Every finding on record at Royal Care Certified Home Health Care, LLC

An on-site investigation of Complaint #107298 was conducted at Royal Care Certified Home Health Care, LLC, located at 30-50 Whitestone Expressway, Flushing, NY 11354 on 06/12/2024 - 06/13/2024. Three (3) clinical records were reviewed and are identified as (Patient #1, #2, and #3) and three (3) Personnel records were reviewed and are identified as (Employee #1, #2 and #3). The Complaint and Incident Log for the period 04/01/2024 to 06/12/2024, Active and Discharged census, Agency's Policies and Procedure were reviewed. The active patient census is 519. The Quality Assurance Supervisor was interviewed. The findings were reviewed at the exit conference on 06/13/2024. The allegation for complaint #107298 was determined to be substantiated. The following deficiencies are being cited as a result of the complaint investigation: G 0576 - All Orders Recorded in Plan of Care G 0598 - Discharge Plan Communication G 0718 - Communication with Physician J 1276 Governing Authority

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview the agency failed to ensure that all orders for changes in the patient's treatment(s) are included/ recorded in the patient's Plan of Care for continuity of care. This was evident for one (1) of three (3) patient care records reviewed (Patient #1). Failure to review, revise and record all orders in the patient's Plan of Care has the potential for negative patient outcome. The findings are: 1.Patient #1 has a Start of Care date of 04/26/2024 and discharge date of 05/28/2024 with the following diagnosis "Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-dominant Side, Parkinson's Disease without Dyskinesia, Essential (Primary) Hypertension, Retention of Urine" documented on the Home Health Certification and Plan of Care for the Certification Period 04/26/2024 to 06/24/2024. The Home Health Certification and Plan of Care for the Certification Period 04/26/2024 to 06/24/2024 signed by MD (Medical Doctor) on 05/23/2024 documents: " Skilled Nurse to instruct patient/caregiver in indwelling urinary catheter management including care of Foley catheter, signed and symptom of complication, perineal care, tube and bag placement. Skilled Nurse for insertion of urinary catheter maintenance with catheter 16 FR/30 CC balloon, change 4 weeks and PRN (as needed), sign and symptoms of complications, perinea care, tube and bag placement." The Clinical Coordination Note dated 05/12/2024 (Sunday) documents: "As per RN (Registered Nurse) - She received a call from the patient's grandson that the "cath" (catheter) is out. The family reports is voiding and did not want to go to ER (Emergency Room). The patient was instructed by RN (Registered Nurse) to follow up with ER (Emergency Room) if no urinary occurred. RN (Registered Nurse) Manager called NP (Nurse Practitioner) #2." The Client Coordination Note dated 06/13/2024 documents: " RN (Registered Nurse) (Clinical Manager) reached out NP (Nurse Practitioner) #2 via text on 05/13/24. Per NP (Nurse Practitioner) #2, hold off on Foley catheter until she has completed her visit 5/15/24." The NP (Nurse Practitioner) Visit Note documents:" Seen on 05/16/2024. Received the bladder ultrasound which shows some urine retention, 500 ml. Called the patient and spoke with the husband and explained what the plan is, to give 2 days of Lasix 20 mg and repeat bladder sonogram on Monday. Patient is urinating with no problem, no discomfort. Patient phone message: - will order loop diuretic to take for 2 days -repeat sonogram on Monday" The NP (Nurse Practitioner) Visit Note documents:" Seen on 05/23/2024. Had called the portable company to get the result of bladder and I was told it was not done because the husband refused. Also, the RN (Registered Nurse) from the agency informed me that patient had refused to take the Lasix I had ordered. Called the husband, no answer, called and spoke with the daughter who refused all my plan of care, patient and family not compliant therefore I had advised the agency to discharge patient since she does not want me as a provider and does not follow my instructions. -Instructed agency to discharge the patient due to noncompliance." The Interim Physician Order dated 05/24/2024 documents: "NP #2 (Nurse Practitioner name) ordered Lasix 20 mg tablet, once a day by mouth for two days. Patient's husband/son verbalized that prescription was called into the local pharmacy." The agency's "Physician Participation in Plan of Care" policy, number 2-019.1 documents: "If the patient is under the care more than one (1) physician, the nurse will be responsible to the physician who signs the certification and plan of care. All other physicians should be made aware of the services being provided to the patient. The primary physician will be informed of the involvement of the medical clinicians. Orders provided by the other physicians involved in the patient's care will be obtained in writing as well." The Interim Physician Order dated 05/24/2024 documents: "NP #2 (Nurse Practitioner) ordered Lasix 20 mg tablet, once a day by mouth for two days. Patient's husband/son verbalized that prescription was called into the local pharmacy." The Clinical record lacks documented evidence of the order for holding off on the Foley catheter until Nurse Practitioner completed visit on 05/15/2024, and order for Lasix and Sonogram prior 05/24/2024 (changes in the Foley care) and communication with the other physicians. (MD who signed 485 and NP (Nurse Practitioner) #1) On 05/12/2024 at 04:00 pm, the Quality Assurance Supervisor was interviewed and did not provide an explanation for the findings.

Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient's discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner's issuing orders for the HHA plan of care, and the patient's 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). This ELEMENT is not met as evidenced by: Based on clinical record review, and staff interviews, the agency failed to communicate with all physicians/caregiver(s)/patient regarding patient's discharge. This was evident for one (1) of three (3) patient care records reviewed (Patient #1). Failure to communicate with all physicians/caregiver(s)/patient regarding patient's discharge has the potential for negative patient outcomes. The findings are: 1.Patient #1 has a Start of Care date of 04/26/2024 and discharge date of 05/28/2024 with the following diagnosis "Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-dominant Side, Parkinson's Disease without Dyskinesia, Essential (Primary) Hypertension, Retention of Urine" documented on the Home Health Certification and Plan of Care for the Certification Period 04/26/2024 to 06/24/2024. The Home Health Certification and Plan of Care for the Certification Period 04/26/2024 to 06/24/2024 signed by MD on 05/23/2024 documents: " Skilled Nurse to instruct patient/caregiver in indwelling urinary catheter management including care of Foley catheter, signed and symptom of complication, perineal care, tube and bag placement. Skilled Nurse for insertion of urinary catheter maintenance with catheter 16 FR/30 CC balloon, change 4 weeks and PRN (as needed), sign and symptoms of complications, perinea care, tube and bag placement." The Interim Physician Order dated 05/24/2024 documents: "NP #2 (Nurse Practitioner) ordered Lasix 20 mg tablet, once a day by mouth for two days. Patient's husband/son verbalized that prescription was called into the local pharmacy." The Client Coordination Note dated 05/28/2024 documents: "As per DPS (Director of Patient Services) and provider NP (Nurse Practitioner) patient/family are still noncompliance with NP's request for patient to take Lasix and have a second bladder scan prior to deciding if Foley catheter is medically necessary. RN (Registered Nurse) (Clinical Manager) spoke with patient's son on Friday (05/24/24), who stated he would speak to patient and her husband as well as his sister in Israel and pick up prescription from the local pharmacy for the two tablet of Lasix (one tablet a day). RN (Registered Nurse) (Clinical Manager) spoke with the patient's husband today 05/28/24, who stated Lasix was not taken as directed and asked if Royal RN (Registered Nurse) would arrive at the house to place a Foley catheter. The RN (Registered Nurse) (Clinical Manager) explained RN (Registered Nurse) cannot place a catheter without an order. Husband stated they had not contacted NP (Nurse Practitioner) #2. RN (Clinical Manager) notified the provider, who stated to discharge the patient from Royal services for noncompliance with her Care Plan." 05/28/2024 (date of discharge) and last OT (Occupational Therapy) visit. The Client Coordination Note dated 05/28/2024 documents: RN (Clinical Manager) spoke with patient's daughter and explained that patient is being discharged for noncompliance with provider NP's#2 Plan of Care. Daughter is insistent that NP (Nurse Practitioner) #1 has seen patient and sent Foley insertion orders, however daughter stated that NP (Nurse Practitioner) #1 was not responding to any calls or messages. Clinical Manager explained that NP (Nurse Practitioner) #2 was the provider that was active in the case. Especially if NP (Nurse Practitioner) #1 had not responded back. Therefore, per NP (Nurse Practitioner) #2 and DPS (Director of Patient Services), patient will be discharged from Royal services. Update 05/29/24 - RN (Registered Nurse) (Clinical Manager) unable to reach NP (Nurse Practitioner) #1. Left detailed voicemail regarding patient's discharge from Royal care CHHA's (Certified Home Health Agency) services. Patient's daughter also aware of the discharge and no order from NP (Nurse Practitioner) #1 to reinsert Foley Catheter found." The Client Coordination Note dated 05/31/2024 documents: "This morning, 5/31/24 NP (Nurse Practitioner) #1 reached out and acknowledged my call to inform them of patient's discharge from Royal and also that they are in fact very late in responding to messages and calls (during the case and after discharge of this case). I explained the reason for discharge and requested a referral to another CHHA (Certified Home Health Agency) and NP (Nurse Practitioner) said they'd work on it." The Discharge-Transfer Summary documents: " Physician: NP (Nurse Practitioner) #1 name Discharge to home or self-care:/reason: Non-compliant with plan of treatment. Episode End Date:05/28/2024 DC(Discharge) Coordination Note: Date of Discipline Discharge: 5/28/24 Reason for Discharge: Noncompliance with POC (Plan of Care) Declined further treatment, evaluation from NP (Nurse Practitioner) Patient discharged for non-compliance." The agency's "Discharge Criteria and Process" policy, number 2-044.1 documents: "Procedure: 1. The organization will verbally notify the patient of the decision to terminate services as soon as a discharge date is known but not late than the next to the last visit when discharge has been planned. Prior notice will not be necessary when services are discharge by the patient or physician; however, information and action taken regarding the request discharge must be documented in the clinical record. 2. Patient and/or family/caregiver and the patient's physician will be informed at least one week in advance of the intended discharge date followed by written notice when feasible where discharge is for cause such as: Failure to cooperate or comply with the plan of care." The Clinical record lacks documented evidence of the communication with the MD (who signed 485), NP (Nurse Practitioner) #1(prior 05/29/2024) and the caregiver/patient regarding the patient's discharge planning in advance. On 05/12/2024 at 03:00 pm, the Quality Assurance Supervisor was interviewed and did not provide an explanation for the findings.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview the agency failed to ensure ongoing communication with all physicians is maintained. This was evident for one (1) of three (3) patient care records reviewed (Patient #1). Failure to ensure ongoing communication with all physicians is maintained has the potential for negative patient outcome. The findings are: 1.Patient #1 has a Start of Care date of 04/26/2024 and discharge date of 05/28/2024 with the following diagnosis "Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-dominant Side, Parkinson's Disease without Dyskinesia, Essential (Primary) Hypertension, Retention of Urine" documented on the Home Health Certification and Plan of Care for the Certification Period 04/26/2024 to 06/24/2024. The Home Health Certification and Plan of Care for the Certification Period 04/26/2024 to 06/24/2024 documents: “Increased pain or ineffective pain control measures will be identified and promptly reported to the Physician.” The OT (Occupational Therapy) Visit dated 05/03/2024 documents: "Indicate Client’s Current Pain Scale Rating: 5 Indicate Client’s Pain Scale Rating for Best/Least Intensity of Pain:7 Indicate Client’s Pain Scale Rating for Worst/Most Intensity of Pain:8” The OT (Occupational Therapy) Visit dated 05/07/2024 documents: "Indicate Client’s Current Pain Scale Rating: 5 Indicate Client’s Pain Scale Rating for Best/Least Intensity of Pain:8 Indicate Client’s Pain Scale Rating for Worst/Most Intensity of Pain:8” The OT (Occupational Therapy) Visit dated 05/09/2024 documents: "Indicate Client’s Current Pain Scale Rating: 5 Indicate Client’s Pain Scale Rating for Best/Least Intensity of Pain:6 Indicate Client’s Pain Scale Rating for Worst/Most Intensity of Pain:7” The OT (Occupational Therapy) Visit dated 05/16/2024 documents: "Indicate Client’s Current Pain Scale Rating: 7 Indicate Client’s Pain Scale Rating for Best/Least Intensity of Pain:4 Indicate Client’s Pain Scale Rating for Worst/Most Intensity of Pain:8” The OT (Occupational Therapy) Visit dated 05/17/2024 documents: "Indicate Client’s Current Pain Scale Rating: 5 Indicate Client’s Pain Scale Rating for Best/Least Intensity of Pain:8 Indicate Client’s Pain Scale Rating for Worst/Most Intensity of Pain:10” The OT (Occupational Therapy) Visit dated 05/21/2024 documents: "Indicate Client’s Current Pain Scale Rating: 6 Indicate Client’s Pain Scale Rating for Best/Least Intensity of Pain:8 Indicate Client’s Pain Scale Rating for Worst/Most Intensity of Pain:9” The OT (Occupational Therapy) Visit dated 05/28/2024 documents: "Indicate Client’s Current Pain Scale Rating: 6 Indicate Client’s Pain Scale Rating for Best/Least Intensity of Pain:8 Indicate Client’s Pain Scale Rating for Worst/Most Intensity of Pain:8” 05/28/2024 (date of discharge) and last OT (Occupational Therapy) visit. The Clinical Record lacks documented evidence of the communication with the Physician(s) regarding the patient’s pain before discharge on 05/28/2024. On 05/12/2024 at 04:00 pm, the Quality Assurance Supervisor was interviewed and did not provide an explanation for the findings.

