DEPARTMENT OF HEALTH AND HUMAN SERVICES -CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xi) PROVIDERJSUPPLIERJCLIA. IDENTIFI CATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING B.WING STREET ADDRESS. CITYSTATE, ZIP CODE 120 WEST JOHN STREET PRINTED: 02/16/200 FORM APPROVEI OMB NO..0938-039 (X3) DATE SURVEY'" COMPLETED 337237 NAME OF PROVIDER OR SUPPLIER 02/08/2007 FAMILY CARE CERTIFIED SERVICESNASSAU CHHA (X4) ID PREFIX I TAG I SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) HICKS VILLE, NY 11801 I I ID PREFIX TAG I PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (x5) COMPLETION DATE G 000!INITIAL COMMENTS A Standard Recertification Survey was conducted on 02/05/07 to 02/08/07 at Family Care Certified 'Services. . G 000! : I " .. .. Twenty one (21) Clinical Records were reviewed ard-are-identified-a s-Patients.#I4o-#24o_.---.... Nine (9) Home Visits were made to Patients #2, #3, #6,#7, #12, #13, #14, #19 and #21. .. ..iften.(15)-Personnel Records were reviewed.t and are identified as Employees #1 to #I5. G 225 484.36(c)(2):ASSIGNMENT & DUTIES OF HOME HEALTH AIDE. The home health aide provides services that are ordered by the physician in the plan of care and that the aide is permitted to perform under state law. I g .. . G 225 Administrator, Director of Nursing I Director of Long Term Program, P1 o Committee, and the HHA Coordinatoito review, assess, design, and implement a plan of action. The CHIA will reinforce with This STANDARD is met as evidenced by:. not Based on review of the clinical records,,the agency's policy and procedure and staff interview, the agency's nursing staff failed to ensure that the paraprofessional staff perform all the ordered o patient-care tasks according to the Plan of Care in six (6) of twelve (12) patients receiving paraprofessional services (Patients #2, #4, #7, re th enueta revised -IA Care Plans are written each recertification period..The, LTRI-ICP will review/rewrite their I-IRA Care Plans every six months. dea p The renfo an . #9, #10 & #21). D t Director of Nursing will Tereinforce procedure that copies of iThe . T The agency's failure to ensure that the paraprofessi6nal staff provides the ordered . patient care tasks according to the Plan of Care I places all patients at risk for poor quality of care re'vised HHA CarePlansare' distributed appropriately within the patients home the medical record and unmet patient care needs. Findings are: LABORATORYDIRECTOR'S OR PROVlOERJSUPPLiER:REPRESENTATIVE'S SIGNATURE and the HI-1A Coordinator.(who in turn will forward a copy to the aide agency). ' I. I TITLE . , . ,',x6)DATE. ,nydeficiency.staterhent'en.ing with'an asterisk () denotes:a deficiency which'the institution may be excused.ffoM-correcing.pfoviding9t is determinedthat . thergafegu;rds8provide sufficient protection to the 'patients" (See Instructions.) Except for nursing homes., the findings-stated-above.ate disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are dlsclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete ' - Event tO:LOP011 . Facility ID: 3869 ' If continuation sheet Page 1 of 0 , DEPARTMENT OIr HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES ".AND STATEMEN(T PLAN OFOF DEFICIENCIES CORRECTION (Xi) IDENTIFICATION PRO VIDER/SUPPLIERJCLIA NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING .ULB. WING PRINTED: APPROVEV FORM 02112007 OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED 337237 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE S120 WEST JOHN STREET 1 ID PREFIX TAG 02/0812007 WSTJLLEN FAMILY CARE CERTIFIED SERVICES NASSAU CHHA (X4).ID PREFIX TAG I .. HICKS VILLE, NY 11801 I 1TREE IXSI COMPIETI0N4 DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE' CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) I G 225 Continued From page 1 Patient #2 was admitted to the agency on 06/27/06 with diagnoses including Varicose Vein Lower Extremities With Ulcer, Venous Insufficiency, Hypertension and Diabetes Mellitus. aReview of the Plans of Care dated 10/22/06 12/23/06 and 12/24/06 - 02/21/07 ordered home health aide (hha) service three (3) - five (5) days x; two (2) - four (4) hours to provide personal care for ADL (Activities of Daily Living), assist for meal preparation, for light housekeeping and for HEP (Home Exercise Program). Review of the aide duty sheets from 11/27/06 01/19/07 consistently failed to document that the hha provided the patient with assistance with the HEP as ordered on the Plan of Care and directed on the:Home Health Aide/Personal Care Aide SCare Plan dated 06/27/06. r During interview with the Nursing Supervisor, Director of Patient Services (DPS) and Quality Assurance Nurse on 02/08/07 at 10:00 AM, the i staff acknowledged the findings. Patient #21 was admitted to the agency on 01/17/00 with diagnoses including Cerebral Vascular Disease and Hypertension. Review of the Plans of Care dated 10/18/06 12/16/06 and 12/17/06 - 02/14/07 ordered PCA (Personal Care Aide) service seven (7) hours xIi six (6) days to assist with change bed linen, light housekeeping and assist with ambulation. Review of the aide duty o theaid Reviw sheets lacked dut shets ackd documentation that the PCA assisted the patient with ambulation on 12/04 - 12108, 12/11 - 12/15, i FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:LOP0t 1. G 225: The Administrator will compose a ; letter requesting meetings with representatives of all HI&A agencies. Letters will be sent by March 9, 2007 requesting meetingDdates for thetwngk of March 1 91 During the meeting, the administrator will review the language in contract detailing the responsibility of the Aide Agency to ce it y of the check the accuracy of the documentation submitted. Discussion to also include communication from . the Aide to the'Nurse as to when they have questions as to the assigned tasks given. The HHA Coordinator, and the LT Office Coordinator will continue to review accuracy of completion of the duty sheet. As part of the Aide supervision sheet, I a new prompt will be added, a irequesting the Nurse to also include. - "documentation instruction" as part of the aide supervisory visit. The I Directors of Nursing for both 'programs will instruct the Nurses of adiint urvisoy this addition to the the supervisory aide I I form. When deemed necessary, the proper will also instruct the aide on completion of the paperwork, INurse by having the aide complete the duty Isheet in the presence of the Nurse. Facility ID: 3869 If continuation sheet Page 2 of 7 FAMILY CARE CERTIFIED SERVICES NURSING VISIT REPORT NAME: f HCC CHN AR# 1'D :I" DATE OF VISIT: GNSjIBLOOD PRESSURE (R) (L) TEMP (0) (R) (A): AP RP RHYTHM RESP 1 K. SITE: DRAINAGE: WCAP:' Y[ LYING: SITTING: STANDING: N O SITE WEIGHT: DESCRIPTION: Pitting( ) Noni-Pitting( LUNGS: (R) DIAGNOSIS: LAST MD. VS: (I NEXT MD VS: MID NAME_ Pallor SOB DOE Palp Periph Circ Homans Signs ( Phlebitis Diaphoresis ( ) Vomiting ( ) ausea ( Anxiety ( Pacemaker SOB [ ) Cough ( ) Sputum Anxiety( )Prod ( )Color Non-Prod ( Hemoptysis ( ) ( ) ( ) Orthopnea Bradycardla Techycardia Cyanosis Mobility ( ) Paresthesla Ambulation ( )ROM Weakness ( )Amputee Deformities ( ) Cast Care Bleeding ( ) Treatments WeightBoaring{ Vomiting Appetite ( ( ( Bleeding Bowel Habits ( ) Nausea Distention URINARY _____Weakness ( Incontinence Diarrhea Flatus ) [ F NE URO Headache ( ) Vomiting ( ) Gait Affect ( Orientation ( Consciousness ( Dizziness ( Nausea ( ) Syncope ) Vertigo ) Herniparosis ) Speech )Seizures Odor Burning Discharge Frequency Color Nocturia ) ) ) ) ) Hematuria Concentration Distention Incontinence Catheter lirrigation Foley Size DIET:_ NUTRITN () ( ) ( ) () ) I . Insulin '" ( Site Rotation ( Urne Test ( S) Test ( S&S Hyperglycemia( FALL.P N )Neuropathy )Skin Care )Foot Care )Vision )S&S Hypoglycemia Transfer Dmoel ( ) ( ) ( (_) MDICATIO: _ o Compliance{ )Changes D INSTRUCTIONS: NARRATIVEMEA Instruct n Reinforce 0l Sale 0 Unsafe 03 Instruction: PainiSite: Scale: 0 1 2 3 4 5 6 7 8 9 Relieved By:_ 10 All instruction with V.U./R.D by PatientS.O: E0 Y I N Pink Note Attached: El Y 0l N