Every finding on record at Marquis Certified Home Care, LLC

The following statement of deficiencies represents the results of a standard re-certification survey of Marquis Certified Home Health Care LLC, Certified Home Health Agency conducted June 21, 2023 through June 22, 2023. The survey consisted of a review of seventeen clinical records, including five discharge records, seven observational home visits, and seven personnel records. The survey included a review of pertinent policies and procedures, Quality Improvement Meeting minutes for the past twelve months, the agency's admission packet, the Emergency Preparedness Plan and complaint log. A focused COVID-19 survey was conducted in conjunction with the re-certification survey and the vaccination records of 10 personnel were reviewed. Pre-survey activities consisted of a review on 06/12/2023 of the agency's Health Commerce System account, the Home Care Registry and Certification and Survey Provider Enhanced Reports (CASPER) for the period March 2022 through February 2023. The agency's Executive Director, Director of Patient Services and Director of Therapy were interviewed. The following deficiencies are identified as a result of the survey: Federal: G0514, G0536, G0572, G0574 and G0590. State: J0404, J0452, J1108, J1156, J1168, J1444, J1460 and L0001.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview evidence is lacking in six of seventeen records (Patient # 2, 10 13, 14, 15 and 17) the initial assessment visit was conducted within 48 hours of receiving the referral for services, within 48 hours of the patient's return home or on the physician ordered start of care date. Failure to conduct the initial assessment within the required time frame has the potential to result in unmet patient needs and negative patient outcomes. Findings: Patient # 2 (start of care 03/02/2023) has diagnoses of Displacement of Ventricular Intracranial Shunt and Spina Bifida with Hydrocephalus. The record contains a referral received on 02/21/2023 with no specific physician ordered start of care date. The initial assessment was conducted on 03/02/2023, nine days after receipt of the physician's referral. The record is lacking documented evidence the initial assessment was completed within 48 hours of receipt of the referral. Patient # 10 (start of care 05/09/2023) has diagnoses of Encounter for Change or Removal of Nonsurgical Wound Dressing and Cellulitis of Right Lower Limb. The record contains a referral faxed to the agency on 04/27/2023 with no specific physician ordered start of care date. The initial assessment was conducted on 05/09/2023, 12 days after receipt of the physician's referral. The record is lacking documented evidence the initial assessment was completed within 48 hours of receipt of the referral. Patient # 13 (start of care 03/29/2023 and discharged 04/21/2023) has diagnoses of Chronic Systolic (Congestive) Heart Failure and Lymphedema. The record contains a referral faxed to the agency on 03/22/2023 with no specific physician ordered start of care date. The initial assessment was conducted on 03/29/2023 which is 7 days after receipt of the physician's referral. The record is lacking documented evidence the initial assessment was completed within 48 hours of receipt of the referral. Patient # 14 (start of care 04/10/2023 and discharged on 05/16/2023) has diagnoses of Acute Diastolic (Congestive) Heart Failure and Atrial Fibrillation. The record contains a Client Episode Coordination Notes Report for an intake dated 03/30/203 noting the patient is currently hospitalized, a hospital discharge date of 04/05/2023 and an initial assessment dated 04/10/2023. The initial assessment was conducted five days after the discharge. The record is lacking documented evidence the initial assessment was completed within 48 hours of the hospital discharge. Patient # 15 (start of care 05/28/2022 and discharged on 07/08/2022) has diagnoses of Pressure Ulcer of Left Buttock State 4 and Hypertensive Heart Disease with Heart Failure. The record contains an intake note dated 05/19/2022 that states the patient, a discharge date of 05/24/2022 from a rehabilitation center and an initial assessment/start of care note dated 05/28/2022. The initial assessment was conducted four days after the discharge. The record is lacking documented evidence the initial assessment was completed within 48 hours of discharge from the rehabilitation center. Patient # 17 (start of care 07/29/2022 and discharged on 09/29/2022) has diagnoses of Alzheimer's Disease and Dementia. The record contains a intake note date 07/21/2023 noting receipt of referral without a physician ordered start of care and an initial assessment note dated 07/29/2023. The initial assessment was conducted 8 days after receipt of the receipt of the referral. The record is lacking documented evidence the initial assessment was completed within 48 hours of receipt of the referral. The findings were confirmed on 06/21/2023 at 3:30 PM, on 06/22/2023 at 11:00 AM and 1:00 PM with the with the Director of Patient Services and Director of Therapy.

