Every finding on record at Visiting Nurse Association of Central New York, Inc.

This statement of deficiencies is the result of an on-site complaint investigation survey for immediate jeopardy allegations of Nascentia at Home, Certified Home Health Agency, Complaint # 94901. The survey was initiated on 12/23/22 through 12/29/22 the immediate jeopardy allegations were not identified however, the complaint allegations were substantiated, and standard level deficiencies are being cited. During the survey the following survey activities were completed: reviews of 4 clinical records, pertinent policies and procedures, and interviews with agency nursing and supervisory staff. Each clinical record was reviewed on 12/30/22. The following deficiencies are being cited as a result of this survey: G 0586 Review and revision of the plan of care G 0608 Coordinate care delivery G 0798 Home health aide assignments and duties

Review and revision of the plan of care CFR(s): 484.60(c) Standard: Review and revision of the plan of care. This STANDARD is not met as evidenced by: Based on reviews of 4 clinical records and interviews with the nursing staff, supervising nurse and Director of Patient Services (DPS), it was determined in 2 of 4 records (patients # 1 and 4) the plans of care were incomplete and/or inaccurate and failed to identify the needs of the patient. Evidence as follows: Patient # 4 was admitted to the agency 06/25/17. Diagnoses included anal abscess, quadriplegia C1-C4 complete, and neuromuscular dysfunction of the bladder. The skilled nurse (SN) and nursing supervisors (NS) failed to effectively communicate with the physician to develop and implement a plan of care for the patient’s wound and catheter. WOUND CARE The 09/27/22 Home Health Certification and Plan of Care (POC) included skilled nursing visits 7 times weekly to provide the following wound care to perianal abscess: cleanse with soap and water, apply skin prep to peri-wound, pack upper open area with Hydrofera Blue (leave small tail out of wound), cover with foam dressing and Tegaderm everyday by skilled nurse and as needed for dressing compromise. On 11/16/22 the SN documented: “Joint visit with (NS), after wound irrigation and assessment, Duoderm placed over wounds, aide (consumer directed) educated how to place Duoderm over wound if become soiled or fall off, instructed to wash area in the event of soiling with soap and water, (aide) acknowledged and taught back.” On 11/17 and 11/18/22, the SN documented Duoderm was placed over all abscesses; however, the wound record report on 11/18/22 included care provided according the previous order to pack upper open area with Hydrofera Blue, cover with foam dressing and Tegaderm. At daily visits 11/19 – 11/22/22, the SNs documented placing Duoderm over the wounds; on 11/23 the note indicated wound care provided per orders and did not specify order. On 11/24/22 the SN completed a comprehensive assessment for recertification and generated the following order: perianal abscess (includes 3 small openings): skilled nurse/cg cleanse with soap and water, irrigate upper wound with 10cc normal saline, pat dry, cover with Duoderm 3x weekly with weekly measurements by SN/caregiver and prn for dressing compromise. On the order it was noted “verbal order: no” and “send to physician: no”. On 11/28/22 the SN documented a telephone call with physician’s office and obtained verbal order for recertification and aforementioned wound care orders. - From 11/18 – 11/28/22 there was no evidence the SN communicated with the physician’s office regarding the need to revise the plan of care / wound care orders. The 11/26/22 Home Health Certification and Plan of Care, which included the updated wound care orders, was faxed to the physician on 12/07/22, and returned with signature on 12/13/22. On the third page of the plan of care the physician wrote the following. “His wound care has been changed to three times per week which may lead to a worsening of his wound status. Please change from 7 times per week to five times per week before going all the way to three times per week.” On 12/16/22, during a telephone interview, the NS stated the agency was unaware of any order to increase the wound care to 5 days per week and the SN was trying to reach the physician for clarification. On 12/22/22, the surveyor interviewed the NS who stated when the plan of care was returned by the physician it was scanned and filed without noting the handwritten order to increase the frequency of wound care. On 12/22/22 the NS contacted the physician’s office and documented a verbal order was given to continue the wound care 3 times per week. -The agency failed to promptly identify the revision in the physician