Patient/Famly involved in POC changes 0 DAYS:_ 'I H fNST?RiQ6 1NS i PLN HOURS:_ PERSONAL CARE:_ HOUSEKEEPING: -ADL:_ ORIENTATION:_ SUPERVISION: DOCUMENTATION REVIEWEO. Describe plan for follow-up. What should be done on the next visit? Include any modifications inthe Care Plan. Signature of Nurse: Next Nursing Visit__ Title: Frequency: Revised 1/06 FCCS #327 PRINTED: 02/16/2007 -" DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES P (X1) PROV I DERISUPPLIER CLIA IDENTIFICATION NUMBER: FORM APPROVED OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______ _____ STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X3) DATE SURVEY COMPLETED 337237 NAME OF PROVIDER OR SUPPLIER . B,W1NG STREET ADDRESS, CITY. STATE, ZIP CODE 02/08/2007 120 WEST JOHN STREET HICKSVILLE, NY 11801 FAMILY CARE CERTIFIED SERVICES NASSAU CHHA (X4) ID . PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIF=YING INFORMATION) ID PREFIX *TAG : PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE TCROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) fx5) COMPLETION DATE G 225 Continued From page 2 12/18 - 12/23, 12/26/06 - 01/05/07, 01/08 - 01/12 and 01/15 - 01/19/07 as directed on the Home. G 225: The Performance Improvement department will be responsible to monitor the accuracy of completion of: the duty sheets. Each quarter, as part of their chart audit in preparation of the PAC meeting, the PI Nurses will review 10 charts for accuracy of completion of the duty sheets. Health Aide/Personal Care Aide Care Plans dated 01/17/06 and 01/11/07. Review of the aide duty sheets from 12/04/06 01119/07 consistently lacked any documentation of the provision of personal care (shower, sponge bath, hair grooming, dressing or skin care) on Tuesdays and Thursdays as directed on the I Home Health Aide/Personal Care Aide Care Plan . dated 01/17/06 and 01/11/07. During interview with the Nursing Supervisor on 02/08/07 at 11:00 AM, the Supervisor acknowledged the findings. Patient # 7 was admitted to the agency on 12/16/05 with the diagnoses including Insulin Dependent Diabetes and Benign Essential Hypertension. The Plan of Care dated 11/14/06 - 01/12/07 ordered PCA service three (3) days, four (4) hours per day for nine (9) weeks toassist the patientwith ADLs, personal care, meal preparation, change bed linen and light housekeeping. Review of the aide duty sheets from 12/11/06- 12/26/06 lacked documentati6n that tlhe PCA had assisted the patient with ambulation using the walker, assisted the patient with toileting, reminded the patient to take medications and assisted the patient with mouth care according to the Plan of Care and as directed on the Home Health Aide/Personal Care Aide Care Plan dated 12/16/06. FORM CMS-2567(02.99) Previous Versions Obsolete Event ID: LOPOl II Fciity ID:3869 If continuation sheet Page 3 of . DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION . PRINTED: 02/16/2007 FORM APPROVED OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. UILDING (X3) DAT E SURVEY ETED (Xl) PROVIDERJSUPPLIERICLIA IDENTIFICATION NUMBER: 3A3 NAME OF PROVIDER OR SUPPLIER B. WING 02/08/2007 STREET ADDRESS, CITY, STATE, ZIP CODE FAMILY CARE CERTIFIED SERVICES NASSAU CHHA. (X4) ID 120 WEST JOHN STREET HICKSVILLE, NY 11801 ID . PREFIX TAG (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) SUMMARY STATEMENT OF DEFICIENCIES PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) i (X5) COMPLETION DATE G 225 Continued From page 3 During survey the agency was requested to provide aide duty sheets for January 2007. The agency did not provide any additional aide duty sheets as requested. Patient #4 was admitted to the agency on 03/24/06 with diagnoses including Congestive * Heart Failure, Ischemic Heart Disease, and Hypertension. Review of the Plan of Care dated 01/11/07 03/11/07 ordered combination of hha/PCA service seven (7) days a week x six (6) to eight (8) hours a day for personal care, assistance with ADL, meal preparation and etc. Review of the aide duty sheets lacked documentation that the paraprofessional assisted the patient with ambulation, assisted the patient with HEP and feeding on 01/11, 01/13, and 01/15 - 01/19/07. Further review of the aide duty sheets I lacked documentation that the paraprofessional assisted the patient with transfer, turning and positioning, elevation/positioning.of extremities and maintained standard precautions as directed on the Home Health Aide/Personal Care Aide Care Plan dated 12/05/06. During interview with the Director of Patient G 225' Services (DPS) on 02/08/07 at 10:30 AM, the DPS acknowledged the survey findings. ! Patient #9 was admitted to the agency on 11/20/00 with diagnoses including Neoplasm of the Genitourinary Organs, Total Abdominal Hysterectomy, Coronary Heart Disease, and .Hypertension. Review of the Plans of Care dated 10/20/06 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LOPOI I Facility ID: 3869 If continuation sheet Page 4 of 7 PRINTED: 02/16/2007 HEALTH AND HUMAN SERVICES * DEPARTMENT OrCENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION RJCLIA (XI) PROVIDERISUPP IDENTIFICATION NUMBER: LIE FORM APPROVED OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING __________ X3) DATE SURVEY COMPLETED 337237 NAME OF PROVIDER OR SUPPLIER J02108/2007 ISTREET ADDRESS, CITY, STATE, ZIP CODE FAMILY CARE CERTIFIED SERVICES NASSAU CHHA (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL. REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG 120 WEST JOHN STREET HICKSVILLE, NY 11801 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE (X51 COMPLETION DATE oDEFICIENCY) G 2251 Continued Frompage 4 12/18/06 and 12/19/06 - 02/16/07 ordered PCA service seven (7) days a week x five (5) hours a day for personal care, for assistance with ADL, meal preparation and etc. G 225! I Review of the aide duty sheets from 12/02/06.01/05/07 lacked documentation that the PCA I assisted the patient with mouth care, and ambulation as directed on the Home Health Aide/Personal Care Aide Care Plan dated 09/06. Review of the aide duty sheets documented that the PCA assisted the patient with feeding on 12/3, i 12/8 - 12/9 -.12/23, 12/31/06 and 01/5 - 01/19/07. This task was not an assigned task on the Home Health Aide/Personal Care Aide Care Plan dated 09/06. During interview with the Director of Patient Services (DPS) on 02/08/07 at 10:30 AM, the DPS acknowledged the survey findings. Patient #10 was admitted to the agency on 04/10/06 with diagnoses of Cerebrovascular Disease, Diabetes Mellitus, Hypertension and Atherosclerosis. Review of the Plans of Care dated 10/07/06 12/05/06 and 12/06/06 - 02/03/07 ordered PCA service seven (7) days a week x eight (8) hours a day to provide personal care, for assistance with ADL and etc. Review of the aide duty sheets from 11/27/06 01/08/07 lacked documentation that the PCA assisted the patient with mouth care on 11/27 12/1, 12/4- 12/8, 12/11, 12/14, 12/15, and12/1812/22/06. Further review of the aide duty sheets lacked documentation that the PCA reminded the FORM CMS.-2567(02-99) Previous Versions Obsolete Event ID: LOPOl 1 Facility ID: 3869 continuation sheet Page 5 of 7 If .; DEPARTMENT OF HEALTH AND HUMAN SERVICES C ENTERS FOR MEDICARE & MEDICAID SERVICES IAND PLAN OF CORRECTION STATEMENT OF DEFICIENCIES (Xl) PROVIDER/SUPPLIERJCLIA PRINTED: 02/16/2007 FORM APPROVED OMB NO.- 0938-0391 A. BUILDNG B.WING STREET ADDRESS, CITY, STATE, ZIP CODE (X2) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER: 337237 -I(X3) DATE SURVEY COMPLETED 02/08/2007 120 WEST JOHN STREET HICKSVILLE, NY 11801 NAME OF PROVIDER OR SUPPLIER FAMILY CARE CERTIFIED SERVICES NASSAU CHHIA (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES . (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG o PRO VIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE G 225 Continued From page 5 patient to take the medications on 01/08 - G 225' 01/11/07 as directed on the Home Health Aide/Personal Care Aide Care Plan dated 12/30/06. During interview with the Director of Patient Services (DPS) on 02/08/07 at 10:00 AM, the DPS acknowledged the survey findings. I "Home Health Aide/Personal Care Aide" under the section identified as "Procedure" noted the ofollowing: . Review of the agency's policy and procedure ! 