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 clinical record review and staff interview, evidence is lacking in one of five therapy only records (Patient # 12), that an updated, maintained, and accurate comprehensive medication review was performed by the Registered Nurse (RN) at the start of care. Failure to update and maintain an accurate medication review has the potential to result in the patient experiencing adverse medication effects, drug reactions and/or interactions and the inaccurate administration of physician ordered medications. Finding: Patient # 12 (start of care 06/02/2023) has diagnoses of Radiculopathy and Spinal Stenosis. The record lacks documented evidence that the RN performed a medication review. The finding was confirmed on 06/21/2023 at 11:05 AM with the Director of Patient Services and Director of Therapy; no additional evidence was provided.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on clinical record review and staff interview the agency failed to ensure services are provided in accordance with the physician's Plan of Care (POC) in one of seventeen patient records reviewed. (Patient # 1). Failure to follow the POC has the potential for patients to receive care that is inconsistent with the physician's orders resulting in unmet patient needs and possible negative patient outcomes. Finding: Patient # 1 (start of care 04/22/2023) has diagnoses of Pressure Ulcer of Right Buttock, Stage 4 and Pressure Ulcer Sacral Region, Stage 2. The record contains a physician's order dated 06/14/2023 for Physician Therapy effective 06/11/2023 1WK1 (1 visit for 1 week), The record lacks documented evidence any PT visits were made the week of 06/11/2023. The finding was confirmed on 06/21/2023 at 3:40 PM with the Director of Patient Services and Director of Therapy; no additional evidence was provided.

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 staff interview the agency failed to ensure a complete physician's Plan of Care (POC) was developed to meet the individualized needs of the patient in nine of seventeen patient records (Patient # 5, 6, 7, 8, 11, 12, 13, 15 and 16). Failure to develop a comprehensive POC has the potential for unmet patient needs and places patients at risk for receiving incorrect and/or inappropriate care. Findings: Patient # 5 (start of care 05/01/2023) has diagnoses of Fracture of Part of Left Femur and Fracture of Shaft of Humorous, Right Arm. The POC for certification period 05/01/2023 through 06/29/2023 contains an order for MiraLAX 17 Gram Oral Powder Packet 2 times a week for Constipation. The order is incomplete as it is lacking reconstitution instructions. Patient # 6 (start of care 06/12/2023) has diagnoses of Encounter for Change or Removal of Surgical Wound Dressing and Displaced Bimalleolar fracture Left Lower Leg. The POC for certification period 06/12/2023 through 08/10/2023 contains an order for Oxygen 2 Liter continuous. The order is incomplete as it is lacking the route for the Oxygen to be delivered. Patient # 7 (start of care 04/08/2023) has diagnoses of Type 2 Diabetes Mellitus with Diabetic Polyneuropathy and Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. The clinical record contains a Physical Therapist Visit Note Report dated 05/23/2023 that states the patient uses a rolling walker and, on a home visit conducted on 06/22/2023 a rolling walker was used during the physical therapy session. The clinical record is lacking a physician's order for the walker. Patient # 8 (start of care 06/03/2023) has diagnoses of Chronic Obstructive Pulmonary Disease with Acute Exacerbation and Long-Term Current Use of Inhaled Steroids. The POC for certification period 06/03/2023 through 08/01/2023 contains an order for Carisoprodol 350 milligrams (MG) tablet twice daily as needed for pain. Take 1 tablet twice daily as needed for pain, no driving...maximum daily dose (MDD) 2 tablets. The order is incomplete as it is lacking a time interval between the as needed doses. Patient # 11 (start of care 04/03/2023) has diagnoses of Epilepsy and Respiratory Failure Unspecified with Hypercapnia. The POC's for certification periods 04/08/2023 through 06/06/2023 and 06/07/2023 through 08/05/2023 both contain an order for Aspirin Childrens 81 MG Chewable tablet oral 1 tablet daily. Both POC's are incomplete as they are lacking bleeding precautions. The POC for certification period 04/08/2023 through 06/06/2023 contains orders for: - Debrox 6.5% Ear Drops 3 drops monthly/PRN for Cerumen Impaction Instill 5 drops (GTTS) into ears for 3 consecutive days monthly as needed. This order requires clarification as to whether the patient is to instill 3 or 5 drops into ears and - Debrox 6.5% Ear drops 3 drops as needed/PRN for Ear Wax Apply to both (B) ears MDD 3 drops each ear. These orders require clarification as to whether this is an additional order that can be taken as well as the previous order. Additionally, the POC for certification period 06/07/2023 through 08/05/2023 contains an order for: -Debrox 6.5% Ear Drops Monthly/as needed (PRN) 3 drops for cerumen impaction-instill 5 drops (gtt) into ears for 3 consecutive days monthly as needed and handwritten over the order states 4 drops. The order requires clarification as to how many drops of medication the patient should instill 3, 4 or 5. Furthermore, the POC's for certification periods 04/08/2023 through 06/06/2023 and 06/07/2023 through 08/05/2023 both contain the following orders: Depakote 250 MG tablet, delayed release 3 tablets every AM for Seizures. Take 3 tablets (tabs) in AM and 2 in PM and Depakote 250 MG tablet delayed release 2 tablets every PM for Seizures Take 3 tabs in AM and 2 tabs in PM. The orders require clarification as to exactly how many tablets the patient should take and when. Patient # 12 (start of care 06/02/2023) has diagnoses of Radiculopathy and Spinal Stenosis. The POC for certification period 06/02/2023 through 07/31/2023 contains an order for Oxygen 2 Liters (L) continuous. The order is incomplete as it is lacking a route for the Oxygen to be delivered. Also, the POC is incomplete as it is lacking Oxygen precautions. Patient # 13 (start of care 03/29/2023 and discharged 04/21/2023) has diagnoses of Chronic Systolic (Congestive) Heart Failure and Lymphedema. The POC for certification period 03/29/2023 through 05/27/2023 contains an order for Aspirin Childrens 81 MG Chewable Tablet Oral Daily. The POC is incomplete as it is lacking bleeding precautions. Also, the POC contains an order for Humalog Kwikpen Units-100 (U-100) Insulin 100 unit/milliliter (ML) subcutaneous daily 16-20 units based on finger stick. The order is incomplete as it is lacking a sliding scale for how much insulin to take for which result of the fingerstick. Patient # 15 (start of care 05/25/2022 and discharged on 07/08/2022) has diagnoses of Pressure Ulcer of Left Buttock State 4 and Hypertensive Heart Disease with Heart Failure. The POC for certification period 05/28/2022 through 07/26/2022 contains an order for Aspirin Low Dose 81 MG delayed Release oral every morning. The POC is incomplete as it is lacking bleeding precautions. Patient # 16 (start of care 08/16/2022 and discharged on 10/13/2022) has diagnoses of Type 2 Diabetes Mellitus with Hypoglycemia without Coma and Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. The POC for certification period 08/16/2022 through 10/14/2022 contains an order for Adult Aspirin Regimen 81 MG Tablet, Delayed Release oral 1 tablet every day. The POC is incomplete as it is lacking bleeding precautions. The findings were confirmed on 06/21/2023 at 11:00 AM and 330 PM and on 06/22/2023 at 11:00 AM with the Director of Patient Services, Director of Therapy; no additional evidence was provided.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview evidence is lacking in one of seventeen records (Patient # 1) the physician was contacted regarding changes that alter or suggest the need to alter the Plan of Care (POC). Failure to consult with the physician when changes occur in the patient's condition has the potential for unmet patient needs and/or negative patient outcomes. Finding: Patient # 1 (start of care 04/22/2023) has diagnoses of Pressure Ulcer of Right Buttock, Stage 4 and Pressure Ulcer Sacral Region, Stage 2. The record contains a physician's order dated 06/14/2023 for Physical Therapy effective 06/11/2023 1WK1 (1 visit for 1 week), The record lacks documented evidence any PT visits were made the week of 06/11/2023 or evidence the physician was notified of the change in the POC. The finding was confirmed on 06/21/2023 at 3:40 PM with the Director of Patient Services and Director of Therapy; no additional evidence was provided.

