Every finding on record at Otsego SNF Operations Associates, LLC

The following statement of deficiencies represents the results of a standard re-certification survey of Centers Home Health Care of Otsego, Certified Home Health Care Agency on March 23 through March 25, 2021. A focused COVID-19 infection control survey was conducted in conjunction with the re-certification survey; the finding were found to be acceptable. The survey consisted of a review of seven clinical records of the agency's twelve active patients and two discharge records, six personnel records for professional and paraprofessional personnel, and three observational home visits. The survey included a review of pertinent policies and procedures, Quality Improvement Meeting minutes for the past twelve months, agency's Admission Packet the Emergency Preparedness Plan and Complaint Log. Pre-survey activities consisted of review on March 2, 2021 of the Agency's Health Commerce System account, Home Care Worker Registry, Criminal History Record Check, Certification and Survey Provider Enhanced Reports (CASPER) for the period December 03, 2019 through November 30, 2020, the agency's compliance with report submissions for the 2018 statistical report and the Emergency Drill conducted June 11 through June 13, 2019. The Administrator, Director of Patient Services, and Associate Vice President of Clinical Operations were interviewed. Findings were reviewed at the the exit conference on March 25, 2021. The following deficiencies are identified as a result of the survey: Federal: G 0514 Registered Nurse Performs Assessment; G 0574 Plan of Care Must Include the Following: G 0590 Promptly Alert Relevant Physician of Changes; G 0798 Home Health Aide Assignments and Duties; and G 1010 Contents of Clinical Record. State: J 0404 Policies and Procedures of Service Delivery; J 1108 Governing Authority; J 1156 Governing Authority; J 1168 Governing Authority; J 1276 Governing Authority; J 1412 Personnel; J 1416 Personnel; J 1420 Personnel; J 1424 Personnel; J 1426 Personnel; J 1440 Personnel; J 1444 Personnel; J 1452 Personnel; J 1460 Personnel; W 0610 Responsibilities of Home Care Services Entities; W 0614 Responsibilities of Home Care Services Entities; R 0504 General Requirements; and R 1022 Responsibilities of Providers; Required Notifications.

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 two of seven records (Patient # 2 and 5) 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 03/18/2021) has diagnoses of Iron Deficiency Anemia and Hypertensive Heart Disease with Heart Failure. The record contains a health center referral dated 03/09/2021 with no specific physician ordered start of care date. The patient was discharged from the health center on 03/12/2021. The Skilled Nurse (SN) conducted the initial assessment on 03/18/2021, four days after the patient's discharge from the skilled nursing center. Patient # 5 (start of care 02/18/2021) has a diagnosis of Neurofibromatosis. The record contains a physician referral dated 01/26/2021 with no specific physician ordered start of care date. The SN conducted the initial assessment on 02/17/2021, twenty days after the agency received the referral. The findings were confirmed on 03/24/2021 at 9:40 AM and 3:00 PM with the Director of Patient Services and the Associate Vice President of Clinical Operations; 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 seven of seven patient records (Patient # 1, 2, 3, 4, 5, 6 and 7). 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 03/18/2021) has diagnoses of Aftercare Following Joint Replacement Surgery and Presence of Right Artificial Knee Joint. The POC for certification period 03/18/2021 through 05/16/2021 contains an order for Halobetasol Propionate 0.05% topical ointment, per instructions, 2 times daily/prn (as needed). The order is incomplete as it lacks specific instructions on where to apply the ointment. The POC also lacks interventions to prevent rehospitalizations. Further, the POC is lacking a risk assessment and interventions to prevent Emergency Department visits. Patient # 2 (start of care 03/18/2021) has diagnoses of Iron Deficiency Anemia and Hypertensive Heart Disease with Heart Failure. The POC for certification period 03/18/2021 through 05/16/2021 contains orders for: - Amlodipine 10 milligrams (mg) tablet, one tablet daily for 180 days. The order is incomplete as it does not state a specific end date. - Gabapentin 300 mg capsule, 1 capsule, 3 times daily for 180 days. The order is incomplete as it does not state a specific end date. - Rosuvastatin 5 mg tablet, 1 tablet daily, two times daily for 180 days. The order is incomplete as it does not state a specific end date. Also, the POC is lacking risks and interventions for Emergency Department visits. Further, the Skilled Nurse (SN) initial assessment (dated 03/18/2021) contains documentation the patient utilizes Durable Medical Equipment (DME), specifically grab bars and a Lifeline (Personal Emergency Response System). The POC is incomplete as it does not contain DME: grab bars nor a Lifeline. Patient # 3 (start of care 03/03/2021) has diagnoses of Encounter for Surgical Aftercare following Surgery on the Skin and Disruption of External Operation (Surgical) Wound. The POC for certification period 03/03/2021 through 05/01/2021 contains orders for: - Cephalexin 500 mg capsule, 1 capsule every 6 hours, take for 10 days. The order is incomplete as it does not state the specific end date. - Docusate Sodium 100 mg capsule, 2 capsules, two times daily, take for 10 days. The order is incomplete as it does not state the specific end date. Also, the POC is lacking risks and interventions for Emergency Department visits. Further, the SN initial assessment (dated 03/03/2021) contains documentation the patient utilizes DME, specifically a cane. The POC is incomplete as it does not contain DME: cane. Patient # 4 (start of care 12/23/2020) has diagnoses of Encounter for