4. "The aide will be instructed on the patient plan of care according to the aide care plan based on patient's needs assessed by the nurse and patient's agreement." 5. "The aide care plan will include the care to be rendered, patient limitations, precautions and changes in patient condition that warrants agency notification.'Care plan will be revised according to patient status and needs." 6. "The aide will document the tasks performed for the patient on the aide duty sheet. This will reflect the aide care plan." During interview with the Administrator and the DPS on 02/07/07 at 2:10 PM, the DPS agreed . with the survey findings. The DPS statedthat the aide duty sheets are only spot checked by the nursing coordinators. The Administrator further stated that the vendoragencies are responsible i ' . to review the aide duty sheets. The agency staff could not provide an explanation for the paraprofessional staffs failure to perform FORM CMS-2567(02-99) Previous Versions Obsolete Event ID; LOP0t I Facility ID: 3869 If continuation sheet Page 6 of 7 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES 7I AND PLAN OF CORRECTION (XI) PROVIDERSUPPLIERJCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING __________ PRINTED: 02/16/2007 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED 337237 NAME OF PROVIDER OR SUPPLIER FAMILY CARE CERTIFIED SERVICES NASSAU CHHA (X4) ID PREFIX SUMMARY STATEMENT OF DEFICIENCIES . (EACH DEFICIENCY MUST BE PRECEDED BY FULL B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 120 WEST JOHN STREET 1 WST JOHN S18EE 0210812007 HICKSVILLE, NY 11801 " ID PREFIX PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE (XS) COMPLETION DATE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) G 225 Continued From page 6 the ordered patient care tasks according to the " G 2251 Plan of Care and the failure to document on the aide duty sheets according to the agency's policy and procedure. I - I , i FORM CMS-2567(O2-99) Previous Versions Obsolete Event ID; LOPO1 1 Facdrity 3869 ID: If continuation sheet Page 7 Of 7 PRINTED: 09/17/2007 FORM APPROVED NYS Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDERJSUPPLIERJCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION " A. BUILDING (X3) DATE SURVEY COMPLETED 0204LB. NAME OF PROVIDER OR SUPPLIER WING STREET ADDRESS. CITY. STATE, ZIP CODE 07/13/2007 FAMILY SERVICE SOCIETY OF YONKERS (X4) ID PREFIX TAG 70 ASHBURTON AVE FL 6o YONKERS, NY 10701 ID PREFIX TAG " o PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H 000. Initial Comments H 000 H 5i2 Medical Orders The agency has conducted a 100% patient record audit to identify the last nursing review and request for medical orders for each patient. The agency has documented the date, of the next required medical orders review and request for each client in an electronic monitoring system. Completely implemented on 9/6/07. A Full survey was conducted on 7/12 & 13/07. A total of six. (6) clinical records were reviewed (#1 through #6). A total of seven (7) personnel records were reviewed (#1 through #7). H 512 766.4(c) Medical Orders 766.4 Medical orders. (c) Such orders shall be reviewed and revised as the needs of the patient dictate but no less frequently than every six months, except where . an authorized practitioner, as part of an authorization, orders personal care services for up to one year for a Medicaid patient This RULE is not met as evidenced by: Based on clinical record review, and'staff interview, the agency failed to ensure that the MD orders were reviewed and revised no less frequently than every six (6) months in three (3) out of six (6) records reviewed (# 1, #2, #6). Findings include: Patient # 1 was admitted to the agency on 1/25/06 with the diagnosis of Parkinson's H 512 Periodic Reviews The Nurse Manager conducts weekly reviews of all clients' medical orders required-for review in the succeeding month. The Nurse Manager conducts medical orders reviews and makes appropriate'and timely requests for medical orders for each client. The Nurse Manager reviews medical, orders for each patient upon receipt. Ongoing Monitoring When medical orders are received for services that the agency is to provide to each patient the next date for review and request for medical orders will be entered into the agency's electronic tracking system by the Nurse Manager. Upon review of each medical order, if the agency needs additional medical orders or medical orders need to be clarified, then such orders will be requested by mail, by FAX or by telephone; properly recorded and authenticated by the, Nurse Manager. If any patient's medical orders are not received within 5 days-preceding the day of required receipt by the agency; then the Nurse Manager will contact TITLE (X6) DATE Disease.thagnynesadtoamdil Initial orders were dated 1/25/06. MD orders were not revised until 3/16/07. Patient #2 was admitted to the agency on 4/18/05 with the diagnoses of Arthritis and Blindness. The Initial MD order was dated 5/4/05. MD STATE FORM LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE STATE FORM 021199 30B711 If continuation sheet 1 of 6 PRINTED: 09/17/2007 FORM APPROVED /S Department of Health NTEMENT OF DEFICIENCIES 0 PLAN OF CORRECTION (Xl) PROV1DER/SUPPLIERCLIA IDENTIFICATION NUMBER: (Y2) M ULTIPLE CONSTRUCTION A. BUILDINGCOMPLETED (X3) DATE SURVEY 0204L001B. ME OF PROVIDER OR SUPPLIER MILY SERVICE SOCIETY OF YONKERS 4) ID REFIX TAG WING 07/13/2007 STREET ADDRESS, CITY, STATE, ZIP CODE '70 ASHBURTON AVE FL 6 YONKERS, NY 10701 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H 512 Continued From Page 1 orders were not revised until 2/12/07. Patient # 1 was admitted to the agency on 1/29/05 with the diagnosis of a Hip Fracture. Initial orders were dated 2/25/05. MD orders were not revised until 8/8/06. On interview of 7/19/07, the Administrator stated that the reason the Medical Orders were signed late was because the agency had a personnel problem in relation to nursing staff. The failure to ensure that MD orders are reviewed and revised no less frequently than every six (6) months has the potential for patients to receive incorrect care and/or treatment that is not in accordance with the physician's wishes. H 722 766.6(a)(10) Patient care record. 766.6 Patient care record., (a) The agency shall maintain a confidential record for each patient admitted to care to include: (10) a discharge summary when the patient is discharged from the agency including: (i) documentation of discharge planning preparation; H 512 the medical practitioner's office by telephone, and FAX the required orders to the medical practitioner's office for immediate review and signature. The Nurse Manager will ensure that follow up contacts are conducted until all appropriate medical orders are received by the agency on a timely basis as required by medical orders regulations. Patients #I 1, 2, and 6 have current, timely and appropriate medical orders r96r7 . Copleted time by 916107. at this time. Completed Ongoing Monitoring The DPS will orient the QIC record, reviewers to the requirementsfor H 722 medical orders and the agency plait of correction. The QIC record reviewers will report compliance with the plan of correction and ofindings of above referenced reviews authority on a quarterly basis. This plan of correction was instituted on 9/6/07. The Director of Patient Services will be responsible to ensure that this plan of correction is instituted and remains in effect. (ii) notification to the patient's authorized practitioner; (iii) reasons for discharge and date of discharge; (iv) summary of care given and patient's progress; TATE FORM TATE FORM Ifcontinuation sheet 2of 6 02199 30B711 PRINTED: 09/17/2007 FORM APPROVED NYS Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION . (Xl) PROVIDERISUPPLIERICLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING ______ _____ (X3) DATE SURVEY COMPLETED 