The following statement of deficiencies represents the results of an onsite complaint investigation of Marquis Certified Home Care, LLC., complaint numbers NY70545, NY93769 and NY94019, conducted on October 25-26, 2022. The survey consisted of a review of six clinical records, 6 personnel records, the COVID-19 vaccination status for 6 employees and interviews with the Assistant Director of Patient Services, Director of Therapy and the Quality Assurance Specialist. The findings were reviewed at the exit conference on October 26, 2022. The complaint allegations for #70545 were found to be unsubstantiated. The complaint allegations for #93767 were found to be partially substantiated and deficiencies are identified. The complaint allegations for # 94019 were found to be partially substantiated and deficiencies are identified. The following deficiencies were identified: Federal: G0572 G0574 G0590 G0592 G1010 State: J0452 J1440 J1444

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on clinical record review and staff interview the agency failed to ensure services are provided in accordance with the physician's Plan of Care (POC) in two of six patient records reviewed. (Patient # 4 and 6). Failure to follow the POC has the potential for patients to receive care that is inconsistent with the physician's orders resulting in unmet patient needs and possible negative patient outcomes. Patient # 4 (start of care 03/11/2021) has diagnoses of Pressure Ulcer of Sacral Region, Stage 4 and Venous Insufficiency (Chronic) (Peripheral). The POC for certification period 09/02/2022 through 10/31/2022 states the SN is to conduct three visits the weeks of 10/03/2022 and10/16/2022. The record contains documentation the SN conducted two of the three visits (10/05/2022 and 10/07/2022) the week of 10/03/2022 and two of the three visits (10/12/2022 and 10/17/2022) the week of 10/16/2022. Patient # 6 (start of care 01/05/2022) has diagnoses of Pressure Ulcer of Left Buttock, Stage 2 and Type 2 Diabetes Mellitus Without Complications. The POC for certification period 09/02/2022 through 10/31/2022 states the SN is to conduct three visits the week of 09/04/2022. The record contains documentation the SN conducted two of the three visits (09/07/2022 and 09/09/2022) the week of 09/04/2022. The findings were confirmed on 10/25/2022 at 3:30 PM and 10/26/2022 at 12:15 PM with the Assistant Director of Patient Services, Director of Therapy and Quality Assurance Specialist; no additional evidence was provided.

