have completed an approved hha training program places patients at risk for poor quality of care. The finding is: A review of the personnel record for Employee #6 is a contracted aide and has a date of hire of 10/6/14. The record documents the aide received a personal care aide (PCA) certificate 8/28/09. The Job Application is dated 7/18/14 and documents the aide worked in Florida as a Pharmacy Technician from 2005 to 2008 and at a nursing home as a CNA (Certified Nurses Assistant) from 2008 through 2009. The record lacks documented evidence as to where the aide worked between 2009 through 2014 or documentation the aide continued in-service hours to maintain the certificate. During an interview with the Administrator on 6/11/21 at 2:30 PM, the Administrator did not provide an explanation for the above findings.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview, the governing authority failed to ensure that a completed discharge summary is sent to the physician who will be responsible for providing care and services to the patient after discharge from the agency, within five days of the patient's discharge. This was evident for two (2) of two (2) discharge records reviewed. ( Patients #6, and #9 ). Failure to ensure that a completed discharge summary is sent to the physician who will be responsible for providing care and services to the patient after discharge from the agency, within five days of the patient's discharge., have the potential for negative patient outcomes The findings are: 1. Patient # 6 has a start of care date of 8/31/20 and a discharge date of 11/23/20. The " Agency Discharge Summary" dated 11/23/20 document: "Field Discharge with Goals Met". The record document the discharge summary was sent/ faxed to the Physician on 12/11/ 21. There is no documented evidence the discharge summary was sent to the within five days of the patient's discharge. There is no documented evidence the physician was notified prior to or at the time of discharge. On 6/9/21 at 12:45 PM, the Administrator was interviewed and did not provide an explanation for the above findings. 2. Patient #9 has a start of care date of 2/27/20 and a discharge date of 4/24/2020; has a Home Health Care Certification and Plan of Care" dated" 2/27/2020 to 4/26/2020" with diagnosis of Dysphagia following Cerebral Infarction. The Home Health Care Certification and Plan of Care dated 2/27/2020 to 4/26/2020 documents:"skilled nursing 1 x week x 1 week, 3 PRN for acute changes , 2x week x 3 weeks then 1 x week x 5 weeks; notify physician if systolic B/P is greater than 160 or diastolic B/P greater than 90". The discharge summary dated 7/28/2020 document a "referral date of 2/24/2020; admission date of 2/27/2020 and a final date of service of 4/24/2020; discharge reason: discharge goals met". There is no documented evidence of when the discharge notice was sent to the physician. There is no documented evidence a Discharge summary was sent to the primary provider within five days of the patient's discharge. There is no documented evidence of a completed discharge summary; and communication to the patient's primary provider of any changes in the patient's progress. During an interview with the Administrator on 6/9/2021 at 12:40 PM, the Administrator/DPS did not provide an explanation for the above findings.