0204L001 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 07/13/2007 FAMILY SERVICE SOCIETY OF YONKERS (X4) ID PREFIX TAG 70 ASHBURTON AVE FL 6 YONKERS, NY 10701 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES * (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H 722 Continued From Page 2 (v) patient status upon discharge including a description of any remaining needs for patient care and supportiveservices; (vi) patient or family ability to self-manage in relation to any remaining problems; and. (vii) recommendations and referral for any follow-up care, if needed. This RULE is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to notify the patient's authorized practioner when the patient was discharged from the agency in three (3) of three (3) discharged charts reviewed (#1, 2, #3). On interview of 7/13/07 the Director of Patient Services (DPS) stated that she was not aware that the patient's MD had to benotified when a patient was discharged. . H 722 H722 Patient Care Record The agency's policy and procedure requires that notification of impending patient discharge is provided to the patient and the medical practitioner(s) and documented by the Nurse Manager at least 48 hours preceding the patient's discharge from the agency. This section of the discharge planning records was not completed in the 3 records reviewed. The current Director of Patient Services was aware of MD's notification requirement prior to survey; Nurse Manager was educated regarding this requirement on July 16, 2007. This education was completedon 7/16/07. The Director of PatientServices will assure the consistent implementation of this practice by monitoring the discharge record of all patients through 9/30/07. Ongoing Monitoring record review sample The QIC review of discharged clients. Tis review will include at least 3 ld at leastd3 ilc reew recently discharged patient records. The QIC will review the discharge recordsfor documentation of discharge notification and report to the governing authority on a quarterly basis. Failure of the agency to notify the MD of a patient's discharge has the potential for patients discharge needs to be unmet. H1142 766.9(o) Governing Authority Section 766.9 Governing authority )HelhPoie ewr cesadincludes 0 Health Provider Network Access and Reporting Requirements, The governing authority or operator of an agency shall obtain from the Department' s Health Provider Network (HPN), HPN accounts for each agency that it operates and ensure that sufficient,, knowledgeable staff will be available to and shall maintain and keep current such accounts. At a minimum, twenty-four hour, seven-day a week contacts for emergency communication and STATE FORM STATE FORM 021199 H1142 30B711 Ifcontinuation sheet 3 of 6 PRINTED: 09/17/2007 FORM APPROVED NYS Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDERJSUPPLIERJCLIA IDENTIFICATION NUMBER: 0204L001 NAME OF PROVIDER OR SUPPLIER FAMILY SERVICE SOCIETY OF YONKERS (X4) ID PREFIX TAG STREET ADDRESS, CITY, STATE, ZIP CODE 70 ASHBURTON AVE FL 6 YONKERS, NY 10701 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING. ______ _____ (X3) DATE SURVEY COMPLETED 07/13/2007 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H1142 Continued From Page 3 alerts, must be designated by each agency in the HPN Communications Directory. A policy defining the agency' s HPN coverage consistent with the agency' s hours of operation shall be created and reviewed by the agency no less than annually. Maintenance of each agency' s HPN accounts shall consist of, but not be limited to, the following: (1) sufficient designation of the agency' s HPN coordinator(s) to allow for HPN individual user application; H1142 (2) designation by the governing authority or operator of an agency of sufficient staff users of the HPN accounts to ensure rapid response to requests for information by the State and/or local Department of Health; (3) adherence to the requirements of the HPN user contract; and (4) current and complete updates of the Commu'nications Directory reflecting changes that include, but are not limited to, general information and personnel rote changes as soon as they occur, and at a minimum, on a monthly basis. H 1142 Governing Authority The governing authority has developed and adopted a policy and procedure regarding implementation of a sufficient number of HPN coordinators and users, adherence to the contracts and agreements for HPN use and requirements for current and timely updates to the agency communication directory to insure receipt and action regarding alerts and requests for information. The Governing Authority has adopted these policies and procedures on this date. This RULE isnot met as evidenced by: Based on review of the agency's policy and procedure manual and interview, the agency failed to comply with the NYCRR related to Health Provider Network (HPN). Findings include: On review of the agency's Policy/Procedure manual, the agency failed to have a policy The Director of Patient Services will be responsible to insure implementation of the HPN policies and procedures. Attached please find the agency developed related to the HPN. STATE FORM STATE FORM o21199 policies and procedures for review. 30B711 If continuation sheet 4 of6 PRINTED: 09/17/2007 FORM APPROVED S Department of Health JEMENT OF DEFICIENCIES PLAN OF CORRECTION (Xl) PROVIDERISUPPLIERJCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING __________ (X3) DATE SURVEY COMPLETED 0204LO01 ME OF PROVIDER OR SUPPLIER B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 07/1312007 MILY SERVICE SOCIETY OF YONKERS ID REFIX TAG .70 ASHBURTON AVE FL 6 YONKERS, NY 10701 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE o4)SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H1142 Continued From Page 4 - H1142 During an interview with the Administrator on 7/16/07, the administrator stated that the agency did not have an HPN policy. Failure to have an HPN Policy has the potential for the agency not having appropriate guidelines for staff to follow relative to the useof the HPN. H1338 766.11 (g) Personnel 766.11 Personnel. The governing authority or operator shall ensure for all health care personnel: o. (g) that personnel records include verifications of employment history and qualifications for the duties assigned and, as appropriate, signed and dated applications for employment; records of professional licensesand registrations; records of physical examinations and health status assessments; performance evaluations; dates of employment, resignations, dismissals, and other pertinent data provided that all documentation and information pertaining to an employee's medical condition or health status, including such records of physical examinations and health status assessment shall be maintained separate and apart from the non-medical personnel record information and shall be afforded the same confidential treatment given patient medical records under section 766.6 of this Part. This RULE is not met as evidenced by: Based on personnel record review and staff interview, the agency failed to verify qualifications for three (3) out of four (4) personal care/home 3, health aides (PCA/HHA) prior to hiring (# 2, #4). Director of On interview of 6/16/07 the Assistant - H1338 Personnel The agency developed a form to document validation of the paraprofessional training certificates preceding this survey. The upper portion of the attached form is completed by FSSYAdministrative Home Care Coordinator (AHCC). TheAHCC transmits the training H1338 certificate along with the Certificate Verification form to the training site by FAXfor review and validation prior to orientation ofprospective employees. The administering agency confirms/denies validation of the training certificate on the lower portion of the agency form, attached for your review. This plan of correction is completed l io a foc Ti on 9/6/07. Further, the agency requires competency testing of all paraprofessionals upon application to validate that applicants have required personal care aide or home health