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 staff interview the agency failed to ensure a complete physician's Plan of Care (POC) was developed to meet the individualized needs of the patient in six of six patient records (Patient # 1, 2, 3,4, 5, and 6). Failure to develop a comprehensive POC has the potential for unmet patient needs and places patients at risk for receiving incorrect and/or inappropriate care. Findings: Patient # 1 (start of care 06/28/2022) has diagnoses of Infection/Inflammation Reaction Due to Internal Left Hip Prosthesis and Unspecified Subluxation of Left Hip. The POC for certification period 08/27/2022 through 10/25/2022 is lacking documented evidence of a description of the patient's risk for emergency department visits and all necessary interventions to address the underlying risk factors for hospital re-admission(s) and emergency room visit(s). Patient # 2 (start of care 02/06/2022) has diagnoses of Pressure Ulcer of Right Heel, Stage 2 and Pressure Ulcer Left Heel, Stage 2. The POC's for certification periods 08/05/2022 through 10/03/2022 and 10/04/2022 through 12/02/2022 both are lacking documented evidence of a description of the patient's risk for emergency department visits and all necessary interventions to address the underlying risk factors for hospital re-admission(s) and emergency room visit(s). Also, the POC's for certification periods 08/05/2022 through 10/03/2022 and 10/04/2022 through 12/02/2022 both contain an order for Aspirin Low Dose 81 milligram (mg) 1 tablet every morning (AM). The POC's are incomplete as they do not include bleeding precautions. Additionally, the POC's for certification periods 08/05/2022 through 10/03/2022 and 10/04/2022 through 12/02/2022 both contain an order for Lumigan 0.01% Eye Drops, 1 drop daily and an order for Timolol Maleate 0.5% Eye Drops 1 drop every am. The orders are incomplete as they do not specify which eye(s) to apply the medication. Patient # 3 (start of care 01/24/2022) has diagnoses of Pressure Ulcer of Left Heel, Stage 3 and Type 2 Diabetes with Diabetic Peripheral Angiopathy without Gangrene. The POC for certification period 09/21/2022 through 11/19/2022 is incomplete as it is lacking documented evidence of a description of the patient's risk for emergency department visits and all necessary interventions to address the underlying risk factors for hospital re-admission(s) and emergency room visit(s). Also, the record contains a physical therapy (PT) recertification assessment dated 09/20/2022 that identifies the patient utilizes Durable Medical Equipment (DME) of a cane and rolling walker in the home. The POC for certification period 09/21/2022 through 11/19/2022 is incomplete as it does not contain this DME. Additionally, the record contains a SN recertification assessment dated 09/16/2022 that identifies the patient utilizes DME of a rollator walker in the home. The POC for certification period 09/21/2022 through 11/19/2022 is incomplete as it does not contain this DME. Patient # 4 (start of care 03/11/2021) has diagnoses of Pressure Ulcer of Sacral Region, Stage 4 and Venous Insufficiency (Chronic) (Peripheral). The POC for certification period 09/02/2022 through 10/31/2022 is incomplete as it lacks documented evidence of a description of the patient's risk for emergency department visits and all necessary interventions to address the underlying risk factors for hospital re-admission(s) and emergency room visit(s). Also, the POC contains orders for a catheter insertion kit and a Foley catheter. The order is incomplete as it does not contain the size of the Foley. The POC also contains orders for DME for 'ostomy'. The order is incomplete as it does not contain size for ostomy supplies. Patient # 5 (start of care 10/13/2022) has diagnoses of Disruption of External Operation (surgical) Wound and Unspecified Fracture of Left Forearm, Subsequent for Closed Fracture with Routine Healing. The POC for certification period 10/13/2022 through 12/11/2022 is incomplete as it lacks documented evidence of a description of the patient's risk for emergency department visits and all necessary interventions to address the underlying risk factors for hospital re-admission(s) and emergency room visit(s). Patient # 6 (start of care 01/05/2022) has diagnoses of Pressure Ulcer of Left Buttock, Stage 2 and Type 2 Diabetes Mellitus Without Complications. The POC for certification period 09/02/2022 through 10/31/2022 is incomplete as it lacks documented evidence of a description of the patient's risk for emergency department visits and all necessary interventions to address the underlying risk factors for hospital re-admission(s) and emergency room visit(s). Also, the record contains physician's orders dated: -09/02/2022 that states "Buttocks-Cleanse Normal Saline, Apply Zinc Oxide, then Miconazole if Indicated, Cover Dry Sterile Dressing (DCD)". The order is incomplete as it is lacking a frequency. -09/27/2022 that states "Patient (PT) Requires Compression to Manage Bilateral Lower Edema". The order is incomplete as it does not indicate what kind of compression to be applied/used or timeframe for use. -10/06/2022 that states "Ruptured Vesicle is Open. Pt will Need Preventive Care to Deter Infection Potential. Cleanse Normal Saline, Apply Zinc Oxide Periwound, Cover Gauze, Wrap Kerlix and Ace Wrap." The order is incomplete as it does not state the location of the vesicle or the frequency of the wound care. The findings were confirmed on 10/25/2022 at 3:30 PM and 10/26/2022 at 12:15 PM with the Assistant Director of Patient Services, Director of Therapy and Quality Assurance Specialist; no additional evidence was provided. -