The following statement of deficiencies represents the results of partial extended re-certification survey of Royal Care Certified Home Health Agency located at 30-50 Whitestone Expressway, Suite 304, Flushing, NY 11354 conducted on 08/28/2023 through 09/01/2023. The active patient census is 703. The survey consisted of a review of eleven (11) personnel records identified as Employee #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11, nineteen (19) clinical records identified as Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, and #19, seven (7) home visits. The survey included a review of pertinent policies and procedures, Quality Improvement Meeting Minutes for past 12 months, PIP (Performance Improvement Projects), Admission Packet, Emergency Preparedness Plan, Complaint Log, Three (3) contracts, and the agency's COVID-19 and Flu policy and procedure, and Vaccination Log. Pre-survey activities consisted of a review on 08/22/2023 of the agency's Health Commerce System account, Certification and Surveyor Provider Enhanced Reports (CASPER) for the period 06/2022 – 05/2023, and the agency compliance with report submissions for the 2021 statistical report and the Emergency Drill for 2019. The allegations in complaint # 97747 were determined to be substantiated. The allegations in complaint #70683 were determined to be unsubstantiated. The allegations in complaint # 59545 were determined to be substantiated. The Administrator, and staff were interviewed. Findings were reviewed at the exit conference on 09/01/2023. The following deficiencies are identified as a result of the survey: G0414 – Accuracy of encoded OASIS data G0536 – A review of all current medications G0544 – Update of the comprehensive assessment G0574 – Plan of care must include the following G0580 – Only as Ordered by a Physician G0706 – Interdisciplinary assessment of the patient G0710 – Provide Services in the plan of care G0798 – Home Health Aide assignments and duties G0862 – Laboratory services/CLIA waivers J0468 – Policies and Procedures Service Delivery

Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient's status at the time of assessment. This STANDARD is not met as evidenced by: Based on clinical record reviews, and staff interview the agency failed to ensure all encoded OASIS assessments accurately reflect each patient's status at the time of the assessment. This was evident for one (1) of nineteen (19) clinical records reviewed (Patient: #7). Failure to ensure all encoded OASIS Assessments accurately reflect the patient's status at the time of the assessment, has the potential for negative patient outcomes. The Findings Are: 1.Patient #7(PAE) has a Start of Care date of 03/30/2023 with the following diagnoses "Unspecified Intracapsular Fracture of Right Femur, Subsequent Encounter for Closed Fracture with Routine Healing, Essential (primary) Hypertension, Type 2 Diabetes Mellitus without Complications, Personal History of Urinary (Tract) Infections " documented on the Home Health Certification and Plan of Care dated 03/30/2023 to 05/28/2023. The OASIS Start of Care dated 03/30/2023 documents:"(M1600) Has this patient been treated for a urinary tract infection in the past 14 days? 0-No" The OASIS Discharge dated 04/20/2023 documents:"(M1600) Has this patient been treated for a urinary tract infection in the past 14 days? 1-Yes" The clinical record lacks documented evidence of the patient being treated for UTI (urinary tract infection) in the past 14 days. During an interview on 09/01/2023 at 11:00 am, with the Director of Education stated: " The patient wasn't treated for a UTI. It was an error." There is no documented evidence of the encoded Discharge OASIS data on 04/20/2023 accurately reflecting the patient's status upon discharge from the agency. On 09/01/2023 at 11:00 am, the Administrator, the Director of Education, and the Quality Assurance Nurse were interviewed and did not provide an explanation for the findings. .

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 reviews, and staff interview the agency failed to ensure an accurate and comprehensive review of each patient's medications. This was evident for one (1) of nineteen (19) clinical records reviewed (Patient: #8). Failure to ensure a review of all patients' current medications are complete, accurate and are reflected in the patient's plan of care has the potential for negative patient outcomes. The Findings Are: 1.Patient #8 (HV- Physical Therapy visit) has a Start of Care Date of 08/14/2023 with the following diagnoses "Other Chronic pain, Dorsalgia, Hemiplegia Following Cerebral Infarction Affecting Left Non-Dominant Side" documented on the Home Health Certification and Plan of Care dated 08/14/2023 to 10/12/2023. The Home Health Certification and Plan of Care dated 08/14/2023 to 10/12/2023 documents: "Keppra XR (extended release) 500 mg 1 tablet oral daily." On 08/28/2023, a home visit was conducted, and the following medication was observed: "Levetiracetam ER 750 mg 2 tablets oral at bedtime." The patient was interviewed and stated:" I take two tablets at bedtime." There is no documented evidence of all the medications being reviewed and reconciled. On 09/01/2023 at 4:05pm, the Administrator, the Director of Education, and the Quality Assurance Nurse were interviewed and did not provide an explanation for the findings. .

Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than- This STANDARD is not met as evidenced by: Based on clinical record reviews, and staff interview the agency failed to ensure all comprehensive assessments are updated and revised. This was evident for one (1) of nineteen (19) clinical records reviewed. (Patient#13). Failure to ensure that all comprehensive assessments are updated and revised has the potential for negative patient outcomes. The Findings Are: * Patient #13 (PAE) has a Start of Care date of 09/19/2022 and discharge date of 11/17/2022, with the following diagnoses "Unspecified Dementia and Muscle Weakness" documented in the Home Health Certification and Plan of Care dated 09/19/2022 to 11/17/2022. The Visit Note Report dated 11/17/2022 documents: M010 This assessment is currently being completed for the following reason: Discharge from Agency M2102D Types and sources of assistance: Determine the ability and willingness of non-agency caregivers (such as family members, friends, or privately paid caregivers) to provide assistance for medical procedures/ treatments (for example, changing wound dressing, home exercise program), if assistance is needed: Assistance needed, but no non-agency caregiver(s) available. M2102F Types and sources of assistance determine the level of caregiver ability and willingness to provide assistance for supervision and safety (for example, due to cognitive impairment), if assistance is needed: assistance needed, but no non-agency caregiver(s) available. On 08/31/2023 at 2:50pm, the Director of Education was interviewed and stated, “It was an error, it should be number 1 (non-agency caregiver currently provide assistance), I’m not sure if this was reviewed.”, There is no documented evidence of an accurate information for the Discharge OASIS M12012D and M210F. There is no documented evidence of an updated comprehensive assessment that includes corrected information. On 08/31/2023 at 3:05pm, the Administrator, the Director of Education, and the Quality Assurance Nurse were interviewed, no further explanation for the findings 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 reviews, and staff interview, the agency failed to ensure each patient's plan of care is individualized and includes all the required information. This was evident for two (2) of nineteen (19) clinical records reviewed. (Patients #5, and #10). Failure to ensure the development the individualized plan of care for all patients, has the potential for negative patient outcomes. The Findings Are: Patient #5 has a Start of Care date of 07/28/2023 with diagnoses Aftercare Following Joint Replacement Surgery and Hypertensive Heart Disease with Heart Failure documented in the Home Health Certification and Plan of Care dated 07/28/2023 to 09/25/2023. The RN (Registered Nurse) Start of Care comprehensive assessment dated 07/28/2023 documents, “patient has no pressure ulcers;” “no wound noted;” and patient is at “low” risk for pressure ulcers. The Home Health Certification and Plan of Care dated 07/28/2023 to 09/25/2023 documents: “Skilled Nurse to perform/teach pressure ulcer care using clean/aseptic technique. Change dressing every SN visit and PRN (as needed) as per MD (Medical Doctor) order;” and goals: “patient/caregiver will verbalized/demonstrate ability to perform wound care. Wound status will improve as evidence by a decrease in size, drainage, absence of infection, and decreased pain by 3 weeks.” There is no documented evidence of the patient having a pressure ulcer that requires wound care. The plan of care lacks documented evidence of being individualized and based on the SOC comprehensive assessment. On 08/31/2023 at 04:00pm, the Administrator and the Director of Education were interviewed. The Director of Education stated it was a “typo,” and the plan of care should not include wound care orders. 2.Patient #10 has a Start of Care date of 07/12/2023 with the following diagnoses "Pressure Ulcer of Left Buttock, stage 3, Laceration without Foreign Body, Right Thigh, Laceration without Foreign Bode, Left Lower Leg, Quadriplegia" documented on the Home Health Certification and Plan of Care dated 07/12/2023 to 09/09/2023. The Home Health Certification and Plan of Care dated 07/12/2023 to 09/09/2023 documents: "Skilled Nurse to perform/teach pressure ulcer care to all wounds until wound consult completed by WC (wound care) specialist. Rinse all wounds, tap dry and cover with gauze and tape." There is no documented evidence of the Plan of Care including wound care treatment frequency. The Physician Order dated 07/18/2023 for the Certification Period 07/12/2023 to 09/09/2023 documents:" Clean wound with Dakin's 0.25%, pat dry, apply skin prep to peri wound skin, apply Silvasorb to wound and cover with DPD (dry sterile dressing) daily." The Physician Order dated 07/31/2023 for the Certification Period 07/12/2023 to 09/09/2023 documents:" Clean wound with Dakin's 0.25%, pat dry, apply skin prep to peri wound, apply Silver Alginate to wound, and cover with DSD, to be done TIW (3 times a week)." The clinical record documents that the patient has multiple pressure injuries. The Physician order dated 07/18/2023, 07/31/2023 does not include location for the wound care treatment. On 09/01/2023 at 04:05pm, the Administrator, the Director of Education, and the Quality Assurance Nurse were interviewed and did not provide an explanation for the 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 or allowed practitioner. This ELEMENT is not met as evidenced by: Based on clinical record reviews, and staff interview the agency failed to ensure that treatments are provided as ordered by a physician for each patient. This was evident for one (1) of nineteen (19) clinical records reviewed. (Patient #14). Failure to ensure all treatments are provided as ordered by the physician has the potential for negative patient outcomes. The Findings Are: * Patient #14 (HV) has a Start of Care date of 07/14/2023 with the following diagnoses "Hypertensive Heart Disease with Heart Failure, Unspecified Atrial Fibrillation, Acute Kidney Failure" documented in the Home Health Certification and Plan of Care dated 07/14/2023 to 09/11/2023. The Email Printout documents: (from nurse practitioner to registered nurse) 08/27/2023 Xeroform every 48 hrs clean with NS (normal saline). 08/31/2023 Clean wds (wounds) with ns apply moisture barrier cream Triad BID (twice a day) on buttocks wds; Xeroform to LEs (lower extremity) wds cover with dsd (dry sterile dressing). The Verbal Order dated 08/28/2023 documents: “As of 8/28/2023 bruise to right lower extremity is resolved.” There is no documented evidence of the wound order clarification for the site of Xeroform and bruise healed on lower extremity on 08/28/2023 but ordered treatment of Xeroform on 08/31/2023. There is no documented evidence of the verbal order: 08/27/2023 for Xeroform, and 08/31/2023 for Triad and Xeroform. There is no documented evidence the wounds were treated as ordered by the nurse practitioner. On 08/31/2023 at 3:05pm, the Administrator, the Director of Education, and the Quality Improvement staff were interviewed and did not provide an explanation for the findings. .

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to ensure of an ongoing interdisciplinary assessments and discussion of the patient's status. This was evident for one (1) of nineteen (19) clinical records reviewed (Patient #14). Failure to ensure of an ongoing interdisciplinary assessments and discussion of the patient's status, has the potential for negative patient outcomes. The Findings Are: * Patient #14 (HV) has a Start of Care date of 07/14/2023 with the following diagnoses "Hypertensive Heart Disease with Heart Failure, Unspecified Atrial Fibrillation, Acute Kidney Failure" documented in the Home Health Certification and Plan of Care dated 07/14/2023 to 09/11/2023. The Policy for Wound Assessment, Prevention and Management documents: “Wound Assessment: 3. When a wound is present the nurse will perform a wound assessment on each visit.” “Wound Prevention: 3. Alterations in the skin integrity will be immediately reported to the physician and orders obtained for treatment where necessary.” “Wound Management: 1. The nurse will notify the patient’s physician to report the condition of the wound according to the assessment conducted and to discuss treatment options.” The Resumption of care order dated 08/24/2023 documents: “wound to right buttock approximately 2.5cm x 0.5cm x 0.1cm, RN cleansed with normal saline and covered with dry dressing, waiting for treatment plan, pictures were taken and sent to (name of nurse practitioner).” Treatment is agency’s protocol. The Visit Note Report dated 08/24/2023 documents: “Resumption of Care” “Wound Assessment: #1 Up (upper) buttock, rt (right); Granulation tissue: Intact; Epithelialization: <25%; Necrotic tissue type: white; Necrotic tissue amount: 75<100%.” The Email Printout documents: 08/27/2023 [from registered nurse (RN) to nurse practitioner (NP)] Pictures were taken at visit on 08/24/2023. 08/27/2023 (from NP to RN) Xeroform every 48 hrs clean with NS (normal saline). 08/31/2023 (from NP to RN) Clean wds (wounds) with ns apply moisture barrier cream Triad BID (twice a day) on buttocks wds; Xeroform to LEs (lower extremity) wds cover with dsd (dry sterile dressing). The Physician Order dated 08/30/2023 documents: “As of 08/28/2023 bruise to right lower extremity is resolved.” There is no documented evidence of the timely reporting of wound to physician or NP and getting a treatment order, reported after 3 days. There is no documented evidence of the discussion of the interdisciplinary team for the assessment – white necrosis and not a pressure ulcer but wound is over a bony prominence – buttocks, treatment site of Xeroform on 08/27/2023, and treatment to lower extremity on 08/31/2023 that is healed on 08/28/2023. There is no documented evidence of the ongoing wound assessment by the registered nurse on home visit dated 08/28/2023. There is no documented evidence of an ongoing interdisciplinary assessment of the patient. On 08/31/2023 at 3:05pm, the Administrator, the Director of Education, and the Quality Assurance Nurse were interviewed and did not provide an explanation for the findings. .