competencies before offers of employment are made. Each new employee personnelfle will be illnbe emlee poneie . reviewedfor required training validation by theAdministrative Director of Home Care (ADHC) before assignment. This plan of correction is completed on 9/6/07. presently The AHCC will validate all stafftraining employed paraprofessional certificates by using this process within 3 months. TE A_ FORM FORM TE 0211 30B711 Ifcontinuation sheet 5 of 6 PRINTED: 09/17/2007 FORM APPROVED NYS Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDERJSUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED _ _ _ A. BUILDING B. WING__ _ _ _ _ _ _ 0204L001 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 07113/2007 FAMILY SERVICE SOCIETY OF YONKERS (X4) ID PREFIX TAG .70 ASHBURTON AVE FL 6 I YONKERS, NY 10701 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H1338 Continued From Page 5 Home Care Services (ADHCS) stated that the agency was not always verifying the aidb credentials s but that they now have a form that is utilized to do this. Failure to verify PCA/HHA credentials has the potential for unqualified staff providing services to the agency's patients. H1338 The AHCC is responsible for implementation of this plan of correction. Completion of validation of all training certificates will be completed by November 1, 2007. Ongoing Monitoring An electronic monitoring feature was added to the audit processfor paraprofessional staff. This feature will generate a report indicating receipt of validation of certificates for all personal care and home health aides. Notfication reports are generated and reviewed by ADHC on a weekly basis. A 50 % sample of new employeefiles will be reviewed by QCI record reviewers through June 2008 and will be reported to the P1 Committee and governing authority. Each employee file will be monitored for all regulatory requirements each year, preceding annual evaluation, bby the ADHC and AHCC. Findings will be reported to the DPS of any paraprofessional in need of requirements before the annual evaluation. The DPS and ADHC will be responsible to assure that all such requirements are fuifilled before ongoing assignment. The Admin. Dir. of Home Care will ensure this Plan of Correction is consistently implemented. ;TATE FORM TATE FORM 021199 30B711 * If continuation sheet 6 of 6 ,, * - PRINTED: 08/282007 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDERISUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUII.DING (X3) DATE SURVEY COMPLETED LC0921A NAME OF PROVIDER OR SUPPLIER B. WING 07117/2007 STREET ADDRESS, CITY, SLATE, ZIP CODE CARING HANDS HOME CARE AGENCY, INC. - 36 JANICE LANE SELDEN, NY 11784 ID PREIFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (X4) ID PREFIX TAG SUMMARY SFA1 EMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL* REGULATORY OR LSC IDENTIFYING INFORMATION) / H 000 Initial Comments H 000 A Full Survey was conducted on 07/17/07 at Caring Hands Home Care, Inc.. One (1) patient record was reviewed and is identified as Patient #1. Seven (7) personnel files were reviewed and are identified as Employees #1 through #7. H 514 766.4(d) Medical orders 766.4 Medical orders. (d)Medical orders shall reference all diagnoses, medications, treatments, prognoses, and other pertinent patient information relevant to the agency plan of care; and (1) shall be authenticated by an authorized practitioner within thirty (30) days after admission to the agency; and (2) when changes in the patient's medical orders are indicated, orders, including telephone orders, shall be authenticated by the authorized practitioner within thirty (30) days. This Rule. is not met as evidenced by: Based on patient record review and interview with the Owner, the agency failed to ensure that the medical orders were signed within 30 days in one (1) of one (1) records reviewed (Patients The agency's failure to ensure that the orders are signed within 30 days.places the patients at risk for unsafe and poor quality care. Findings are: LABORATORYIECTORS ORPR fSUPPLIEPRESENTATIVE-S SIGNATURE TITLE (X6) YAE *H514 STATE FORM 02119 D4JR1 1 Ifcontinuatlon sheet1 of 18 r VX"I FORM APPROVED New York StateDe artment of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDERISUPPLIERICLIA IDENTIFICATION NUMBER: u B LC921AWING NAME OF PROVIDER OR SUPPLIER TREE AT (X2) MULTIPLE CONSTRUCTION A BUILDING I ING_ _ _ _ _ _ _ _ _ (X3) DATE SURVEY COMPLETED 07/17/2007. STREET ADDRESS, CITY, STAT E, ZIP CODE CARING HANDS HOME CARE AGENCY, INC. (X4) tO. PREFIX TAG 36 JANICE LANE SELDEN, NY 11784 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ,{i (X5) ' COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) II H 514; Continued From Page 1 Patient #1 was admitted to the agency on 04128/06 with diagnoses including Acute Encephalomyelitis, Tracheostomy, and SQuadriplegia. H 514 L . . .. I H 514 A) The Director of Nursing will conduct an inservice training on medical order transcription with both the medical and nursing staff in 10103107 according to the agency's medication/ Review of medical orders dated 01/25, 01/26, transcription policy and procedure. Authorized 01/27 and 01/31/07 lacked physician's signature practitioner must sign orders within 30 days. Within thirty (30) days. Inservice to include clinical nursing supervisor, primary day nurses and Home visit MD. 0current O w (Dr.Spears) And or other primary physicians on During an interview with the Owner on 07/17107 other cases. at 12:00 Noon, the Owner acknowledged the B) To prevent the re-occurrence of this issue all findings. charts will be audited monthly starting 10104107 I until 100% compliance is obtained x 2; following, 05117/2006 REPEAT DEFICIENCY FROM quarterlyaudits will be performed to ensure SURVEY compliance. 6 a csr oC) The quality improvement staff will develop a medical order transcription audit tool based on i H 602 H 602 766.5(a) Clinical supervision the agency's policy and procedure in 10104107.. ' Staff will perform audit based on an established supervision. The governing 766.5 Clinical calendar. All charts will be included in the audit authority shall ensure for all health care services for one year. The Director of Nursing will inthat service all staff regarding the agency's medical (a) sufficient numbers of appropriately trained and oriented supervisory staff are available to ensure the quality of patient care services s provided by the agency. Such supervision shall include: (1) ongoing review of cases and delegation of assignments by appropriate health care professionals; (2) in-home visits to direct, demonstrate and evaluate the delivery of patient care: (3) provision of clinical consultation; and. orders transcription policy and the audit thatwill be conducted in 10104107. D) Following chart audit a written report will be generated by the quality improvement staff; findings will be presented for discussed during the quarterly Quality Improvement Committee meeting. Ongoing in-services to continue. (4) professional consultation on agency policies and procedures. This Rule is not met as evidenced by: STAl-[ FORM STATEFORM =110. I D4JR1 I, I coninaition see 7010 ,I , PRINTED: 07/30/2007 New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORREC nON (Xl) PROVIDER/SUPPLIERJCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING FORM APPROVED (X3) DATE SURVEY COMPLETED LCO921 A NAME OF PROVIDER OR SUPPLIER B. WING 07/17/2007 STREET ADDRESS, CITY, STATE, ZIP CODE CARING HANDS HOME CARE AGENCY, INC. (X4) ID PREFIX TAG 36 JANICE LANE SELDEN, NY 11784 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES " (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H 602 Continued From Page 2 Based on patient record review and staff interview, the agency failed to ensure that the nursing staff were supervised and evaluated during the delivery of patient care in one (1) of one (1) patients reviewed. (Patient #1) The agency's failure to supervise and evaluate the provision of skilled nursing services places the patient at risk for poor quality care. Findings are: Patient #1 was admitted to