Every finding on record at North Shore University Hospital, Inc., D/B/A North Shore Home Care

An onsite complaint survey # 110498 was conducted at North Shore Home Care, Certified Home Health Agency located at 972 Brush Hollow Road, Westbury NY 11590. The complaint survey started on 11/13/2024 and exited on 11/14/2024. The complaint survey was authorized by Centers for Medicare and Medicaid Services (CMS) to evaluate the Agency’s compliance with Conditions of Participation 484.55 Comprehensive Assessment of Patients (G510) and 484.60 Care Planning, Coordination, Quality of Care (G570). The Agency’s active patients census as of 11/13/2024 is 799 patients for the Westbury and New York City branches. The survey consisted of a review of three (3) clinical records, identified as (Patients #1, #2, and #3) and two (2) employee records identified as (Employees #1 and #2). Additional reviews include the Complaint Logs for the months of 03/07/2024 to 06/13/2024. The Agency has no documented patient complaints received for the months of 07/01/2024 to 11/13/2024. The Home Care Workers policy was reviewed pertaining to the Home Care Registry Aides Profile. Interviews were conducted with the Assistant Vice President of Clinical Services, Director of Patient Services and The Registered Nurse on 11/14/2024. The allegations in Complaint 110498 are determined substantiated. The following deficiencies are cited as a result on the survey: G528- Health, Psychosocial, functional, and cognitive needs G534 - Medical, Nursing, Rehabilitation, Social and discharge needs G574- Plan of Care must include. J1406 - 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 clinical record review and staff interview, the Agency failed to ensure Comprehensive Assessments include all pertinent Endocrine and Muscular skeletal status. This was evident in one (1) of three (3) records reviewed (Patient #1). Failure to ensure that Comprehensive Assessments include the patient's Endocrine and Muscular Skeletal status, has the potential for negative outcome. . Patient #1 has a start of care date 09/28/2024 with diagnoses of "Hypertensive Heart Disease with Heart Failure, Acute Diastolic Congestive Heart Failure, ST Elevation Myocardial Infarction of Unspecified Site, Arteriosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Presence of Coronary Angioplasty Implant and Graft, Pre-Diabetes, Hyperlipidemia, Cannabis use, Long Term use of Anticoagulant, Long Term use of Antithrombotic/Antiplatelets, Long Term use of Oral Hyperglycemic drugs" as documented on the "Home Health Certification and Plan of Care" for certification period 09/28/202 to 11/26/2024. The "Home Health Certification and Plan of Care" for certification period 09/28/202 to 11/26/2024 documents an order for Skilled Nurse services "1 -3 week 9, 4 as needed visits (one to three visits a week for nine weeks, four visits as needed)". Skilled Nurse to "assess patient's strength, skilled observation and assessment of mental status, neurovascular status, cardiopulmonary status, musculoskeletal status, gastrointestinal status, genitourinary status, skin integrity, nutrition, hydration and home safety". The start of care "OASIS Assessment" report dated 09/28/2024, the Skilled Nurse documents "Endocrine and Hematopoietic status" and Musculoskeletal status as "NA" (Not Applicable). The comprehensive assessment lacks documented evidence of the patients' Endocrine system and Muscular-skeletal assessment pertinent to the patients primary and secondary diagnoses. The survey findings and interview were conducted with the Assistant Vice President of Clinical Services, Director of Patient Services on 11/14/2024 at 01:00 PM. No explanation was provided. Interview conducted with the Skilled Nurse on 11/14/2024 at 01:30PM, the Skilled reported that she did assess the muscular skeletal system but components in this category was not applicable.

