Every finding on record at Tri-Borough Certified Health Systems of New York, LLC

An on-site complaint investigation for complaint #103863 was conducted at Family Care Certified Services CHHA, located at 1414 Utica Avenue, Brooklyn, NY 11203 on 01/22/2024. 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 Log for the period 07/01/2023 to 01/20/2024, Active census, the agency's Policies and Procedure were reviewed. The active patient census is 53. The Director of Patient Services/Administrator was interviewed. The findings were reviewed at the exit conference on 01/22/2024. The allegation in complaint #103863 was determined substantiated. The following deficiencies are being cited as a result of the complaint investigation: G-0580 - Only as ordered by a physician. G-0710 - Provide services in the plan of care.

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 review and staff interview, the agency failed to ensure that treatments are administered only as ordered by the physician for each patient. This was evident for one (1) of three (3) clinical records reviewed. (Patient #1). Failure to ensure that treatments are administered only as ordered by the physician has the potential for negative patient outcomes. The findings are: 1.Patient #1 has a Start of Care date of 06/14/2021 with the following diagnoses "Chronic Venous Hypertension with Ulcer of Bilateral Low Extremity, Non-Pressure Chronic Ulcer of other Part of Right Lower Leg with other Specified Severity, Non-Pressure Chronic Ulcer of other Part of Left Lower Leg with other Specified Severity " documented on the Plan of Care dated 12/01/2023 to 01/29/2024. The Plan of Care dated 12/01/2023 to 01/29/2024 documents:” SN (Skilled Nurse) to apply Unna Boot to Right Lower Leg: Apply Unna Boot and Ace Bandage 1 x week by SN (Skilled Nurse) as preventative treatment. Start Effective Date: 11/27/2023." The Skilled Nurse Visit Note dated 12/05/2023, 12/07/2023, 12/14/2023, 12/26/2023, 12/28/2023 documents: "Interventions/Education Provided: Wound to right lower extremity cleanse with NS (Normal Saline), pat dry. Unna boot applied to wound, covered with Kling and secured with Ace bandage." The Interventions/Education Provided section dated 12/05/2023, 12/07/2023, 12/14/2023, 12/28/2023 documents: " Interventions: SN (Skilled Nurse) to apply Unna Boot to Right Lower Leg: Apply Unna Boot and Ace Bandage 2 x week by SN." The Plan of Care dated 12/01/2023 to 01/29/2024 documents:” SN (Skilled Nurse) to apply Unna Boot to Left Lower Leg: Apply Unna Boot and Ace Bandage 1 x week by SN. Start Effective Date: 11/27/2023. SN (Skilled Nurse) to provide Wound to Left Lower Leg Inner, lower aspect: remove outer dressing only, apply dry sterile gauze, secure with Kling bandage and ACE bandage 2 x week. Start Effective Date: 11/27/2023." The Skilled Nurse Visit Note dated 12/05/2023, 12/07/2023, 12/12/2023, 12/14/2023, 12/19/2023, 12/22/2023, 12/26/2023, 12/28/2023 documents: "Interventions/Education Provided: Wound to left medial leg cleanse with NS (Normal Saline), pat dry covered with DSD (Dry Sterile Dressing), wrapped with Kling and secured with Ace bandage. SN Wound/Integumentary Interventions: SN to apply Unna Boot to Left Lower Leg: Apply Unna Boot and Ace Bandage 2 x week by SN." The Skilled Nurse Visit Note dated 01/05/2024 documents: "Interventions/Education Provided: Nurse cleansed venous ulcer to left lateral ankle with NS (Normal Saline), applied DSD (Dry Sterile Dressing), Unna Boot Kling and Ace wrap. Patient has a dorsal wound to the left dorsal foot cleansed wound with NS (Normal Saline), applied Silvadene cream DSD (Dry Sterile Dressing), and Kling wrap wound is granular with small serous drainage etiology of wound is unknown. VN (Visiting Nurse) called PCP (Primary Care Physician) and obtained wound care orders. " There is no documented evidence of an interim or supplemental orders for the change in the wound care treatment. There is no documented evidence of the SN (Skilled Nurse) administering wound treatment only as ordered by the physician. On 01/22/2024 at 05:15 pm, the Director of Patient Services was interviewed and did not provide an explanation.

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: 1.Patient #2 has a Start of Care date of 11/27/2023 with the following diagnoses "Pressure Ulcer of Right Buttock, stage 2, Hypertensive Heart Disease with Heart Failure, Type 2 Diabetes Mellitus without Complication " documented on the Plan of Care for the Certification Period dated 11/27/2023 to 01/25/2024. The Plan of Care dated 11/27/2023 to 01/25/2024 documents: ” RN (Registered Nurse)/DNP/LVN (Licensed Vocational Nurse):2 x week for 3 weeks starting 11/28/2023 Start Date:11/28/2023 End Date: 12/16/2023; RN (Registered Nurse)/DNP/LVN (Licensed Vocational Nurse): 3 x week for 1 week starting 12/17/2023 Start Date: 12/17/2023 End Date: 12/23/2023; RN (Registered Nurse)/DNR/LVN (Licensed Vocational Nurse): 1 x wee for 4 weeks starting 12/24/2023 Start Date: 12/24/2023 End Date:01/20/2024.” There is no documented evidence of the RN (Registered Nurse) providing care for the patient: week of 11/27/2023 - 2 (two) missed visits; week of 12/03/2023 - 1 (one) missed visit, week of 12/10/2023 - 1 (one) missed visit, week of 12/17/2023 -1 (one) missed visit. There is no documented evidence of the patient receiving RN (Registered Nurse) services as ordered on the plan of care. On 01/22/2024 at 05:15 pm, the Director of Patient Services was interviewed and did not provide an explanation.