Every finding on record at Suffolk County Dept of Health Services Bureau of Public Health Nursing Chha

. Based on policy review and staff interview, the Governing Authority failed to establish a comprehensive Emergency Preparedness Plan. This was evident in review of the Emergency Preparedness Plan and Emergency Disaster policy. Failure to establish a comprehensive Emergency Preparedness Plan, has the potential for negative patient outcome.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. This STANDARD is not met as evidenced by: Based on policy review and staff interview, the Governing Authority failed to establish a comprehensive Emergency Preparedness Plan. This was evident in review of the "Emergency/Disaster Preparedness" policy. Failure to establish a comprehensive Emergency Preparedness Plan, has the potential for negative patient outcome. 1) The "Emergency/Disaster Preparedness" policy revised 10/01/2023 lacks documented evidence of the procedure/process to cooperate with local and state Emergency management systems, procedure to coordinate/communicate, share information or medical documents for patients under the agency's care with local and state Emergency management systems. 2) There is no documented evidence of the Agency's participation in Emergency Drill annually. Interview conducted with the Acting Director of Patient Services on 10/23/2024 at 11am and findings review, no explanation provided.

…. The following statement of deficiencies represents the results of a standard re-certification survey of Suffolk County DOH Bureau of Public Health Nursing Certified Home Health Agency, located at 3500 Sunrise Highway, Great River, New York 11739 conducted on 10/21/2024 through 10/24/2024. The survey consisted of a review of eight (8) clinical records including two (2) discharge records, four (4) personnel records for professional, four (4) contracts, and two (2) observational home visits. The survey included a review of pertinent policies and procedures including Health Commerce System, Influenza Vaccination, Organization and Administration of Services, Covid-19 and Infection Control. The Quality Improvement Committee meeting minutes for the past 12 months, Quality Assessment and Performance Improvement, Patient Admission Packet, Emergency Preparedness Plan, and Patient Complaint Log dated 10/2023 to 10/2024 were reviewed. Pre-survey activities consisted of review on 10/17/2024 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 07/2023 to 07/2024. (There are no reports available for this agency due to this provider primary patient population is Maternal Child Health). There are no Oasis assessment elements reports available. Additional survey preparation includes the agency’s compliance with report submissions for the 2022 statistical report and the Emergency Drill conducted 06/11/2019 through 06/13/2019. The Director of Patient Services was interviewed. Findings were reviewed at the exit conference on 10/24/2024. The following deficiencies are identified as a result of the survey: Federal citations: G0548 - Within 48 hours of patient's return G0572 - Receive services per Plan of Care G0614 - Written visit schedule G0642 - Program Scope G0658 - Performance Improvement Projects G0718- Communication with Physicians E004 - Emergency Develop and maintain Emergency Plan State citations: J0508 - Patient referrals and admissions J1156 - Governing Authority J1168 - Governing Authority J1460 - Personnel J1512 - Record and Reports

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interviews, the Agency failed to ensure that Skilled Nurse services is provided within forty-eight (48) of receipt of referral or hospital discharge. This was evident in two (2) of eight (8) records reviewed. (Patients #3 and #6) Failure to ensure Skilled Nurse services are provided within forty eight (48) hours of referral or hospital discharge, has the potential for negative patient outcome. 1) Patient #3 has a start of care date of 10/16/2024 with diagnoses of "Mental Disorder complicating Puerperium, Anemia complicating Puerperium, and Encounter for care examination of Lactating Mother" as documented on the "Home Health Certification and Plan of Care" for certification period 10/16/2024 to 12/14/2024. The referral is dated of 10/10/2024 and a hospital discharge date of 10/10/2024. The agency’s initial visit is dated 10/16/2024. The "Home Health Certification and Plan of Care" for certification period 10/16/2024 to 12/14/2024 documents an order for Skilled Nurse 2 - 4 every 2 months 2 (two to four visits a month for two months). Skilled Nurse to perform assessment of the "cardiopulmonary evaluation, vital signs, postpartum status, nutrition, mobilization, hydration, lochia, skin integrity, signs/symptoms infection, medication review and compliance, coping skills, family violence, home/environment safety, adequate follow-up with Medical Doctor/clinic for postpartum visit, signs/symptom mood disorder, and need for referral to community resources PRN (as needed". The Skilled Nurse "Non-Oasis Comprehensive Assessment" visit is dated 10/16/2024. The Agency did not perform an initial patient visit within forty-eight (48) hours of receipt and acceptance of a community referral or return home from the hospital. The survey findings were reviewed with the Director of Patient Services on 10/21/2024 at 03:57 PM. The Director of Patient Services was interviewed on 10/23/2024 at 10:55 AM. No explanation was provided. 