Every finding on record at Your Choice at Home, Inc

The following statement of deficiencies represents the results of partial extended re-certification survey of Your Choice at Home located at 380 Henry Street, Brooklyn, NY 11201 conducted on 07/31/2023 through 08/03/2023. The agency reports an active patient census of 207. A standard re-certification survey was initiated on 07/31/2023. Deficient practices were identified within Level 1 standards in 484.60 Care Planning, Coordination of Services resulting in a partial extended survey. The survey consisted of a review of seven (7) personnel records identified as Employee #1,#2,#3,#4,#5,#6, and #7, 10 clinical records identified as Patient #1,#2,#3,#4,#5,#6,#7,#8,#9, and #10, four (4) home visits, and (5) discharge clinical records. 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 policy and procedure, and Vaccination Log. Pre-survey activities consisted of a review on 07/28/2023 of the agency's Health Commerce System account, Certification and Surveyor Provider Enhanced Reports (CASPER) for the period 05/2022 – 04/2023, and the agency compliance with report submissions for the 2021 statistical report and the Emergency Drill for 2019. The Administrator/Director of Patient Services, and staff were interviewed. Findings were reviewed at the exit conference on 08/03/2023. The following deficiencies are identified as a result of the survey: G0414 – HHA administrator contact information G0446 – Contact info Federal/State funded entities G0450 – Access to auxiliary aids and language service G0580 – Only as Ordered by a Physician G0808 – Onside supervisory visit every 14 days

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on review of the agency's Patient Admission packets and staff interview the agency failed to provide and include the administrator's name, contact information in all admission packets. This was evident for ten (10) of ten (10) clinical records reviewed. (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10). Failure to provide and include the administrator's name in the admission packets for all patients has the potential for negative outcome. The Findings Are: The agency's admission packets were reviewed on 08/02/2023. There is no documented evidence that Administrator Name is included in Admission packet. There is no documented evidence of the patients receiving a copy of the Patient Bill of Rights with all the required information. On 08/02/2023 at 01:45pm, the Administrator/Director of Patient Services was interview and did not provide an explanation for the finding.

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on review of the agency's Patient Admission packets and staff interview the agency failed to ensure that the Patient Bill of Rights includes information for Federally funded and state-funded entities that serve the area where the patient resides. This was evident for ten (10) of ten (10) clinical records reviewed. (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10). Failure to ensure the contact information for the Federally - funded and State funded agencies that are in the area where the patients reside was provided to all patients, has the potential for negative patient outcomes. The Findings Are: The agency's admission packets were reviewed on 08/02/2023. The Patient Bill of Rights lacks documented evidence of information for the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. There is no documented evidence of the patients receiving a copy of the Patient Bill of Rights with all the required information. On 08/02/2023 at 01:45pm, the Administrator/Director of Patient Services was interview and did not provide an explanation for the finding.

Access to auxiliary aids and language service CFR(s): 484.50(c)(12) Be informed of the right to access auxiliary aids and language services as described in paragraph (f) of this section, and how to access these services. This ELEMENT is not met as evidenced by: Based on review of the Patient Bill of Rights, the agency failed to ensure that the Patient Bill of Rights includes information about the patient's right to access auxiliary aids and language services. This was evident for ten (10) of ten (10) clinical records reviewed. (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10). Failure to ensure the Patient Bill of Rights includes information about the patient's right to access auxiliary aids and language services, has the potential for negative patient outcomes. The Findings Are: The agency's admission packets were reviewed on 08/02/2023. The Patient Bill of Rights included in the Admission packet does not include documented evidence of the patient 's right to access auxiliary aids and language services. There is no documented evidence of the patients receiving a complete copy of the Patient Bill of Rights with all the required information. On 08/02/2023 at 01:45pm, the Administrator/Director of Patient Services was interview and did not provide an explanation for the finding.

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 provided as ordered by a physician for each patient. This was evident for one (1) of ten (10) clinical records reviewed. (Patient#1). Failure to ensure all treatments are provided as ordered by the physician has the potential for negative patient outcomes. The Findings Are: 1. Patient #1 (HV) has a Start of Care date of 05/17/2023 with the following diagnoses "Venous Insufficiency, Non-Pressure Chronic Ulcer of Lower Limb" documented in the Home Health Certification and Plan of Care dated 05/17/2023 to 07/15/2023. The Home Health Certification and Plan of Care dated 05/17/2023 to 07/15/2023 documents: SN (skilled nursing) 1WK1 (once a week for one week) – effective 5/17/2023, 1WK1 – effective 5/21/2023; Wound #1, 2: cleanse the wounds with NS (normal saline), pat dry, apply A&D (vitamin A and D) ointment to peri wound, apply Hydrogel on the wound and wrap the right lower leg with Unna boot and wrap with ACE bandage twice a week.” The clinical record documents registered nurse home visit on 05/17/2023 and 05/22/2023. There is no documented evidence of a clear order of nursing visits - once a week but wound care is twice a week. There is no documented evidence of the treatments are administered as ordered by the physician. The Physician’s Order dated 07/03/2023 documents: SN 1WK2 (once a week for two weeks) – effective 7/3/2023 – cleanse right lower leg stasis ulcers with NS, pat dry, apply Mupirocin then Calcium Alginate, cover with dsd (dry sterile dressing) 3 times a week. There is no documented evidence of a clear order of nursing visits - once a week but wound care is three times a week. On 08/02/2023 at 02:00pm, the Administrator/Director of Patient Services, the Director of Operations, and the Supervisor were interviewed and did not provide an explanation for the findings. .

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview the agency failed to ensure that all home health aides (hha) providing services to patients receiving skilled services are supervised no less frequently than every fourteen (14) days. This was evident for one (1) of ten (10) clinical records reviewed. (Patient: #9). Failure to ensure that home health aide supervision is conducted every fourteen (14) days patients who are receiving skilled services, has the potential for negative patient outcomes. The Findings Are: 1. Patient #9 with date of birth 10/07/2009 has a Start of Care date of 09/01/2021 with the following diagnosis "Autistic Disorder" documented in the Home Health Certification and Plan of Care dated 06/23/2023 to 08/21/2023. The Duty Sheet documents aide services were being provided from 06/23/2023 to 07/21/2023. The clinical records documents aide supervision done on 07/04/2023. There is no documented evidence that the aide is being supervised in home every 14 days. On 08/02/2023 at 02:00pm, the Administrator/Director of Patient Services, the Director of Operations, and the Supervisor were interviewed and did not provide an explanation for the findings. .