ordered plan of care received on 12/13/22. CATHETER CARE On 11/28/22, the SN documented the patient went to the emergency department for blood in his urine, and returned home with a urinary catheter. The SN notified the physician’s office. On 11/29 and 12/01/22, the SN documented the patient had not yet seen his primary care physician nor urologist; and on 12/16 and 12/21/22 that the patient still had no referral to urology and was advised the agency could not provide catheter care until they had orders from the provider. On 12/27/22 the surveyor interviewed the DPS regarding whether orders for catheter were obtained; they had not been. - From the time the patient returned home from the hospital on 11/28, through 12/27/22, the skilled nurse and nursing supervisors failed to communicate with the physician to develop a plan of care for the catheter. On 12/30/22 at 1:30 pm the record was reviewed with the Administrator, DPS and Nursing Supervisor. They acknowledged the findings and no additional information was provided. 1. Patient # 1 was admitted to the agency on 05/29/20 with diagnoses of Stage 3 pressure ulcer, type 2 diabetes, and quadriplegia (paralysis) (C-1 - C-4) neck injury. The home health certification and plans of care were incomplete and or inaccurate as follows: Catheter The 05/18/22 and 07/13/22 SN recertification assessment failed to identify if the patient had an indwelling/suprapubic catheter. The resulting plans of care for the certification periods 05/19/22 - 07/17/22 and 07/18/22 - 09/15/22, included the following inconsistent skilled nursing instructions: skilled nurse (SN) to insert "16 Fr 10 ml balloon Foley (urinary catheter) every 4 weeks and as needed", "SN for administration of bladder instillation/irrigation into Foley in urethra with 60 ccs NS (normal saline) as needed for blockage". Interventional Radiology to manage the Suprapubic Catheter. Maintenance and as needed dislodgement or stoppage". It was unclear if the orders incorrectly identified the presence of a urethral catheter, or if the patient actually had both catheters in place. There was no plan for managing the catheter including emptying the catheter bag, changing the night bag to the day bag and failed to identify the person responsible to provide this care. Diabetes/Diabetic Management The 05/18/22 SN recertification assessment included documentation that the patient uses a continuous sensor that is changes every 2-3 weeks to monitor blood sugars. The SN also documented the patient checks blood sugar 3-4 times a day. The 07/13/22 SN recertification assessment only included the patient checks blood sugars 4-5 times a day, nothing about the continuous monitor. The 05/19/22 - 07/17/22 and 07/18/22 - 09/15/22 plans of care failed to include: frequency for blood sugar testing - the plan of care indicates the patient checks blood sugars occasionally. specifics related to the use of continuous glucose monitor including the person responsible to assist the patient with changing the sensor - the patient is a quadriplegic with limited use of upper extremities identified on the 05/18/22 recertification assessment. Wound Care The 05/19/22-07/17/22 and 07/18/22 - 09/15/22, plans of care included wound care to the Stage 3 pressure ulcer right gluteus ordered 3 times a week and as needed by caregiver/SN. The plan of care failed to include: frequency the wound care would be performed by the SN versus the caregiver. plan for the SN to ensure the caregiver is competent in providing wound care. plan to ensure that wound care was provided if the caregiver was not available. On 07/20/22, the patient record contained an order for a Stage 3 pressure ulcer located "above the scrotum near the anus". The wound care frequency was changed to everyday (qd) and as needed (PRN) for dressing compromise performed by SN/caregiver. The person responsible for the daily wound care was not specified and the SN frequency was once weekly. The 09/16/22 - 11/14/22 and 11/15/22 - 01/13/23 plans of care included SN visits 1 time per week for 9 weeks and the following inconsistent wound care orders: wound care to stage 3 pressure ulcer above the scrotum near the anus perform qd and prn for dressing compromise by SN/Caregiver. The plan of care failed to include how daily wound care would be completed if the caregiver was not available. wound care to stage 3 pressure ulcer R Gluteus perform 3 times a week and prn for dressing compromise by Caregiver/SN. The recertification assessments completed on 09/14 and 11/10/22 failed to include the presence of two wounds. On 12/30/22, the findings above findings were reviewed with the DPS, and Supervising Nurse, they acknowledged the findings and provided no additional information.