2) Patient #6 has a start of care date of 09/10/2024 with diagnoses of Gestational Hypertension without proteinuria complicating childbirth, Mild to moderate Pre-Eclampsia complicating puerperium, Encounter for Lactating Mother, and Anemia complicating Puerperium as documented on the "Home Health Certification and Plan of Care" for certification period 09/10/2024 to 11/08/2024. The referral and hospital discharge are dated 09/06/2024. The agency's initial visit is dated 09/10/2024. The "Home Health Certification and Plan of Care" for certification period 09/10/2024 to 11/08/2024 documents an order for Skilled Nurse 2 - 4 every 2 months 2 (two to four visits a month for two months). Skilled Nurse to perform assessment of the "cardiopulmonary evaluation, vital signs, postpartum status, nutrition, mobilization, hydration, lochia, skin integrity, signs/symptoms infection, medication review and compliance, coping skills, family violence, home/environment safety, adequate follow-up with Medical Doctor/clinic for postpartum visit, signs/symptom mood disorder, and need for referral to community resources PRN (as needed). The Skilled Nurse "Non-Oasis Comprehensive Assessment" visit is dated 09/10/2024. The Agency did not perform an initial patient visit within forty-eight (48) hours of receipt and acceptance of a community referral or return home from the hospital. The survey findings and interview were conducted with the Director of Patient Services on 10/22/2024 at 03:44 PM. No explanation was provided.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on clinical records review and staff interviews, the Agency failed to ensure Skilled Nurse services and treatments are provided in accordance to the Plan of Care. This was evident in one (1) of eight records reviewed. (Patient #6). Failure to provide Skilled Nurse services and treatments as ordered in the Plan of Care, has the potential for negative patient outcome. 1) Patient #6 has a start of care date of 09/10/2024 with diagnoses of Gestational Hypertension without proteinuria complicating childbirth, Mild to moderate Pre-Eclampsia complicating puerperium, Encounter for Lactating Mother, and Anemia complicating Puerperium as documented on the "Home Health Certification and Plan of Care" for certification period 09/10/2024 to 11/08/2024. The "Home Health Certification and Plan of Care" for certification period 09/10/2024 to 11/08/2024 documents an order for Skilled Nurse 2 - 4 every 2 months 2 (two to four visits a month for two months). Skilled Nurse to instruct "patient monitoring and recording Blood Pressure twice a day as per Medical Doctor. Call Medical Doctor id Blood Pressure greater that 140/90. Visit the Emergency Room if Blood Pressure greater than 160/110". The Skilled Nurse visit report dated 09/10/2024 documents a Blood Pressure reading of 120/78 and instructions given to the patient on "automated Blood Pressure monitoring 2x (twice) daily". Blood Pressure parameters 140/90 - 160/110 as ordered in the Plan of Care. The Skilled Nurse visit report dated 09/19/2024 documents a Blood Pressure reading of 112/74 and instructions given to the patient on "automated Blood Pressure monitoring 2x (twice) daily". There is no documented evidence of the patient's Blood Pressure readings and recorded parameters as ordered in the Plan of Care. The Agency did not provide Blood Pressure monitoring based on the patient's medical diagnoses of Gestational Hypertension and Pre-Eclampsia complicating puerperium, as ordered in the Plan of Care. The survey findings and interview were conducted with the Director of Patient Services on 10/22/2024 at 03:44 PM. No explanation was provided.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on clinical record reviews and staff interviews, the Agency failed to provide their patients with a written Skilled Nurse visit schedule consistent with the Plan of Care. This was evident in five (5) of eight records reviewed. (Patients #3, #4, #5, #6 and #7). Failure to provide written Skilled Nurse visit schedules, has the potential for negative patient outcome. 1) Patient #3 has a start of care date of 10/16/2024 with diagnoses of "Mental Disorder complicating Puerperium, Anemia complicating Puerperium, and Encounter for care examination of Lactating Mother" as documented on the "Home Health Certification and Plan of Care" for certification period 10/16/2024 to 12/14/2024. The "Home Health Certification and Plan of Care" for certification period 10/16/2024 to 12/14/2024 documents an order for "Skilled Nurse 2 - 4 every 2 months 2 (two to four visits a month for two months)". "Skilled Nurse assessment cardiopulmonary evaluation, vital signs, postpartum status, nutrition, mobilization, hydration, lochia, skin integrity, signs/symptoms infection, medication review and compliance, coping skills, family violence, home/environment safety, adequate follow-up with Medical Doctor/clinic for postpartum visit, signs/symptom mood disorder, and need for referral to community resources PRN (as needed)". The initial Skilled Nurse/Registered Nurse "Non-Oasis Comprehensive Assessment" visit is dated 10/16/2024. There is no evidence of Skilled Nurse/Registered Nurse visit after the initial visit. The clinical record lacks documented evidence of written visits schedule was provided to the patient for planned Skilled Nurse visits. The survey findings were reviewed with the Director of Patient Services on 10/21/2024 at 03:57 PM. The Director of Patient Services was interviewed on 10/23/2024 at 10:55 AM. No explanation was provided. 