Fitting and Adjustment of Urinary Device and Malignant Neoplasm of Prostate. The POC for certification periods 12/23/2020 through 02/20/2021 and 02/21/2021 through 04/21/2021 contain orders for: - Artificial Tears (Hypromellose) 0.3% eye gel, daily/prn, 1 drop to eye daily as needed for dryness. The order is incomplete as it fails to specify which eye or both to apply the gel to. - Levothyroxine 75 micrograms (mcg) tablet, 1 tablet daily. The order is incomplete as it does not state the medication is to be taken 30 minutes to 1 hour prior to consuming food. - Triamcinolone Acetonide 0.1% topical ointment cream, 2 times daily/prn, apply twice a day to affected areas times 2 - 3 weeks. The order is incomplete as it does not specify the specific sites to apply the cream to. - Votaren 1% topical gel, 4 times daily/prn, apply 2 grams daily. The order is incomplete as it does not state the specific area to apply the gel to. - Hydrocodone 10 mg - Acetaminophen 325 mg tablet, 1 tablet, 4 times daily/prn. The order is incomplete as it does not state the time frame between dosages. Also, the POC is incomplete as it does not state the risks and interventions for Emergency Department visits. Further the SN reassessment (dated 02/17/2021) documents the patient utilizes DME, specifically a tub chair and glucometer. The POC for certification period 02/21/2021 through 04/21/2021 lacks DME: tub chair and glucometer. Patient # 5 (start of care 02/18/2021) has a diagnosis of Neurofibromatosis. The POC for certification 02/18/2021 through 04/18/2021 contains an order for Keoconazole 2% topical cream, daily, apply to affected areas. The order is incomplete as it does not specify the affected areas. Also, the POC is incomplete as it does not contain risks and interventions for Emergency Department visits. Patient # 6 (start of care 06/19/2020, discharged 6/23/2020) has diagnoses of Encounter for Change or Removal of Nonsurgical Wound Dressing and Cellulitis of Right Lower Limb. The POC for certification period 06/19/2020 through 08/17/2020 is lacking risks and interventions for Emergency Department visits. Also, the SN documents in the initial assessment (dated 06/19/2020) the patient utilizes DME, specifically a standard walker, Hoyer lift, grab bars and diabetic supplies. The POC is incomplete as it lacks DME: standard walker, Hoyer lift, grab bars and diabetic supplies. Patient # 7 (start of care 04/21/2020, discharged 05/11/2020) has diagnoses of Hemiplegia Following Cerebral Infarction Affecting Right Dominant Side and Essential (Primary) Hypertension. The POC for certification period 04/21/2020 through 06/19/2020 lacks risks and interventions for Emergency Department visits. The findings were confirmed on 03/24/2021 at 9:35 AM, 9:40 AM, 1:50 PM, 2:20 PM, 3:00 PM, 03/25/2021 at 10:15 AM and 3:50 PM with the Director of Patient Services and the Associate Vice President of Clinical Operations; no further 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 seven records (Patient # 5) 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 # 5 (start of care 02/18/2021) has a diagnosis of Neurofibromatosis. The Skilled Nurse (SN) documents in a visit note (dated 02/26/2021), "Patient reports some weeping or discharge on this pillow case this morning." There is no documentation the physician was notified of this change. The SN documents in a visit note (dated 03/15/2021), "Small Neurofribromatosis lesion on left upper shoulder remains red. Patient noted some blood on T-shirt overnight." There is no documentation the physician was notified of this change. The findings were confirmed on 03/24/2021 at 3:00 PM with the Director of Patient Services and the Administrator; no additional evidence was provided.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on review of one clinical record of a patient receiving paraprofessional aide services and staff interview the agency failed to ensure in one of one records reviewed (Patient # 3) the aide Plan of Care (POC) was complete to meet the individualized needs of the patient. Failure to ensure the development of a comprehensive aide POC to reflect the patient's needs has the potential to result in inappropriate care, unmet patient needs and possible negative outcomes. Findings: Patient # 3 (start of care 03/03/2021) has diagnoses of Encounter after Surgery of Skin and Disruption of External Operation wound. The physician POC for certification period 03/03/2021 through 05/01/2021 documents Nutritional Requirements: Cardiac Diet, Low Fat, Low Sodium. The aide POC (dated 03/03/2021) states Diet: Regular/Low Sodium. The aide POC is incomplete as it does not state the complete diet requirements. Also, the physician POC states Safety Measures: ambulation, ankle precautions, COVID-19 precautions, fall precautions, foot precautions, skin, universal, endurance and wound precautions. The aide POC is incomplete as it does not state any of these precautions. Further, the physician POC states Allergies: No known allergies. The aide POC states Allergies: Mushrooms. The aide POC requires clarification of allergies. The findings were confirmed on 03/24/2021 at 1:50 PM with the Director of Patient Services and Administrator; 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 seven records (Patient # 5), 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 # 5 (start of care 02/18/2021) has a diagnoses Neurofibromatosis. The clinical record contains a physician "face to face" encounter (dated 01/12/2021) that states the patient is homebound due to poor mobility and fall risk. The clinical record contains a Skilled Nurse initial assessment (02/18/2021) that documents, "The patient has no restrictions from leaving the home." The record requires clarification if the patient is home bound as certified by the physician or not. The finding was confirmed on 03/24/2021 at 3:00 PM with the Director of Patient Services and the Administrator; no additional evidence was provided.