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on clinical record reviews, and staff interview the agency failed to provide services that are ordered by the physician as indicated in the plan of care. This was evident for seven (7) of nineteen (19) clinical records reviewed (Patients: #2, #3, #5, #6, #10, #13, and #18). Failure to provide services that are ordered by the physician as indicated in the plan of care, has the potential for negative patient outcomes. The Findings Are: * Patient #13 (PAE) has a Start of Care date of 09/19/2022 and discharge date of 11/17/2022, with the following diagnoses "Unspecified Dementia and Muscle Weakness" documented in the Home Health Certification and Plan of Care dated 09/19/2022 to 11/17/2022. The Home Health Certification and Plan of Care dated 09/19/2022 to 11/17/2022 documents: “OT (occupational therapy) 1WK1 (once a week for one week).” The Physician Order dated 10/07/2022 documents: “PT (physical therapy) effective 10/02/2022 1WK1.” There is no documented evidence of the services being provided OT from 09/19/2022 to 09/24/2022 - missed one visit and PT from 10/02/2022 to 10/08/2022 – missed one visit. On 08/31/2023 at 3:05pm, the Administrator, the Director of Education, and the Quality Assurance Nurse were interviewed and did not provide an explanation for the findings. * Patient #18 with date of birth 09/16/2016 has a Start of Care date of 10/03/2022 with the following diagnoses "Autistic Disorder, Specific Developmental Disorder of Motor Function” documented in the Home Health Certification and Plan of Care dated 07/30/2023 to 09/27/2023. The Home Health Certification and Plan of Care dated 07/30/2023 to 09/27/2023 documents: SN (skilled nursing) 3WK1 (three times a week for one week); OT 2WK8 (twice a week for eight weeks). There is no documented evidence of the services being provided for SN from 07/30/2023 to 08/05/2023 - missed 3 visits and OT between 07/30/2023 to 08/05/2023 - missed one visit, 08/06/2023 to 08/12/2023 - missed one visit, 08/13/2023 to 08/19/2023 - missed one visit, and 08/20/2023 to 08/26/2023 - missed one visit. On 08/31/2023 at 3:05pm, the Administrator, the Director of Education, and the Quality Assurance Nurse were interviewed and did not provide an explanation for the findings. 1.Patient #6 has a Start of Care date of 02/20/2023 with the following diagnoses "Encounter for Orthopedic Aftercare Following Surgical Amputation, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus with Diabetic Neuropathic, Hyperlipidemia " documented on the Home Health Certification and Plan of Care dated 02/20/2023 to 04/20/2023 and 04/21/2023 to 06/19/2023. The Physician Order dated 04/04/2023 for the Certification Period 02/20/2023 to 04/20/2023 documents:" PT (Physical Therapy) Effective 04/02/2023 3WK3 (three times a week for three weeks)." The clinical record lacks documented evidence of the PT visit for the week of 04/09/2023 (one missed visit), and week of 04/16/2023(one missed visit). The Physician Order dated 03/13/2023 for the Certification Period 02/20/2023 to 04/20/2023 documents: "HHA (Home Health Aide) effective 03/12/2023 5WK5(five times per week for five weeks), 1WK1(one time per week for one week)." There is no documented evidence of the aide's services being provided from 03/12/2023 to 03/30/2023 five times per week. The Home Health Certification and Plan of Care dated 04/21/2023 to 06/19/2023 documents:" PT (Physical Therapy) Effective 04/23/2023 2WK6 (two times a week for six weeks)." The Clinical Record lacks documented evidence of the PT visit for the week of 04/23/2023(one missed visit). The clinical record lacks documented evidence of the patient receiving PT and HHA services as ordered, and no documented evidence of the physician being notified of the missed visits. On 08/31/2023 at 3:35pm, the Administrator, the Director of Education, and the Quality Assurance Nurse were interviewed and did not provide an explanation for the findings. 1.Patient #10 has a Start of Care date of 07/12/2023 with the following diagnoses "Pressure Ulcer of Left Buttock, stage 3, Laceration without Foreign Body, Right Thigh, Laceration without Foreign Bode, Left Lower Leg, Quadriplegia" documented on the Home Health Certification and Plan of Care dated 07/12/2023 to 09/09/2023. The Physician Order dated 07/26/2023 for the Certification Period 07/12/2023 to 09/09/2023 documents: "SN (skilled nurse) effective 07/30/2023 5WK1 (five times per week for one week), 6WK1(six times per week for one week)." The Clinical Record lacks documented evidence of the RN visit for the week of 07/30/2023(two missed visits), week of 08/06/2023 (four missed visits). The clinical record lacks documented evidence of the patient receiving SN services as ordered, and no documented evidence of the physician being notified of the missed visits. On 08/31/2023 at 3:35pm, the Administrator, the Director of Education, and the Quality Assurance Nurse were interviewed and did not provide an explanation for the findings. Patient #2 has a Start of Care date of 07/31/2023 with diagnoses Encounter for Change or Removal of Nonsurgical Wound Dressing and Contusion of Right Lower Leg Subsequent Encounter documented in the Home Health Certification and Plan of Care dated 07/31/2023 to 09/28/2023. The Home Health Certification and Plan of Care dated 07/31/2023 to 09/28/2023 documents: “Skilled Nurse to observe and assess integumentary status to identify changes and intervene to minimize complications;” and “Skilled Nurse to perform/teach wound care to hematoma on RLE (right lower extremity).” The Plan of Care documents the following goal for the wound: “wound status will improve as evidenced by a decrease in size, drainage, absence of infection, and decreased pain by 6 weeks.” The agency’s “Wound Assessment, Prevention, and Management” Policy documents: “Wounds will be measured minimally once a week to assess for changes in the wound status.” The SN Visit Note Report dated 08/08/2023 documents the SN measured the wound, during the week of 08/06/2023 to 08/12/2023. The SN Visit Note Reports dated 08/14/2023, 08/16//2023, 08/17/2023, 08/21/2023, 08/23/2023 and 08/25/2023 document “no” measurements taken, during the subsequent weeks of 8/13/2023 to 8/19/2023 and 8/20/2023 to 8/26/2023. The clinical record lacks documented evidence of the SN performing weekly wound measurements to assess for changes in the wound status as indicated in the plan of care and in accordance with the agency's policy, On 08/30/2023 at 2:10pm, the Administrator and the Director of Education were interviewed, and did not provide an explanation for the finding. Patient #3 has a Start of Care date of 07/13/2023 with diagnoses Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, Hypertensive Heart Disease with Heart Failure, Obesity, Type 2 Diabetes Mellitus Without Complications, Muscle Weakness (Generalized) documented in the Home Health Certification and Plan of Care dated 07/13/2023 to 09/10/2023. The RN SOC comprehensive assessment dated 07/13/2023 documents: “Patient is non ambulatory;” “patient has stage 2 (pressure ulcer) on the sacrum. " The Home Health Certification and Plan of Care dated 07/13/2023 to 09/10/2023 documents: “Skilled Nurse to observe and assess integumentary status to identify changes and intervene to minimize complications;” “Skilled Nurse to perform/teach pressure ulcer care to stage 2 sacral area. Cleanse with NS (Normal Saline) apply Silvadene cover with none, using clean/aseptic technique. Change dressing twice a day by caregiver and PRN (as needed).” The Plan of Care documents the following goals for the wound: “Changes in skin integrity will be identified and reported to the physician for prompt intervention;” and “wound status will improve as evidenced by a decrease in size, drainage, absence of infection, and decreased pain by 5 weeks.” The agency’s “Wound Assessment, Prevention and Management” Policy documents: “When a wound is present the nurse will perform a wound assessment on each visit.” The SN Visit Note Reports dated 07/13/2023, 07/18/2023, 07/24/2023, 07/29/2023, 08/01/2023, 08/04/2023, and 08/08/2023 document: “wound assessed, no.” The clinical record lacks documentation of the SN performing a wound assessment to identify changes in the wound status on each visit as indicated in the patient’s plan of care and in accordance with the agency’s policy. On 09/01/2023 at 12:00pm, the Administrator and the Director of Education were interviewed, and did not provide an explanation for the finding. Patient #5 has a Start of Care date of 07/28/2023 with diagnoses Aftercare Following Joint Replacement Surgery and Hypertensive Heart Disease with Heart Failure documented in the Home Health Certification and Plan of Care dated 07/28/2023 to 09/25/2023. The Home Health Certification and Plan of Care dated 07/28/2023 to 09/25/2023 documents the following orders for Skilled Nurse (SN) visit frequency: “SN 4WK1 (four visits a week for one week)” for the first week. The clinical record documents one SN visit conducted on 7/28/2021 during the first week - three missed visits. The clinical record lacks documented evidence of the SN conducting fours visits for the first week. There is no documented evidence of the patient receiving the services ordered by the physician as outlined in the Plan of Care. On 08/31/2023 at 04:00pm, the Administrator and the Director of Education were interviewed. The Director of Education stated the visit frequency for the first week was entered incorrectly, and it should be one visit a week for one week and three prn (as needed) visits for the certification period.