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview evidence is lacking in two of six patient records (Patient # 4 and 6) the physician was contacted regarding changes that alter or suggest the need to alter the Plan of Care (POC). Failure to consult with the physician when the POC has been altered has the potential for unmet patient needs and/or negative patient outcomes. Patient # 4 (start of care 03/11/2021) has diagnoses of Pressure Ulcer of Sacral Region, Stage 4 and Venous Insufficiency (Chronic) (Peripheral). The POC for certification period 09/02/2022 through 10/31/2022 states the SN is to conduct three visits the weeks of 10/03/2022 and10/16/2022. The record contains documentation the SN conducted two of the three visits (10/05/2022 and 10/07/2022) the week of 10/03/2022 and two of the three visits (10/12/2022 and 10/17/2022) the week of 10/16/2022. The record lacks documented evidence the physician was notified of the missed visits. Patient # 6 (start of care 01/05/2022) has diagnoses of Pressure Ulcer of Left Buttock, Stage 2 and Type 2 Diabetes Mellitus Without Complications. The POC for certification period 09/02/2022 through 10/31/2022 states the SN is to conduct three visits the week of 09/04/2022. The record contains documentation the SN conducted two of the three visits (09/07/2022 and 09/09/2022) the week of 09/04/2022. The record lacks documented evidence the physician was notified of the missed visit. The findings were confirmed on 10/25/2022 at 3:30 PM and 10/26/2022 at 12:15 PM with the Assistant Director of Patient Services, Director of Therapy and Quality Assurance Specialist; no additional evidence was provided.

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to ensure a physician's plan of care (POC) reflects and/or is based on current information from the patient's updated comprehensive assessment in one of six records reviewed (Patient #4). Failure to ensure the physician's POC reflects and is based on current information from the patient's updated comprehensive assessment has the potential for unmet patient needs and places patients at risk for receiving incorrect and/or inapppriate care. Patient #4 (start of care 03/11/2021) has diagnoses of Pressure Ulcer of Sacral Region, Stage 4 and Venous Insufficiency (Chronic) (Peripheral). The record contains a physician's POC for certification period 09/02/2022 through 10/31/2022 that contains Durable Medical Equipment (DME) orders for catheter insertion set, cane, Hoyer lift, hemi-walker, wheelchair and Foley catheter. The SN recertification assessment dated 08/29/2022 does not include this DME. The record lacks documented evidence the physician's POC reflects and is based on information from the patients updated comprehensive assessment. The finding was confirmed on 10/25/2022 at 3:30 PM with the Assistant Director of Patient Services, Director of Therapy and the Quality Assurance Specialist; no additional evidence was provided.

Contents of clinical record CFR(s): 484.110(a) Standard: Contents of clinical record. The record must include: This STANDARD is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to ensure in one of six records (Patient # 4), that professional staff maintain an accurate, current and clearly documented record related to the provision of the patient's care. Failure to maintain an accurate, current and clearly documented record has the potential for staff to make clinical decisions based on inaccurate and/or missing information with the potential to result in negative patient outcomes. Finding: Patient # 4 (start of care 03/11/2021) has diagnoses of Pressure Ulcer of Sacral Region, Stage 4 and Venous Insufficiency (Chronic) (Peripheral). The clinical record contains a physician's plan of care (POC) for certification period 09/02/2022 through 10/31/2022 that states a goal for the patient is: "Wound status will improve as evidenced by a decrease in size, drainage, absence of infection and decreased pain during certification period". The wound care policy "Wound Care Policy-Policy No II-21" does not include instruction for weekly measurements of wounds. The clinical record lacks documented evidence wounds were measured for the weeks of 10/09/2022-10/15/2022 and 10/16/2022-10/22/2022. The record is unclear as to how the goal will be determined to be met or unmet if the wounds are not measured consistently for decrease in size. The finding was confirmed on 10/25/2022 at 3:30 PM with the Director of Patient Services, Director of Therapy and the Quality Assurance Specialist; no additional evidence was provided.

The following statement of deficiencies represents the results of an onsite complaint investigation of Marquis Certified Home Care, LLC., complaint number NY00276763, conducted on June 24, 2021. The survey consisted of a review of three clinical records and interviews with the Associate Director of Patient Services. The findings were reviewed at the exit conference on June 24, 2021. The complaint allegations were found to be unsubstantiated. The following deficiencies were identified: Federal: G 0574 Plan of Care Must Include the Following; and G 1022 Discharge and Transfer Summaries. State: J 1108 Governing Authority.