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 a review of clinical records, pertinent policies and procedures, interviews with agency staff, the Director of Patient Services (DPS), Supervising Nurses, and representatives from the Managed Long Term Care Program (MLTC), it was determined in 1 of 4 patients (Patient # 1) the agency failed to provide adequate care coordination to ensure that the patient's needs were met. Evidence as follows: Patient # 1 admitted to the agency on 05/29/20 with diagnoses of Stage 3 pressure ulcer, Type 2 diabetes, and quadriplegia (C-1 - C-4) neck injury. Between 05/18/22 and 12/29/22, the SN completed recertification assessments every 2 months and SN visits weekly to perform wound assessments. The SN documented that the patient's primary caregiver was from an entity that provides consumer directed aides (CDAs) and was available 24 hours a day/ 7 days a week. The SN failed to assess and coordinate services when the of the availability of CDAs changed and the patient no longer had consistent services to assist with basic activities of daily living, wound care, diabetic management and suprapubic catheter care, for a quadriplegic patient with limited upper extremity movement. Wound Care The 09/16/22 - 11/14/22 and 11/15/22 - 01/13/23 plans of care included SN visits 1 time per week for 9 weeks and the following wound care orders: - wound care to stage 3 pressure ulcer above the scrotum near the anus - cleanse with soap and water, Triad cream around wound, cover with Hydrofera blue, Drawtex, and then abdominal pad, tape in place perform qd (everyday) and prn for dressing compromise by SN/Caregiver. - wound care to stage 3 pressure ulcer R Gluteus cleanse with soap and water, Triad cream around wound, cover with Hydrofera blue to wound bed, then cover with abdominal pad perform 3 times a week and prn for dressing compromise by Caregiver/SN. The SN failed to coordinate with the physician to clarify wound care frequency, identify the person responsible to provide daily wound care when and if the CDA was not available. The SN conducted weekly assessment visits between 09/01/22 and 12/29/22. During the weekly visits, the SN frequently documented concerns about the lack of consistent CDA services. The SN documented during several visits that the patient wasn't safe without consistent CDA services, but that the patient chose to live at home. There was minimal documentation that the SN communicated the issues to the Supervising Nurse, Managed Long Term Care (MLTC) case manager, and/or physician to ensure that the patient's needs were met. During each visit the SN documented only the wound located above the scrotum, not the Right gluteus. On 12/28/22, the MLTC provided documentation of visits completed by the CDA from 06/01/2022 to 11/29/2022. The surveyor reviewed visits completed between 09/01/2022 to 11/29/22. - Between 09/01/22 and 09/30/22, there were no CDA visits documented for 20 out of 30 days. - Between 10/01/22 and 10/31/22, there were no CDA visits documented for 20 out of 31 days. - Between 11/05/22 and 11/30/22, there were no CDA visits documented for 26 out of 30 days. Without the assistance of the Consumer Directed Aides, the patient calling family or friends, the following patient needs identified in the assessments and plans of care could not be met: - wound care - daily or three times a week and as needed when dressing soiled - personal care - including showers, bathing - transfer of patient out of bed using Hoyer lift (mechanical transfer equipment) - toileting hygiene - care of the suprapubic catheter - basic activities of daily living - preparation of food, water, assistance with medication management - diabetic management including blood glucose testing. The SN visits were completed weekly, from 09/01/22 to 12/29/22. On 09/14/22 - The SN documented in the recertification assessment, "The patient knows that he is not safe in his home without sufficient aide service as of right now he wants to stay in his own home." The SN failed to discuss with the patient how often the patient is without assistance from the aide or coordinate with the Supervising Nurse to develop a solution. The SN documented there was diarrhea in the wound, although the SN completed wound care, the patient will need a shower and change the dressing. The SN left written instructions for the sister. The SN failed to assess the caregiver's competence in providing wound care. The SN documented that the MLTC is working on getting him aide services, but it was unclear if the SN asked the MLTC or the patient how long it had been since the patient had an aide. On 10/04/22 - the SN visited the patient and documented the patient was lying in stool no aide available, the SN did not assess how the patient would manage obtaining food and medications for the day. On 10/07/22, the patient called the agency on-call system requesting visit because there was no aide available, and the patient was lying in "feces". The SN completed a visit and documented the patient was lying in feces and stated there is a friend who comes over in the morning and evening to assist him. On 10/12/22 the SN case manager visited and documented patient lying in very large stool cleaned patient up. Offered the patient the name of a private hire aide that the patient could pay for out of pocket. There was no communication with the Supervising Nurse or the MLTC to discuss the lack of aide service to meet the patient's needs. On 10/19/22 the patient seen in the emergency room for the suprapubic catheter coming out and urine leaking from his penis. There was no discussion with the Supervising Nurse or physician regarding the availability of aide services and the possibility of adding agency aides to assist with care. On 10/27/22 the SN visited and documented the patient asking for a catheter placed in his urethra, due to the suprapubic catheter still leaking. The SN documented cleaning wound but not replacing dressing, that patient has a friend coming to provide a