Patient's needs CFR(s): 484.55(c)(4) The patient's medical, nursing, rehabilitative, social, and discharge planning needs; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, the Agency failed to ensure the continued Home Health Aide service needs of the patient upon discharge. This was evident in one (1) of one (1) discharge record reviewed. (Patient #1) Failure to ensure the continued need for Home Health Aide services, has the potential for negative patient outcome. Patient #1 has a start of care date 09/28/2024 with diagnoses of "Hypertensive Heart Disease with Heart Failure, Acute Diastolic Congestive Heart Failure, ST Elevation Myocardial Infarction of Unspecified Site, Arteriosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Presence of Coronary Angioplasty Implant and Graft, Pre-Diabetes, Hyperlipidemia, Cannabis use, Long Term use of Anticoagulant, Long Term use of Antithrombotic/Antiplatelets, Long Term use of Oral Hyperglycemic drugs" as documented on the "Home Health Certification and Plan of Care" for certification period 09/28/202 to 11/26/2024. The Consent for services dated 09/28/2024 documents "Home Health Aide" services 1-3x (one to three times) a week. The "Home Health Certification and Plan of Care" for certification period 09/28/202 to 11/26/2024 documents an order for Skilled Nurse services "1 -3 week 9, 4 as needed visits (one to three visits a week for nine weeks, four visits as needed)". Skilled Nurse to assess the patient's "home safety". The start of care "OASIS Assessment" report dated 09/28/2024, the Skilled Nurse documents the patient's "Current ability to dress lower body - someone must help the patient put on undergarments, slacks, socks, shoes. Bathing - able to bathe in shower or tub with intermittent assistance of another person. Toileting - when reminded assisted or supervised by another person, able to get to and from toilet and transfer. Transferring - able to weight bear and pivot during transfer process, but unable to transfer self. Ambulation/Locomotion - able to walk only with the supervision or assistance of another person at all times". The Skilled Nurse visit notes dated 10/01/24, 10/5/24, and 10/8/24, the Skilled Nurse documents “waiting for Home Health Aide” services. Home Health Aide services was provided on 10/18/24, 10/21/24 – 10/25/24, and 10/28/24. The patient has a discharge date of 10/28/2024 and remains in the community with no Home Health Aide services. The clinical record lacks documented evidence that the Home Health Aide needs of the patient was referred to other community resources prior to discharge. A telephone interview was conducted with the patient on 11/14/2024, the patient reported that she "was notified of discharge, remains in the community awaiting for aide services from long-term care to start December 1, 2024". The patient was discharged to the community without Home Health Aide services in place to meet the patient’s need for assistance with Activities of Daily Living and continued Home Health Aide services. The survey findings and interview were conducted with the Assistant Vice President of Clinical Services, Director of Patient Services on 11/14/2024 at 01:00 PM. No explanation 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 establish an individualized Plan of Care that includes Home Health Aide services. This was evident in one (1) of three (3) records reviewed. (Patient #1). Failure to establish an individualized Plan of Care, has the potential for negative patient outcome. Patient #1 has a start of care date 09/28/2024 with diagnoses of "Hypertensive Heart Disease with Heart Failure, Acute Diastolic Congestive Heart Failure, ST Elevation Myocardial Infarction of Unspecified Site, Arteriosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Presence of Coronary Angioplasty Implant and Graft, Pre-Diabetes, Hyperlipidemia, Cannabis use, Long Term use of Anticoagulant, Long Term use of Antithrombotic/Antiplatelets, Long Term use of Oral Hyperglycemic drugs" as documented on the "Home Health Certification and Plan of Care" for certification period 09/28/202 to 11/26/2024. The "Home Health Certification and Plan of Care" (Plan of Care) for certification period 09/28/202 to 11/26/2024 documents an order for Skilled Nurse services "1 -3 week 9, 4 as needed visits (one to three visits a week for nine weeks, four visits as needed)". Skilled Nurse to "assess patient's strength, skilled observation and assessment of mental status, neurovascular status, cardiopulmonary status, musculoskeletal status, gastrointestinal status, genitourinary status, skin integrity, nutrition, hydration and home safety". Physical Therapy services 1 -3 week 9 (one to three visits a week for nine weeks) to assess "muscle strength, balance, pain, transfer, stair negotiation, ADL (Activities of Daily Living), Endurance, Limited Ambulation, therapeutic exercise, transfer training, gait training, balance activities, stair instruction, establish or upgrade HEP (Home Exercise Program)". The start of care "OASIS Assessment" report dated 09/28/2024, the Skilled Nurse documents "Reason for homebound - patient is at risk for fall, patient with unsteadiness with ADL's, SOB (Shortness of Breath with ambulating long distances. Condition affecting Respiratory status - Dyspnea with moderate exertion (for example, while dressing, using commode or bedpan, walking distances less than 20 feet). Current ability to dress lower body - someone must help the patient put on undergarments, slacks, socks, shoes. Bathing - able to bathe in shower or tub with intermittent assistance of another person. Toileting - when reminded assisted or supervised by another person, able to get to and from toilet and transfer. Transferring - able to weight bear and pivot during transfer process, but unable to transfer self. Ambulation/Locomotion - able to walk only with the supervision or assistance of another person at all times". The Skilled Nurse documents "start of care intervention/care plan - Home Health Aide ordered - yes - awaiting placement". The Plan of Care lacks an order for Home Health Aide services ordered on 09/28/2024 based on the Skilled Nurse assessment of the patient's immediate care needs for Home Health Aide services. The Agency did not ensure that the Plan of Care include Home Health Aide services to meet the immediate care needs of the patient. The survey findings and interview were conducted with the Assistant Vice President of Clinical Services, Director of Patient Services on 11/14/2024 at 01:00 PM. No explanation was provided.