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 staff interview the agency failed to ensure a complete physician's Plan of Care (POC) was developed to meet the individualized needs of the patient in three of three patient records (Patient # 1, 2 and 3). Failure to develop a comprehensive POC has the potential for unmet patient needs and places patients at risk for receiving incorrect and/or inappropriate care. Findings: Patient # 1 (start of care 04/03/2021, discharged 06/01/2021) has diagnoses of Pneumonitis due to Inhalation of Food and Vomit and Parkinson's Disease. The POC for certification period 04/03/2021 through 06/01/2021 lacks documented evidence of Emergency Room visit risk assessment and interventions. Also, the Registered Nurse (RN) visit note, dated 04/03/2021 states the patient utilizes Durable Medical Equipment (DME), specifically a standard walker, bedside commode, hospital bead and oxygen equipment. The POC does not contain these DME. Patient # 2 (start of care 12/15/2020, discharged 04/13/2021) has diagnoses of Malignant Neoplasm of Colon and Neoplasm Related Pain. The POC for certification period 02/13/2021 through 04/13/2021 lacks documented evidence of Emergency Room visit risk assessment and interventions. Also, the RN visit noted, dated 02/10/2021 states the patient utilizes DME, specifically grab bars. The POC does not contain this DME. Further, the POC contains an order for Refresh Optive 0.5%-0.9% Eye Drops, 1 drop every 6 hours. The order is incomplete as it does not state which eye (or both) to instill the medication in. Patient # 3 (start of care 01/29/2021, discharged 03/09/2021) has diagnoses of Hydronephrosis with Renal and Ureteral Calculous Obstruction and Type II Diabetes Mellitus without Complications. The POC for certification period 01/29/2021 through 03/29/2021 lacks documented evidence of Emergency Room visit risks and interventions. The findings were confirmed on 06/24/2021 at 11:35 AM, 11:40 AM and 12:40 PM with the Associate Director of Patient Services; no additional evidence was provided.

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 clinical record review and staff interview the agency failed to ensure in three of three records of patients discharged (Patient # 1, 2 and 3) that a comprehensive discharge summary was prepared. Failure to prepare a comprehensive discharge summary places patients at risk for poor coordination of patient services and unmet patient needs upon discharge from the agency. Findings: Patient # 1 (start of care 04/03/2021, discharged 06/01/2021) has diagnoses of Pneumonitis Due to Inhalation of Food and Vomit. The record contains a discharge summary that fails to include patient and family post-discharge instructions. Patient # 2 (start of care 12/15/2020, discharged 04/13/2021) has diagnoses of Malignant Neoplasm of Colon and Neoplasm Related Pain. The record contains a discharge summary that fails to include: - complete medication orders. The summary contains the following orders: - Acetaminophen 325 milligrams (mg), 2 tablets, oral as needed (prn). The order is incomplete as it fails to state the maximum daily dosage (MDD) and the time interval between dosages. - Dicyclomine 10 mg capsule, 1 capsule, Gastric Tube (G-Tube) prn. The order is incomplete as it fails to state the MDD and the time interval between dosages. - Loperamide 2 mg tablet, 1 tablet, prn. The order is incomplete as it fails to state the MDD and the time interval between dosages. - Morphine Extended Release (ER) 60 mg tablet, 1 tablet, prn. The order is incomplete as it fails to state the MDD and the time interval between dosages. - Mucinex 600 mg tablet ER, 1 tablet oral, prn. The order is incomplete as it fails to state the MDD and the time interval between dosages. - Clonazepam 1 mg tablet, 1 tablet, prn. The order is incomplete as it fails to state the MDD and the time interval between dosages. - Sildenafil 100 mg tablet, per instructions oral, 30 to 60 minutes. The order requires clarification of the instructions, dosage and timing for the medication. Also, the discharge summary lacks the patient and family post-discharge instructions. Patient # 3 (start of care 01/29/2021, discharged 03/09/2021) has diagnoses of Hydronephrosis with Renal and Ureteral Calculous Obstruction and Type II Diabetes Mellitus without Complications. The record contains a discharge summary that fails to include: - complete medication orders. The summary contains the following orders: - Januvia 100 mg tablet, 1 tablet oral, as directed. The order requires clarification of "as directed". - Doxycycline Monohydrate 100 mg capsule, per instructions, oral , every 112 hours. The order requires clarification of "per instructions". - Metaxalone 800 mg tablet, per instructions, oral, one time a day. The order requires clarification of "per instructions". - Metformin ER 500 mg tablet, per instructions, oral, one time a day. The order requires clarification of "per instructions". - Methenamine Hippurate, 1 gram tablet, per instructions, oral, daily. The order requires clarification of "per instructions". - Tramadol 50 mg tablet, per instructions, oral, every 12 hours. The order requires clarification of "per instructions". Also, the discharge summary fails to include patient and family post-discharge instructions. The findings were confirmed on 04/24/2021 at 11:40 AM, 11:45 AM and 12:30 PM with the Associate Director of Patient Services; no additional evidence was provided.

The following statement of deficiencies represents the results of an onsite complaint investigation of Marquis Certified Home Care, Llc., complaint number NY00271829, conducted on February 26 through March 1, 2021. The survey consisted of a review of four clinical records, six personnel records, the agency's complaint log and COVID-19 personnel tracking logs. The Associate Director of Patient Services, the Administrator and the Chief Human Resources Officer were interviewed. The findings were reviewed at the exit conference on March 1, 2021. The complaint allegations were found to be partially substantiated. The following deficiencies were found: Federal: G 0536 A Review of all Current Medications; G 0572 Plan of Care G 0574 Plan of Care Must Include the Following; G 0590 Promptly Alert Relevant Physician of Changes; G 0726 Nursing Services Supervised by Registered Nurse; and G 1010 Content of Clinical Record. State: J 1108 Governing Authority; J 1412 Personnel; J 1424 Personnel; J 1440 Personnel; and J 1444 Personnel.