the agency on: 04/28/06 with diagnoses including Acute H 602 . Encephalomyelitis, Tracheostomy and Quadriplegia. The Plan of Care from the start of care to 10/28/07 ordered Skilled Nursing (SN) twenty four (24) hours x seven (7) days for this ventilator dependent patient. Record review lacked documentation of in-home supervision of the provision of patient care. The record lacked documentation of on-going communication with the nurses providing patient care. During an interview with the Owner on 07/17/07 at 12:00 Noon, the Owner stated the nurses are to be supervised at least annually and acknowledged that there was no documented supervision of the nurses providing care to this patient. REFER TO PERSONNEL 766.11 (k) H 712 766.6(a)(5) Patient care record 766.6 Patient care record. STATE FORM -D H 712 ~ll 1 Ifoti fi nshee3 of 18 Pg. #3,4 H71 2 766.6(a) (5) Patient Care Record Completion Date September 19th, 2007 A) Corrective Actions: The Director of Nursing shall be the responsible designee to ensure the plan of corrections of the Patient Care Record. Current Physician Therapist (NS) has been consulted regarding therapy notes. New therapy notes are being changed and revised I .See new notes/ still being revised/ Physical Therapist currently being counseled on therapeutic patient notes B) Identifying potential for Reoccurrence of Deficiency Cited: All therapists are to use a new therapy form. Therapist Job description to also include , identifying data in notes, random therapy notes to be reviewed at QA meeting every four months. C) Systematic Changes: New Quality Assurance.committee to include one therapist. New QA therapist. -Denise Reigel Cappaccid -Speech Therapist (see resume)(currently being faxed, she's on vacation) D) Monitoring System: Director of Nursing every two-week review of therapy notes to include more specific notes. New QA Committee to review random notes every four months. * 2.See 'adjusted QA agenda * 3.See adjusted Physical Therapist Notes * 4.See adjusted Chart Review Form 3 PRINTED: 07/30/2007 New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIERCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING FORM APPROVED (X3) DATE SURVEY COMPLETED LCO921A NAME OF PROVIDER OR SUPPLIER B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 07/1712007 CARING HANDS HOME CARE AGENCY. INC. (X4) ID PREFIX TAG 36 JANICE LANE SELDEN, NY 11784 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H712 Continued From Page 4 treatments with no specific information for each visit. H 712 During an interview with the Owner on 07/17/07 at 11:55 AM, the Owner stated "I know they are not good". H1002 766.9(a) Governing authority Section 766.9 Governing authority. the governing authority or operator, as defined in Part 700 of this Title, of a licensed home care services agency shall: (a) be responsible for the management and operation of the'agency; (b) ensure compliance of the home care services agency with all applicable Federal, State and. local statutes, rules and regulations. This Rule is not met as evidenced by: H1002 )Q"'CC,-ep+Cd VN17 5I- _ 1. 0 n 1t[z, P -e5 (fr.". . . _ ".-.f " AOI4 A&.. 5. I '5 :5 Based on patient record review, policy and procedure review, personnel record review and interview with the Owner, the Governing Authority (GA) failed to ensure compliance with all applicable Federal, State, and local statutes, rules and regulations as evidenced by the following deficiencies which are a repeat deficiencies from the survey of 05/17/06. The GA's failure to ensure compliance with all rules and regulations, and to ensure the provision of responsible operation and management of the home care agency places all patients at risk for poor quality of care. This was evident in the following deficiencies: 766.4 Medical Orders STATE FORM e c , -05o L-eocq c-_5 6o "j r D4JR11 1 If i/ , ' i s t 5 of 18 PRINTED: 08/28/2007 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDER/SUPPLIERCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED LC0921 A NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE, ZIP CODE 07/1712007 CARING HANDS HOME CARE AGENCY. INC. (X4) ID PREFIX TAG 36 JANICE LANE SELDENNY 11784 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR I.SC IDENTIFYING INFORMATION) H1002 Continued From Page 5 766.5 'Clinical Supervision 766.6 Patient Care Record 766.11 Personnel 766.12 Records and Reports H1008 766.9(d) Governing authority Section 766.9 Governing authority. The governing authority or Operator, as defined in Part 700 of this Title, of a licensed home care services agency shall: (d).adopt and approve amendments to Written policies regarding the management and operation of the home care services agency and the provision of health care services. This Rule is not met as evidenced by: Based on review of the agency's policy and procedure manual and staff interview, the Governing Authority (GA) failed to maintain written policies and procedures which are current and complete. The GA's failure to maintain current and complete policies and procedures places the patients at risk for poor quality of care. Findings are: Review of the agency's policy and procedure manual lacked documentation of review and revision since 1/15/00. During an interview with the Owner on 07/17/07 at 11:30AM, the Administrator acknowledged that the policy and procedure manual needed to be reviewed and revised. REPEAT DEFICIENCY FROM 05/17/2006 STATE FORM 919 H1002 H1008 . _R , -lcontinuapon-sh9,1 It 6 Of18 PRINTED: 08/28/2007 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVDEPJSUPPLIERICLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING B. WING __________ LC0921A NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE, ZIP CODE 0711712007 36,JANICE LANE SELDEN, NY 11784 ID PROVIDER'S PLAN OF CORRECTION (X5) CARING HANDS HOME CARE AGENCY, INC. (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX TAG (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYINGINFORMATION) PREFIX TAG (EACH CORRECTIVE ACTION SI IOULD BE CROSS-REFERENCED TO rHE APPROPRIATE DEFICIENCY) COMPLETE DATE H1008 Continued From Page 6 SURVEY H1014 766,9(g) Governing authority Section 766.9 Governing authority. The governing authority or operator, as defined in Part 700 of this Title, of a licensed home care services agency shall: (g) employ or contract for a sufficient number of staff to coordinate, direct and deliver services to patients accepted for care in accordance with prevailing standards of professional practice. This Rule is not met as evidenced by: Based on onsite visit, personnel record review and interview with the Owner, the Governing Authority (GA) failed to ensure that the agency employed sufficient staff to coordinate and direct patient care services. The GA'S failure to ensure that there are adequate staff present for the coordination and delivery of patient care services places the patients at risk for poor quality of care. H1008 H1014 Findings are: On 07/17/07 at 8:45 AM, the surveyors arrived at the 36 Janice Lane in Selden, NY 11784. The office door was locked and no staff members were present. On the office door the Administrator has posted a note for the Department of Health that read "You have reached Caring Hands, If I am not here (Bridget Durkin) I may have'stepped out. DOH please call me on my cell phone if I am not here". STATE FORM 021 DJR11, / m. contil aon s eet 7of18 /RP7/9 PRINTED: 08/28/2007 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) .PROVIDERISUPPLIERCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3),DATE SURVEY COMPLETED LCO921A NAME OF PROVIDER OR SUPPLIER 0711712007 STREET ADDRESS, CITY, STATE, ZIP CODE CARING HANDS HOME CARE AGENCY, INC. (X4) ID PREFIX TAG 36 JANICE LANE 'SELDEN, NY 11784 1 t ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) I(XS) COMPLETE [ATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H10141 Continued From Page 7 The surveyor called the cell phone number and left a message for the Owner to call back. The Owner never called the surveyors back. At 9:00 AM, the landlord stated that her father was