shower. Dressing prepared for friend to apply after shower. The SN failed to discuss the lack of aide services with the Supervising Nurse, MLTC or physician to develop an adequate safe plan to meet the patient's needs. On 11/02/22 the SN visited patient and documented in the narrative note - "patient does not have adequate support to be safely in his home. He is aware he is not in a good situation. He is choosing to stay in this situation. He is constantly searching for reliable aides and hasn't been able to find any." " Diarrhea today. Small flies flying around. The wound continues to show signs of worsening, the patient has not been to wound MD for a while DT (due to) no aide to get him ready." The SN documented "I made patient aware of the flies, cleaned patient up best he could, got dressing ready for friend who is coming later to shower the patient and provide wound care." On 11/02/22 the record contained a case conference note requesting a wound care specialist consultation. The case conference note included only the name of the SN case manager. It is unclear if the request for a wound care specialist referral was ever processed, and no visit was completed. On 11/10/22 the SN completed a recertification visit the SN documented nothing about the aide issue only that his blood sugars were low. On 11/10/22 a case conference note entered by the SN case manager to the Supervising Nurse included the following: - would like to submit this patient to the "root cause analysis program"(program of multi discipline review to identify patient care solutions) - has lost his regular aide - he is a quadriplegic - relies on the aides to come in am and pm to get him to his chair and perform wound care - he has developed increased shoulder pain missing wound physician's appointments - wound care specialist appointment requested but not completed - has no one there in the morning to get food and his blood sugars in the morning are low - offered social worker but has MLTC There was no evidence that the patient was ever referred to the "root cause analysis program" until 12/22/23. On 12/01/22, the SN documented that the patient had a "helper" and the SN provided teaching regarding changing the urine bag, and that the patient was in the Hoyer lift. The "helper" will only be available occasionally. The record contained a case conference note dated 12/07/22 indicating that the SN sent communication to the MLTC regarding a suggestion to find additional aide service from a co-worker of the patient who was helping, and she had several ideas about how to increase CDA services. On 12/14/22 the SN visited the patient and documented the wound was "bleeding a lot today it dripped all over the floor when the caregiver transferred him from bed to his shower chair." "pain bad for pt" There was no follow-up with the MLTC and the co-worker. On 12/14/22 there was a case conference documented regarding the use of an electric mechanical lift (Hoyer lift). There was no discussion of the deterioration of wound, lack of aide service, request for wound care specialist, or to review the record. There was no evidence of care coordination or a plan to meet this patient's needs until 12/21/22. The DPS was contacted by phone to discuss the client and inquire about the aide service. On 12/21/22, the DPS stated that they are now providing a home health aide 2 hours a day 7 days a week. On 12/23/22, 10:30 am, an interview was conducted with the SN case manager regarding the lack of CDA services. The SN stated the patient wants to live in his own apartment and that he has interviewed multiple aides but cannot find reliable aides. The SN states that he has had multiple communication with the MLTC. This is inconsistent with the documentation. On 12/21/22 the above findings were reviewed with the DPS, Administrator and the Supervising Nurses. The acknowledged the findings and agreed to continue to ensure the patient's needs were met. Failure to ensure that care coordination was provided resulted in the personal care needs not met, wound deterioration, and low blood sugar readings for patient # 1 and the potential for negative outcomes for the agency patient population.

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 a review of clinical records, and interviews with the Administrator, Director of Patient Services (DPS) and Clinical Managers, it was determined in 1 of 1 record of a patient with home health aide services (patient #4) the skilled nurse (SN) failed to develop complete and accurate assignments and aide written instructions. This was evidenced by: Patient # 4 was admitted to the agency 06/25/17. Diagnoses included anal abscess, quadriplegia C1-C4 complete, and neuromuscular dysfunction of the bladder. The 09/27/22 and 11/26/22 Home Health Certifications and Plans of Care included a home health aide daily, and skilled nursing visits three times weekly and as needed for wound care to the coccyx / buttocks. The skilled nurse failed to appropriately assign, and provide adequate instructions to, the Home Health Aide (HHA) as follows: WOUND CARE The 09/27/22 and 11/26/22 aide care plan failed to include any instructions regarding bathing relative to the wound and dressing present on the patient’s coccyx area. CATHETER CARE On 11/28/22 the patient went to the emergency department and returned with a Foley catheter. The skilled nurse failed to update the aide care plan to include any instructions for providing catheter care. ASSIGNMENT The Plan of Care included a HHA 7 days per week. Review of aide completed visits for November 2022 revealed on 11/01, 11/03, 11/08, 11/15, 11/17 and 11/22/22, a Personal Care Aide (PCA) was assigned to the patient rather than a HHA. HHA and PCA are not interchangeable. On 12/30/22 at 1:30 pm the record was reviewed with the Administrator, DPS and Nursing Supervisor. They acknowledged the findings and no additional information was provided. Failure to ensure that home health aide assignments and care plans are complete has the potential for unmet patient needs.