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 clinical record review and staff interview, evidence is lacking in one of one therapy only records (Patient # 1), that an updated, maintained, and accurate comprehensive medication review was performed by the Registered Nurse (RN) at the start of care. Failure to update and maintain an accurate medication review has the potential to result in the patient experiencing adverse medication effects, drug reactions and/or interactions and the inaccurate administration of physician ordered medications. Finding: Patient # 1 (start of care 02/02/2021) has diagnosis of Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Stage 1 - 4 and Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. The record lacks documented evidence that the RN performed a medication review. The finding was confirmed on 02/26/2021 at 12:20 PM with the Associate Director of Patient Services; no additional evidence was provided.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on clinical record review and staff interview the agency failed to ensure services are provided in accordance with the Plan of Care (POC) in one of four records (Patient # 4). Failure to follow the POC has the potential for patients to receive care inconsistent with the physician's orders resulting in unmet patient needs and possible negative patient outcomes. Finding: Patient # 4 (start of care 01/30/2021) has diagnoses of Pressure-Induced Deep Tissue Damage of Left Ankle and Acute Embolism and Thrombosis of Left Popliteal Vein. The record contains a physician's order for certification period 01/30/2021 through 03/30/2021 contains an order for Physical Therapy two times a week times one week, then three times a week times three weeks. The record lacks evidence of a third visit being conducted the week of 02/07/2021. The finding was confirmed on 02/26/2021 at 2:10 PM with the Director of Patient Services; no additional evidence was provided.