2) Patient #4 has a start of care date of 10/03/2024 with diagnoses of "Pre-term Newborn Gestational Age 33-week, Newborn small Gestational age, Disturbance of Temperature Regulation of Newborn, and Neonatal Jaundice associated with preterm delivery" as documented on the "Home Health Certification and Plan of Care" for certification period 10/03/2024 to 12/01/2024. The "Home Health Certification and Plan of Care" for certification period 10/03/2024 to 12/01/2024 documents an order for "Skilled Nurse 2 - 3 every month 2 (two to three visits a month for two months)". Skilled Nurse assessment "cardiopulmonary evaluation, vital signs, neurological, gastrointestinal, genitourinary, elimination, hydration, nutrition, skin integrity, signs/symptoms infection, medication review and compliance, appropriate growth and development, adequate parenting skills, childcare, parenting coping, preventative health maintenance, need for community referrals". The initial "Pediatric Assessment" is dated 10/03/2024. There is no evidence of Skilled Nurse/Registered Nurse visit after the initial visit. The clinical record lacks documented evidence of written visits schedule was provided to the patient for planned Skilled Nurse visits. The survey findings and interview were conducted with the Director of Patient Services on 10/22/2024 at 03:38 PM. No explanation was provided. 3) Patient #5 has a start of care date of 09/30/2024 with diagnoses of "Severe Pre-eclampsia complicating puerperium, Anemia complicating puerperium, and Encounter care of Lactating Mother" as documented the "Home Health Certification and Plan of Care" for certification period 09/30/2024 to 11/28/2024. The "Home Health Certification and Plan of Care" for certification period 09/30/2024 to 11/28/2024 "Skilled Nurse 2 - 4 every month 2 (two to four visits a month for two month)". Skilled Nurse to perform assessment of "cardiopulmonary evaluation, vital signs, postpartum status, nutrition, mobilization, hydration, lochia, skin integrity, signs/symptoms infection, medication review and compliance, coping skills, family violence, home/environment safety, adequate follow-up with Medical Doctor/clinic for postpartum visit, signs/symptom mood disorder, and need for referral to community resources PRN (as needed)". The initial "Comprehensive Non-Oasis Assessment" is dated 09/30/2024. The clinical record lacks documented evidence of written visits schedule was provided to the patient for planned Skilled Nurse visits. The survey findings and interview were conducted with the Director of Patient Services on 10/22/2024 at 03:43 PM. No explanation was provided. 4) Patient #6 has a start of care date of 09/10/2024 with diagnoses of Gestational Hypertension without proteinuria complicating childbirth, Mild to moderate Pre-Eclampsia complicating puerperium, Encounter for Lactating Mother, and Anemia complicating Puerperium as documented on the "Home Health Certification and Plan of Care" for certification period 09/10/2024 to 11/08/2024. The "Home Health Certification and Plan of Care" for certification period 09/10/2024 to 11/08/2024 documents an order for Skilled Nurse 2 - 4 every 2 months 2 (two to four visits a month for two months). Skilled Nurse to perform assessment of the "cardiopulmonary evaluation, vital signs, postpartum status, nutrition, mobilization, hydration, lochia, skin integrity, signs/symptoms infection, medication review and compliance, coping skills, family violence, home/environment safety, adequate follow-up with Medical Doctor/clinic for postpartum visit, signs/symptom mood disorder, and need for referral to community resources PRN (as needed). The Skilled Nurse "Non-Oasis Comprehensive Assessment" visit is dated 09/10/2024. The clinical record lacks documented evidence of written visits schedule was provided to the patient for planned Skilled Nurse visits. The survey findings and interview were conducted with the Director of Patient Services on 10/22/2024 at 03:44 PM. No explanation was provided. 5) Patient #7 has a start of care date of 08/05/2024 with diagnoses of Unspecified Asthma with status Asthmaticus as documented on the "Home Health Certification and Plan of Care" for certification period 08/05/2024 to 10/03/2024. The "Home Health Certification and Plan of Care" for certification period 08/05/2024 to 10/03/2024 documents an order for Skilled Nurse 2 - 4 every 2 months 2 (two to four visits a month for two months). Skilled Nurse to perform "physical assessment, cardiopulmonary evaluation, vital signs, weight, monitor nutrition, hydration status, use and care of flow meter and Nebulizer. The initial "Pediatric Assessment" is dated 08/05/2024. The clinical record lacks documented evidence of written visits schedule was provided to the patient for planned Skilled Nurse visits. The survey findings and interview were conducted with the Director of Patient Services on 10/22/2024 at 03:44 PM. No explanation was provided.