able to reach the Owner and that the Owner would arrive in 30 minutes. During interview with the landlord, the landlord stated that the Owner is usually "In and out of the office everyday". During interview with the Owner at 9:20 AM,the Owner informed the surveyors that the agency's opnrotin9 hours are from 10:00 AM to 4:00 PM 'H1014 7 (I) Monday to Friday. The Owner could not provide OIl explanation for the lack of staff to coordinate 1 patient care services during the survey- A) A multidiscipline Quality Improvement Committee will be held quarterly starting 10117107, including a designated consumer participant(Ms.Louise Kaiser) and physician (DrDesiree Sachse). . In addition the Policy and Procedure subcommittee (766.9 d), chalred by the Director of Nursing will present 2 written report I on Policy and Procedure review and reviaion for discussion and approval to the Quality Improvement Committee. The administrative staff will send a written quarterly notice to each committee member. notice will include place, date and time of the including a tentative agenda. A copy of the notice and agenda will be filed in lhe administrative office along with a signed copy of i the meeting's minutes and attendance sheeL C) All agency staff will be informed of the reI organization of the Quality Improvement" Committee in writing by the Director of Nursing on 010101107. 0) The administrative staff will perform bi-annual review of the files, which will contain the original notices, agendas and signed minute; tnding will be discussed inthe Quality Improvement Committee- Additionally, review of employee file a request for contracts for staff revealed that the reqesy for cntrts v staff rvd Se Therapy (ST), Medical Social Worker (MSW) and home health aide (hha) services. These services arcurrently on the agency's license. agency does not have staff to provide Speech jB) During an interview with the Owner on 07/17/07 -meeting at 12:30 PM, the Owner stated that she does not have staff or the contract to provide ST,MSW, and hha services. k-l0361 766.9(1) Governing authority Section 766.9 Governing authority. The governing authority or operator, as defined in Part 700 of this Title, of a licensed home care services agency shall: H1036 (I) appoint a quality improvement committee to STA I-e FORM . D4JR11 - I II If coinuation SM.He1 ol18 8 .. PRINTED: 08/28/2007 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDERISUPPLIEWICLIA IDENTIFICATION NUMBER: SB. (X2) MULTIPLE CONSTRUCTION A. BUILDING _____ _____ ___ (X3) DATE SURVEY COMPLETED WING________ LCO921 A NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, SlArE, ZIP CODE 0711.7/2007 CARING HANDS HOME CARE AGENCY. INC (X4) ID PREFIX TAG 36 JANICE LANE SELDEN, NY 11784 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FUIL REGULATORY OR LSC IDENTIFYING INFORMATION) H1036 Continued From Page 8 establish andoversee standards of care. The quality improvement committee shall consist of a consumer and appropriate health professional H1 036 persons including a physician if professional health care services are provided.The committee shall meet at least four times a year to: (1) review policies pertaining to the delivery of the health care services provided by the agency and recommend changes in such policies to the governing authority for adoption; (2) conduct a clinical record review of the safety, adequacy, type and quality of services provided which includes: (i) random selection of records of patients currently receiving services and patients discharged from the agency within the past three months; and (ii) all cases with identified patient complaints as specified in subdivision (j) of this section; (3) prepare and submit a written summary of. review findings to the governing authority for necessary action; and (4) assist the agehcy in maintaining liaison with other health care providers in the community. This Rule is not met as evidenced by: Based on review of Quality Improvement (QI) meeting minutes and interview with the Owner, the Governing Authority (GA) failed to ensure the Q1 committee met four times a year and included a physician and a consumer and reviewed agency policies and procedures. The GA's failure to ensure that the QI committee met four times a year and included all required members places patients at risk for 'receiving STATE FORM . . . - I o Ia i hee of 49 PRINTED: 08/28/2007 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDERISUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION ______ A. BUILDING B. WING_________ W " _____ ___ (X3) DATE SURVEY COMPLETED LC0921A NAME OF PROVIDER OR SUPPLIER 07/17/2007 STREETADDRESS. CIT , STATE, ZIP CODE CARING HANDS HOME CARE AGENCY, INC. (X4) ID PREFIX TAG 36 JANICE LANE SELDEN, NY 11784 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (5) COMPLETE DATE H1036 Continued From Page 9 poor quality care. Findings are: A request for QI-meeting minutes from 2006 2007 was made by the surveyors during the entrance conference. The Owner could only provide two (2) meetings dated 09/08 and 10/05/06. The Owner could not provide H1 036 documentation of any meetings conducted in 2007. The QI meeting minutes failed to include all the required members, both of the meetings lacked the attendance of physician and a consumer. The QI meeting minutes also lacked documentation that the agency r6viewed policies and procedures pertaining to the delivery of the health care services provided by the agency. During an interview with the Owner on 07/17/07 at 11:00 AM, the Owner could not locate the QI minutes for this year and could not provide an explanation why the physician and consumer were absent from both 2006 meetings. REPEAT DEFICIENCY FROM 05/17/2006 SURVEY Hi 142 766.9(o) Governing Authority Section 766.9 Governing authority (o) Health Provider Network Access and Reporting Requirements. The governing authority or operator of an agency shall obtain from the Department' s Health Provider Network (HPN), HPN accounts for each agency that it operates and ensure that sufficient, STATE FORM 021199 H1 142' K ,a + n4jn iatoneet0 t 1 of 18 /zW/UuI ,H I-(N UL:uW FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIERCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED LC0921 A NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. 7IP CODE 07/1712007 36 JANICE LANE SELDEN, NY 11784 ID PREFIX TAG CARING HANDS HOME CARE AGENCY. INC. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULAIORY OR LSC IDENTIFYING INFORMATION) I I PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE .I -DEFICIENCY) (X5) COMPLETE DATE 111142 Continued From Page 10 knowledgeable staff will be available to and shall maintain and keep current such accounts. At a Hl142 minimum, twenty-four hour, seven-day a week contacts for emergency communication and alerts, must be designated by each agency in the HPN Communications Directory. A policy defining the agency' s HPN coverage consistent with the agency' hours of operation shall be created and reviewed by the agency no less than annually. Maintenance of each agency' s HPN Saccounts shall consist of, but not be limited to, accfolowung sadeveloped (1) sufficient designation of the agency 's HPN coordinator(s) to allowfor HPN individual user /h . 