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 clinical record reviews, and staff interview the agency failed to develop individualized written patient care instructions for a home health aide. This was evident for one (1) of six (6) patient receiving home health aide (HHA) services. (Patient #15). Failure to develop individualized written patient care instructions for a home health aide, has the potential for negative patient outcomes. The Findings Are: * Patient #15 (HV) has a Start of Care date of 08/09/2023 with the following diagnoses "Hypertensive Heart Disease with Heart Failure, Unspecified Dementia” documented in the Home Health Certification and Plan of Care dated 08/09/2023 to 10/07/2023. The Home Health Certification and Plan of Care dated 08/09/2023 to 10/07/2023 documents: “hha 1WK1, 5WK3 (home health aide once a week for one week, five times a week for three weeks)” “Nutritional Requirements: No concentrated sweets, low Na (sodium), low cholesterol, NFR (renal diet).” The Aide Care Plan Report dated 08/09/2023 documents: Prepare meal – every visit, prepare snack – every visit. The Duty Sheet documents aide providing services on 08/12/2023, 08/14/2023 to 08/18/2023, 08/21/2023 to 08/24/2023. The Aide’s Care Plan Report lacks documented evidence of the patient’s diet and instruction to report changes in patient’s condition to the registered nurse. On 08/31/2023 at 3:05pm, the Administrator, the Director of Education, and the Quality Assurance Nurse were interviewed and did not provide an explanation for the findings. .

Laboratory services/CLIA waivers CFR(s): 484.100(c)(1) Laboratory services. If the HHA engages in laboratory testing outside of the context of assisting an individual in self-administering a test with an appliance that has been cleared for that purpose by the Food and Drug Administration, the testing must be in compliance with all applicable requirements of part 493 of this chapter. The HHA may not substitute its equipment for a patient's equipment when assisting with self-administered tests. This STANDARD is not met as evidenced by: Based on clinical record reviews, and staff interview, the agency failed to ensure the CLIA Certificate of Waiver was kept current. This was evident for one (1) of nineteen (19) clinical records reviewed. (Patient #3). Failure to maintain the CLIA Certificate of Waiver may result in the provision of unauthorized laboratory services and the agency's inability to ensure the accuracy and safety of laboratory tests performed on the patient. The Findings Are: Patient #3 has a Start of Care date of 07/13/2023 with diagnoses Type 2 Diabetes Mellitus Without Complications and Long Term (Current) Use of Oral Hypoglycemic Drugs documented in the Home Health Certification and Plan of Care dated 07/13/2023 to 09/10/2023. The Home Health Certification and Plan of Care dated 07/13/2023 to 09/10/2023 documents the following diabetes management orders: "Skilled Nurse may administer 4 ounces of fruit juice or one tablespoon of sugar if the blood sugar analysis is between 60-80 and recheck blood sugar in 15-20 minutes. If subsequent blood sugar is greater than 80 mg/dl administer meds otherwise notify physician.” There is no documented evidence of the agency having a CLIA Waiver in place to perform blood sugar testing in the home. On 09/01/2023 at 12:00pm, the Administrator and the Director of Education were interviewed, and did not provide an explanation for the finding.

This Statement of Deficiencies is a result of an on-site investigation of complaint IQIES 98339 conducted on 6/13/23 at Royal Care Certified Home Health , ID# 337189, located at 30-50 Whitestone Expressway, Suite 304- Flushing, New York 11354. The agency reports an active patient census of 710. The investigation consisted of a review of three (3) clinical records identified as (Patient #1, #2, and #3) one (1) personnel record identified as (Employee #1), the agency’s complaint/ Incident logs for the period 1/1/23 – 6/9/23, and pertinent policies and procedures. Interviews were conducted throughout the survey with the DPS (Director of Patient Services). The findings were reviewed at the Exit conference on 6/13/23. The allegations in Complaint # 98339 were determined to be substantiated. The following deficiencies were identified. G 0374 Accuracy of Encoded OASIS G 484 Document complaint and resolution G 550 Discharge G 0608 Coordinate care delivery G 0710: Provide services in the POC G 0716 Preparing clinical notes G 0800 Services Provided By HHA

Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient's status at the time of assessment. This STANDARD is not met as evidenced by: Based on clinical record review and staff interview the agency failed to ensure all encoded Oasis assessments accurately reflects the patient's status at the time of the assessment. This was evident for one (1) of three (3) clinical records reviewed (Patient #1). Failure to ensure all encoded Oasis Assessments accurately reflect the patient's status at the time of the assessment has the potential risk for negative patient outcomes. The findings are: 1.Patient #1 has a start of care date of 2/22/22 , discharge date 5/24/23 with diagnosis “ Autistic Disorder documented on the Home Health Certification and Plan of Care for Certification Periods 2/17/23- 4/17/23 and 4/18/23 – 6/16/23. The Client Coordination Note Report documents “Note Date 06/07/2023 : Entered By: Clinical Manager: Note: Caregiver switched to another CHHA. DC from Agency Name : 5/24/23.” The Discharge OASIS documents: “Visit Date: 05/24/2023: PT Discharge Data Collection Only No Visit Made. Discharge Disposition: Patient remained in the community (without formal assistive services) Discharge /Transfer/ Death Date: 5/26/2023. Electronically signed: 6/13/2023 03:37 PM. Patient #1 clinical record documents the discharge date of 5/24/23 to another Certified Home Health Agency. The clinical record lacks evidence of the Oasis Assessments accurately reflecting the patient's status at the time of the assessment. On 6/13/23 at 4:45PM the Director of Patient Services was interviewed and did not provide an explanation for the findings.

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on Complaint log review, clinical record review, and staff interview, the agency failed to ensure the complete investigation and resolution of all patient complaints. This was evident for one (1) of three (3) clinical records reviewed.(Patient #1). Failure to ensure all complaint logs are complete with investigation findings, resolution dates and response/ notification to complainants has the potential for negative patient outcomes. The findings are: 1.Patient #1 has a start of care date of 2/22/22 , discharge date 5/24/23 with diagnosis “ Autistic Disorder documented on the Home Health Certification and Plan of Care for Certification Periods 2/17/23- 4/17/23 and 4/18/23 – 6/16/23. The Agency’s Complaint /Grievance Process Policy No. 1-010.1 documents “All complaints will be logged , tracked, and trended by the Director of Patient Services who will log and maintain files on all complaints. The Complaint Log will contain the dates of receipt and resolution of each complaint.” The Client Coordination Note Report documents “Note Date: 05/05/23 “Clinical Manager Note : with Caregiver received a call from caregiver on 5/3/23, she was not happy for current HHA hours.” On 6/13/23 at 10:45AM the complaint log was reviewed. The log lacks documented evidence of a complaint for Patient #1. The Client Calendar Report and the HHA eXchange Duty Sheet were reviewed on 6/13/23 for the period 5/5/23 -5/23/23. The documented HHA service hours being provided are less than the hours ordered. The complaint log lacks documented evidence of being complete and of a thorough investigation of Patient#1 ‘s complaint. On 6/13/23 at 4:40PM the Director of Patient Services was interviewed and stated the hours being provided are incorrect. On 6/14/23 at 10:15 AM a follow-up call was made to the Director of Patient Services; no additional information was provided.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview the agency failed to ensure a Discharge OASIS (Outcome Assessment) was completed in timely manner for all patients. This was evident for one (1) of three (3) discharged clinical records reviewed (Patient #1). Failure to ensure the timely completion of the Discharge OASIS has the potential for negative patient outcomes. The findings are: 1.Patient #1 has a start of care date of 2/22/22 , discharge date 5/24/23 with diagnosis “ Autistic Disorder documented on the Home Health Certification and Plan of Care for Certification Periods 2/17/23- 4/17/23 and 4/18/23 – 6/16/23. On 6/13/23 at 3:24PM the Discharge Oasis was requested. The Visit Note Report documents: “Visit Date: 05/24/2023: PT Physical Therapy) Discharge Data Collection Only- No Visit Made. Electronically signed: 06/13/2023 03:37 PM" The clinical record lacks documented evidence of the Discharge Oasis being completed in a timely manner. On 6/13/23 at 4:45PM the Director of Patient Services was interviewed and did not provide an explanation for the findings.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on clinical Record review and staff interview the agency failed to ensure coordination of services for the delivery of care to meet the patient's needs. This was evident for one (1) of three (3) clinical records reviewed. (Patients #1). Failure to ensure coordination of services for the delivery of patient care has the potential for negative patient outcome. The findings are: 1.Patient #1 has a start of care date of 2/22/22, discharge date 5/24/23 with diagnosis “ Autistic Disorder documented on the Home Health Certification and Plan of Care for Certification Periods 2/17/230- 4/17/23 and 4/18/23 – 6/16/23. The Physician Order dated 4/20/23 documents, “HHA continuation for personal care assistance with ADLs 6 hrs/day weekdays Mon-Fri: Weekend Sat/Sun 12 hrs/day.” The Physician Order dated 4/20/23 documents “HHA order update: HHA effective 04/30/2023 6WK 1, 5WK6.” The Client Coordination Note Report documents “PT (Physical Therapy) Note Date: 05/01/23: Evaluation done, patient will benefit from physical therapy visit to improve balance, gait”. The Client Coordination Note Report documents “Note Date: 05/05/23 “Clinical Manager Note : with Caregiver received a call from caregiver on 5/3/23, she was not happy for current HHA hours.” The Agency’s Complaint Form Dated 5/12/23 documents, Nature of Complaint: Service Delivery: Communication: Follow-up Date: 5/15/2023: “Patient currently does not have significant skilled needs for HHA services to provide 12 hours of services on weekend. Patient is currently receiving a total of 20 hours of HHA services (5 days X4 hours) during the weekdays (DPS).” The clinical record lacks documented evidence of the Physical Therapist, the Clinical Manager and the Director of Patient services coordinating with Patient #1’s caregiver regarding the physician orders and the hha service hours being provided. On 6/13/24 at 4:50PM the Director of Patient Services was interviewed and did not provide an explanation for the findings.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated 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 provide services that are ordered by the physician as indicated in the plan of care. This was evident for one (1) of three (3) clinical records reviewed (Patient #2). Failure to provide services that are ordered by the physician as indicated in the plan of care, has the potential for negative patient outcomes. The findings are: Patient #2 has a start of care date of 2/20/23 with diagnosis “Encounter for Orthopedic Aftercare Following Surgical Amputation” on the Home Health Certification and Plan of Care for Certification Periods 4/21/23 to 6/19/23. The Home Health Certification and Plan of Care documents Frequency/Duration of Visits: PT (Physical Therapy) Effective 04/23/23 2WK6 ( two times a week for 6 weeks). The Client Calendar Report documents “ Client : Patient #2: Visit Date:05/25, 5/30, 6/1, and 6/6/23 : Begin Time: No entry/ Blank: End Time : No entry/ Blank : The clinical record lacks documented evidence of Patient #2 receiving PT services as ordered. The Client Coordination Note Report documents “Note Date:6/13/23: Missed Visit Notification: Entered By PT(Physical Therapy) for the dates 5/25/, 5/30, 6/1, and 6/6/23. The clinical record lacks documented evidence of physician being notified of Patient #2 not receiving services as ordered prior to surveyor onsite visit 6/13/23. On 6/13/23 at 2:30Pm the Director of Patient services was interviewed and did not provide an explanation for the findings.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview the agency failed to ensure all clinical notes are complete and documented in the patient’s clinical record. This was evident for one (1) of three (3) clinical records reviewed. (Patient #2). The findings are: Patient #2 has a start of care date of 2/20/23 with diagnosis “Encounter for Orthopedic Aftercare Following Surgical Amputation” on the Home Health Certification and Plan of Care for Certification Period 4/21/23 to 6/19/23. The Client Coordination Note Report documents “Note Date:6/13/23: Missed Visit Notification: Entered By PT(Physical Therapy) " for the dates 5/25/, 5/30, 6/1, and 6/6/23. The Client Coordination Note Report documents “Note Date: 6/13/23 :Note Type: Narrative : Entered By: PT: Note: Patient has been seen for therapy on 5/2/23 and 5/22/23, HHA Supervision also done." The clinical record lacks documented evidence of clinical notes being documented in the clinical record timely. On 6/13/23 at 3:00PM the Director of Patient Services was interviewed and stated, "the documentation is late."