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 staff interview the agency failed to ensure a complete Plan of Care (POC) was developed to meet the individualized needs of the patient in four of four records (Patient # 1, 2, 3 and 4). Failure to develop a comprehensive POC has the potential for unmet patient needs and places patients at risk for receiving incorrect and/or inappropriate care. Findings: Patient # 1 (start of care 02/02/2021) has diagnoses of Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1 - 4 Chronic Kidney Disease and Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. The POC for certification period 02/02/2021 through 04/02/2021 contains orders for: - Camphor-Menthol 0.5% - 0.5% topical every 12 hours. Apply a small amount topically twice a day for area with itching. The order is incomplete as it does not state the specific area to apply the medication to. - Cold and Hot (Salicylate-Menthol) 30% - 10% Topical every 8 hours for muscle pain. Apply moderate amount topically 3 times a day as needed for muscle pain. The order is incomplete as it does not state the specific area to apply the medication to. - Eucerin Topical Cream. Apply a moderate amount topically every day for skin. The order is incomplete as it does not state the specific area to apply the medication to. - Insulin Aspart U-100. 100 units/milliliter (ml) subcutaneous solution. Inject 15 to 28 units subcutaneous 3 times a day before meals for diabetes. Blood glucose under 100, take 15 to 18 units. If Blood Glucose over 100 take 20 to 24 units. Blood Glucose over 200 take 28 units. The order requires clarification of the ranges given and when the different amounts should be used. - Miconazole Nitrate 25 Topical Powder, every 12 hours. Use a moderate amount topically twice a day as needed for fungal infection. The order is incomplete as it does not state the specific area to apply the medication to. - Mupirocin 2% topical ointment. Every 12 hours apply a thin film topically twice a day for infection on the knee and toes. The order is incomplete as it does not state the specific area to apply the medication to. - Nitroglycerin 0.4 milligrams (mg) sublingual tablet. Dissolve one tablet under the tongue every five minutes as needed, up to three does for chest pain. The order is incomplete as it fails to state what the patient is to do if the chest pain is unresolved. Also, the POC lacks interventions for risks for re-hospitalizations. Further, the POC lacks risks and interventions to prevent emergency department visits. Patient # 2 (start of care 01/21/2021) has diagnoses of Hemiplegia following Cerebral Infarction affecting Right Dominant Side and Dysarthria Following Cerebral Infarction. The POC for certification period 01/21/2021 through 03/21/2021 contains an order for Clonidine 0.1 mg/24 hour (every 24 hours) weekly transdermal patch. The order is incomplete as it does not state to rotate the site of the patch placement. Also, the Skilled Nurse initial assessment (dated 01/21/2021) documents the patient utilizes Durable Medical Equipment (DME) and Supplies, specifically a wide base quad cane and a rolling walker. The POC lacks these DME. Further, the POC lacks interventions for risks for re-hospitalizations. Also, the POC lacks risks and interventions to prevent emergency department visits. Patient # 3 (start of care 02/05/2021) has diagnoses of COVID-19 and Atelectasis. The POC for certification period 02/05/2021 through 04/05/2021 contains orders for: - Levothyroxine 175 mcg (microgram) tablet daily. The order is incomplete as it fails to instruct the patient to take the medication thirty minutes to one hour prior to consuming food. - Pfizer-Biotech COVID-19 vaccine 30 mcg/0.3 ml IM (intramuscular). Administer 0.3 ml in the muscle as directed. The order is incomplete as it does not state who is to administer the injection or when. Also, the POC is lacking risks and interventions to prevent emergency department visits Further, the SN notes in the initial assessment (dated 01/30/2021), the patient utilizes DME and Supplies, specifically a rollator, wheelchair, bedside commode, tub chair, hospital bed, grab bars and incontinence briefs. The POC lacks these DME and Supplies. The POC states the patient is on a 1800 ADA (American Diabetic Association) diet, regular, no added fat, no added salt. The Speech Language Pathologist (SLP) documents in a note (dated 02/10/2021) the patient is on a pureed diet. The POC requires clarification of the diet. Patient # 4 (start of care 01/30/2021) has diagnoses of Pressure-Induced Deep Tissue Damage of Left Ankle and Acute Embolism and Thrombosis of Left Popliteal Vein. The POC for certification period 01/30/2021 through 03/30/2021 contains an order for Omeprazole 40 mg capsule, delayed release, 2 times a week. The order is incomplete as it does not state which days of the week to take the medication. The POC also contains DME: blood glucose monitor. The POC is incomplete as it lacks orders for blood glucose monitoring. The SN documents in the initial assessment (dated 02/05/2021) the patient utilizes a cane, grab bar and a tub chair. The POC is lacking theses DME. Also, the POC lacks interventions for risks for re-hospitalizations. Further, the POC lacks risks and interventions to prevent emergency department visits. The findings were confirmed on 02/26/2021 at 12:10 PM, 2:10 PM and 2:15 PM with the Associate Director of Patient Services; no additional evidence was provided.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview evidence is lacking in three of four records (Patient # 2, 3 and 4) the physician was contacted regarding changes that alter or suggest the need to alter the Plan of Care (POC). Failure to consult with the physician when changes occur in the patient's condition has the potential for unmet patient needs and/or negative patient outcomes. Finding: Patient # 2 (start of care 01/21/2021) has diagnoses of Hemiplegia following Cerebral Infarct, affecting Right Dominant Side and Dysarthria Following Cerebral Infarction. The POC for certification period 01/21/2021 through 03/21/2021, contains orders for Physical Therapy (PT) visits 2 times a week for seven weeks. The record lacks documented evidence any PT visits were made the week of 01/31/2021. The record lacks documented evidence the physician was notified of the change to the POC. Patient # 3 (start of care 02/05/2021) has diagnoses of COVID-19 and Atelectasis. The Skilled Nurse documents in Visit Notes (dated 02/10, 02/12 and 02/15/2021) the patient has a rash on back and buttocks. The nurse documents she recommends using antihistamines and ointments. The record lacks documented evidence the physician was notified of the rash and that an order was obtained for treatment. Patient # 4 (start of care 01/30/2021) has diagnoses of Pressure-Induced Deep Tissue Damage of Left Ankle and Acute Embolism and Thrombosis of Left Popliteal Vein. The POC for certification period 01/30/2021 through 03/30/2021 contains an order for PT two times a week for one week. The record lacks documented evidence of a second visit being conducted the week of 02/07/2021. The record lacks documented evidence the physician was notified of the change in the POC. The findings were confirmed on 02/26/2021 at 2:10 PM with the Associate Director of Patient Services; no additional evidence was provided.

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to ensure adequate supervision of the Licensed Practical Nurse (LPN) staff in one of four records reviewed (Patient # 3). Failure to adequately supervise LPN staff has the potential to result in the provision of inappropriate and/or incorrect care and negative patient outcomes. Finding: Patient # 3 (start of care 02/05/2021) has diagnoses of COVID-19 and Atelectasis. The record contains a LPN visit note (dated 02/15/2021). There is no documented evidence that the visit note was reviewed. The finding was confirmed on 02/26/2021 at 2:10 PM with the Associate Director of Patient Services; no additional evidence was provided.

Contents of clinical record CFR(s): 484.110(a) Standard: Contents of clinical record. The record must include: This STANDARD is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to ensure in one of four records (Patient # 3), that professional staff maintain an accurate, current and clearly documented record related to the provision of the patient's care. Failure to maintain an accurate, current and clearly documented record has the potential for staff to make clinical decisions based on inaccurate and/or missing information with the potential to result in negative patient outcomes. Finding: Patient # 3 (start of care 02/05/2021) has diagnoses COVID-19 and Atelectasis. The clinical record contains an Occupational Therapy (OT) note (dated 02/17/2021) that documents in the Vital Signs section, that the patient's blood pressure (BP) is 124/38 which is outside the physician ordered parameters. In the same note, the OT documented under "Physician Contacted", No. The OT also documented in the note under "Comments", MD aware. The record requires clarification if the physician was contacted. The finding was confirmed on 02/26/2021 at 2:10 PM with the Associated Director of Patient Services; no additional evidence was provided.