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on record review and staff interview, the Agency failed to measure, analyze, and track quality indicators. This was evident in review of the Quality Assessment Performance Improvement program and Quality Improvement meeting minutes. Failure to measure, analyze and track quality indicators, has the potential for negative outcome. 1) The Quality Improvement meeting minutes dated 09/26/2023, 11/30/2023, 03/01/2024, 05/31/2024, and 09/10/2024 lack documented evidence of how the agency measure, analyze, and track quality indicators. The survey findings and interview were conducted with the Director of Patient Services on 10/24/2024 at 10:58 AM. No explanation was provided.

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record review and staff interview, the Agency failed to conduct Quality Improvement projects annually to reflect the scope and complexity of the services. This was evident in review of the Quality Improvement meeting minutes for the years 2023 and 2024. Failure to perform annual Quality Improvement projects, has the potential for negative outcome. 1) The Quality Improvement meeting minutes dated 09/26/2023, 11/30/2023, 03/01/2024, 05/31/2024, and 09/10/2024 lack documented evidence of the Agency's improvement projects focusing on the scope and complexity of the services and operations. The survey findings and interview were conducted with the Director of Patient Services on 10/24/2024 at 10:58 AM. No explanation was provided.

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 communicate with the Physician services not provided as per the Plan of Care. This was evident in two (2) of eight (8) records reviewed. (Patients #4, #5). Failure to communicate with the Physician, has the potential for negative patient outcome. 1) Patient #4 has a start of care date of 10/03/2024 with diagnoses of "Pre-term Newborn Gestational Age 33-week, Newborn small Gestational age, Disturbance of Temperature Regulation of Newborn, and Neonatal Jaundice associated with preterm delivery" as documented on the "Home Health Certification and Plan of Care" for certification period 10/03/2024 to 12/01/2024. The "Home Health Certification and Plan of Care" for certification period 10/03/2024 to 12/01/2024 documents an order for "Skilled Nurse 2 - 3 every months 2 (two to three visits a month for two months)". Skilled Nurse to perform assessment of "cardiopulmonary evaluation, vital signs, neurological, gastrointestinal, genitourinary, elimination, hydration, nutrition, skin integrity, signs/symptoms infection, medication review and compliance, appropriate growth and development, adequate parenting skills, child care, parenting coping, preventative health maintenance, need for community referrals". The initial "Pediatric Assessment" is dated 10/03/2024. The Registered Nurse documents planned revisits for 10/08/2024. The "Case Communication Reports" dated 10/08/24, 10/09/24, 10/10/24, and 10/16/24 document missed visits/attempted visits. There is no documented evidence of communication to the Physician of no Skilled Nurse/Registered Nurse visits made from 10/3/2024 to 10/21/2024 (survey date). The survey findings and interview were conducted with the Director of Patient Services on 10/22/2024 at 03:38 PM. No explanation was provided. 2) Patient #5 has a start of care date of 09/30/2024 with diagnoses of "Severe Pre-eclampsia complicating puerperium, Anemia complicating puerperium, and Encounter care of Lactating Mother" as documented the "Home Health Certification and Plan of Care" for certification period 09/30/2024 to 11/28/2024. The "Home Health Certification and Plan of Care" for certification period 09/30/2024 to 11/28/2024 "Skilled Nurse 2 - 4 every month 2 (two to four visits a month for two month)". Skilled Nurse to perform assessment of "cardiopulmonary evaluation, vital signs, postpartum status, nutrition, mobilization, hydration, lochia, skin integrity, signs/symptoms infection, medication review and compliance, coping skills, family violence, home/environment safety, adequate follow-up with Medical Doctor/clinic for postpartum visit, signs/symptom mood disorder, and need for referral to community resources PRN (as needed)". The initial "Comprehensive Non-Oasis Assessment" is dated 09/30/2024. The Registered Nurse documents planned revisits for 10/03/2024. The "Case Communication Reports" dated 10/03/24, 10/04/24, 10/08/24, and 10/18/24 document missed visits/attempted visits. There is no documented evidence of communication to the Physician of no Skilled Nurse/Registered Nurse visits made from 10/3/2024 to 10/21/2024 (survey date). The survey findings and interview were conducted with the Director of Patient Services on 10/22/2024 at 03:43 PM. No explanation was provided.