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview the agency failed to ensure the Home Health Aide (hha) provides services as ordered. This was evident for one (1) of three (3) clinical records reviewed. (Patient # 1). Failure to ensure the Home Health Aide provides services as ordered has the potential for negative patient outcome. The findings include: 1.Patient #1 has a start of care date of 2/22/22. Discharge date 5/24/23 with diagnosis “ Autistic Disorder documented on the Home Health Certification and Plan of Care for Certification Periods 2/17/23- 4/17/23 and 4/18/23 – 6/16/23. The Physician Order documents: “Date 4/20/23 HHA continuation for personal care assistance with ADLs 6 hrs/day weekdays Mon-Fri: Weekend Sat/Sun 12 hrs/day.” The Physician Order documents: “Date 5/4/23 HHA order update: HHA effective 04/30/2023 6WK 1, 5WK6.” The Client Calendar Reports documents “ Client : Patient #1: Visit Date:04/18/2023 – 05/24/2023: Begin Time: End Time : Status: V (visit): The HHA Visit Dates 5/5/23 – 5/23/23 documents Patient #1 receiving HHA services for less than six (6) hours per day. The clinical record lacks documented evidence of hha services being provided to Patient #1 as ordered. On 6/13/23 at 4:15PM the Director of Patient Services was interviewed and did not provide an explanation for the findings.

This Statement of Deficiencies is a result of an on-site investigation of complaint 71603, conducted at Royal Care Certified Home Health Care, LLC, located at 30-50 Whitestone Expressway, Flushing, NY 11354 on 09/29/2022. The active patient census is 552. The investigation consisted of a review of three (3) clinical records (identified as Patients #1, #2, and #3), three (3) personnel records (Employees #1, #2, and #3), the agency's complaint, accident/incident report for the past six months, discharges for the month of August, and interviews with the Administrator, the Director of Patient Services, and the Registered Nurse Educator. Pre-survey activities consisted of review on 9/28/2022 of the agency's Health Commerce System account. A review of the agency's COVID -19 and Infection Control Policies and Procedures and vaccination log was conducted. Findings were reviewed at the exit conference. The allegation is substantiated. A Statement of Deficiencies will be issued. The following deficiencies are being cited as result of the survey: G - 0434 - Participate in Care G - 0572 - Plan of Care

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview the governing authority failed to ensure that patient be informed about any changes in the care to be furnished. This was evident for one (1) of three (3) patient care records reviewed (Patient #1). Failure to ensure that patient and the legal representative be informed about any changes in the care to be furnished has the potential for negative patient outcomes. The findings are: 1. Patient #1 has a Start of Care date of 6/22/2022 with the following diagnoses "Encounter for Surgery Aftercare Following Surgery on the Teeth or Oral Cavity, End Stage Renal Disease (ESRD), Anemia” documented in the Home Health Certification and Plan of Care dated 06/22/2022 to 08/20/2022. The Home Health Certification and Plan of Care dated 06/22/2022 to 08/20/2022 documents: “SN 1WK1 (once a week for one week), 2WK1(twice a week for one week), 1WK3(once a week for three weeks). PT (Physical Therapy) effective 6/26/2022 1WK1. OT (Occupational Therapy) effective 6/26/2022 1WK1, 2WK2 (twice a week for two weeks). Hha (home health aide) effective 6/26/2022 5WK4 (five times a week for four weeks).” The clinical record lacks documented evidence of the patient receiving the following services : RN - the week of 7/3/2022 to 7/9/2022 (missed one visit), OT– the week of 7/3/2022 to 7/9/2022 (missed one visit) and 7/10/2022 to 7/16/2022 (missed one visit) and aide services (from 6/26/2022 to 7/23/2022 – five times a week for four weeks - no visits). There is no documented evidence of the patient or the family being informed that the agency is unable to provide the services . On 9/29/2022 at 2:39pm, the DPS and the Registered Nurse Educator were interviewed and did not provide an explanation for the findings

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 governing authority failed to ensure that each patient receive the services that are written in an individualized plan of care. This was evident for one (1) of three (3) patient care records reviewed (Patient #1). Failure to ensure that each patient receives the services that are written in an individualized plan of care has the potential for negative patient outcomes. The findings are: 1. Patient #1 has a Start of Care date of 6/22/2022 with the following diagnoses "Encounter for Surgery Aftercare Following Surgery on the Teeth or Oral Cavity, End Stage Renal Disease (ESRD), Anemia” documented in the Home Health Certification and Plan of Care dated 06/22/2022 to 08/20/2022. The Home Health Certification and Plan of Care dated 06/22/2022 to 08/20/2022 documents: “SN 1WK1 (once a week for one week), 2WK1(twice a week for one week), 1WK3(once a week for three weeks). PT (Physical Therapy) effective 6/26/2022 1WK1. OT (Occupational Therapy) effective 6/26/2022 1WK1, 2WK2 (twice a week for two weeks). Hha (home health aide) effective 6/26/2022 5WK4 (five times a week for four weeks).” The clinical record lacks documented evidence that the patient received services for: RN - the week of 7/3/2022 to 7/9/2022 (missed one visit), OT– the week of 7/3/2022 to 7/9/2022 (missed one visit) and 7/10/2022 to 7/16/2022 (missed one visit), aide services (from 6/26/2022 to 7/23/2022 – five times a week for four weeks). There is no documented evidence of the patient receiving SN, OT, and aide services as ordered on the plan of care. On 9/29/2022 at 2:39pm, the DPS and the Registered Nurse Educator were interviewed and did not provide an explanation for the findings.