766.9 (o) A) The governing bodyloperator of the agency a new tentative policy and proOedure for HPN. (Plan will be submitted to the DO for review and if necessary revision). HPN training hasjust begun and a new HPN coordinator will be trained online within the next two weeksB) To prevent a re-occurrence ofthis issue and or similar issues a specific period for regulatory body updates and discussion Will be included in the Quality Improvement Committee meeting starting 10117107.1nservice of designated personnel to access the HPN system will be ongoing. C) The governing bodyfoperator will present pertinent data regarding HPN and other regulatory body information in the Quality Improvement Committee meeting. D) The governing bodyloperator will perform biannual review of minutes to ensure the QIC has adequately covered HPN and other regulatory I application: (2) designation by the governing authority or operator of an agency of sufficient staff users of the HPN accounts to ensure rapid response to rquests tor information by the State and/or local Department of Health; (3)adherence to the requirements of the HPN rotrc, and (4) current and.complete updates of the Communications Directory reflecting changes I . I that include, but are not limited to, general informationd persnne role changes as soon as they occur, and at a minimum, on a monthly basis. This Rule, is not met as evidenced by: Based on review of the agency's Policy and .Procedure manual and interview with the Owner, the agency failed to develop comprehensive policies and procedures regarding the agency's maintenance of their. Health Provider Network body information accordingly. - I (HPN) account. STATE FORM . . A" D JR11 " i _l continuvtion shool 11of 10 If PRINTED: 08/28/2007 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDERSUPPLIERICLIA IDENTIFICATION NUMBER: -B. (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED _ _ _ WING__ _ _ _ _ _ LC0921A NAME OF PROVIDER OR SUPPLIER . . 07/17/2007 STREET ADDRESS. CITY, STATE, ZIP CODE CARING HANDS HOME CARE AGENCY, INC. (X4) ID PREFIX TAG 36 JANICE LANE SELDEN, NY 11784 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H1142 Continued From Page 11 The agency's failure to ensure current information on the Communication Directory on the HPN places the agency at risk for not receiving the information provided on the HPN. Findings are: Review of the agency's HPN Policy and Procedure failed to address the agency's HPN coverage consistent with the agency's hours of operation, adherence to the requirements of the HPN user contract, and a procedure to ensure current and complete updates of the Communication Directory reflecting changes that include, but are not limited to, general H1142 information and personnel role changes as soon as they occur, and at a minimum on a monthly basis. Additionally, the Policy and Procedure lacked date of review and implementation as well as approval by the Quality Assurance Committee and the Governing Authority. During an interview with the Owner on 07/17/07 at 1:00 PM, the Owner stated that "the agency has an account but does not access that often". The Owner could not recall when she had last accessed the HPN account. The Owner could not demonstrate access to HPN. The Owner stated that she accesses the HPN from her home. It should be noted that according to the HPN accounts management in Albany on 07/16/07, the HPIN accounts management stated that currently the HPN account for Caring Hands Home Care Agency is an "inactive" account and the last time the HPN account was accessed by this agency was on December 8, 2006. STATE FORM 021M D4J Ifo wtirsnaio sheet 12 of 18 V/k 7 PRINTED: 08/28/2007 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIERCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONST RUCTION A. BUILDING (X3) DATE SURVEY COMPLETED LC0921 A NAME OF PROVIDER OR SUPPLIER B.WING STREET ADDRESS, CITY, STATE, ZIP CODE 07/17/2007 CARING HANDS HOME CARE AGENCY, INC. (X4) ID PREFIX TAG 36 JANICE LANE SELDEN, NY 11784 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED B;Y FULL REGULATORY OR LSC IDENTIFYING INFORMlTON) H1142 Continued Frhom Page 12 REPEAT DEFICIENCY FROM 05/17/2006 SURVEY H1302 766.11 (a) Personnel 766.11 Personnel. * The governing authority or operator shall ensure for all health care personnel: (a) the development and implementation of written personnel policies and procedures, which are reviewed at least annually and. revised as necessary. This Rule is not met as evidenced by: Based on review of personnel files, policy and procedure review, and staff interview, the agency failed to ensure personnel policy and procedures are reviewed at least annually and revised as necessary. Findings are: Review of policy and procedure manual documented that the personnel policies and procedures were last reviewed in the year 2000. During an interview with the Owner on 07/17/07 at 12:30 PM, the Owner acknowledged the survey findings and could not provide an explanation for the agency's failure to review and revise personnel policies and procedures at least annually. REPEAT DEFICIENCY FROM 05/17/2006 SURVEY .H1302 H1 142 STATE FORM -4 1 1 RZII1 7 I uation shee 130of18 e27 PRINTED: 0812812007 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDER/SUPPLIERJCLA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING LC0921 A NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 07117/2007 36 JANICE LANE SELDEN, NY 11784 ID PREFIX TAG PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) () COMPLETE DATE . CARING HANDS HOME CARE AGENCY, INC. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULl. REGULATORY OR LSC IDENTIFYING INFORMATION) Hmi5oD Continued From Page 13 IH1350 H1350 H13501 706.11(k) Personnel 766.11 Personnel. The governing authority or operator shall ensure 1for all health care personnel: that an annual assessment of the Wh performance and effectiveness of all personnel is conducted including at least one in-home visit to obiBIyt pffumianue, if applicable. .A) I This Rule is not met as evidenced by: Based on review of personnel filesand interview 766.11 (k) The Director of Nursing wil ensure the following: According to the agency's Personnel Policy, all staff will with the Owner, the agency failed to ensure that I o I all health care personnel received an annual I performance assessment which includes at least one (1) in-home visit observation in six (6) of six I I (6) employees that required annual performance 1 evoluationg. (Employees #1 through #6) The ogency's failure to ensure that all employees re-.vc nnua peformnceevalatins wichAnnual receIve annual performance evaluations which included at least one in-home visit observation places the patients at risk for receiving poor quality care. Receive an annual performance review by their - . designated Supervisor, including at home-site evaluations for clinical staff ".......... .. . Members starting 10i12107. The Director of Nursing will provide The supervisor(s) with in-service training. reinforcing the performance review processB) Based on established written criteria all personnel files will Be reviewed by the Human Resource Committee (DON, Marilyn Magloglin RN and any other Icontracted Findings are: Employee #1- documented an annual performance evaluation dated 06/03/07 but lacked documentation of at least one in-home vi " performance evaluation dated 07/11/07 but lacked documentation of at least one in-home visit observation. Employee #3 - lacked an annual performance STATE FORM Employee 2 - documented an annual o RN if deemed necessary) quarterly or as needed. C) The review process will be ongoing. Written status reports Will be kept on file. The Director of Nursing will send a notice to staff regarding the annual performance evaluation process on 10112107. 0) The Human Resource Committee will submit a biannual report to the Quality Improvement o Committee regarding the status of the clinical employee performance reviews starting 1011 7107. D4JR1 1 I W4JRIA.r _a c11 Ue~ t 14 of 18 PRINTED: 0812812007 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDERISUPPLIERICLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED LC0921A NAME OF PROVIDER OR SUPPLIER B.WING STREET ADDRESS, CITY, STATE, ZIP CODE 07/17/2007 CARING HANDS HOME CARE AGENCY, INC. I (P) ID TAO i I'ACH 36 JANICE LANE SELDEN, NY 11784 ID ) PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES DEFICIENCY MUST BE PRECEDED BY FULL I I PROVIDER's PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (XS) I COMPLETE DATE REGULATORY OR LSC IDENTIFYING INFORMATION) 1-1350 Continued From Page 14 evaluation for year 2006. This employee has 1 been employed since September of 1995. Employee #4 - documented an annual performance evaluation dated 05130/07 but locked documentation of at least one in-home visit observation. - H1350 I l Employee #5 - lacked an annual performance mtaludtion for year 2007- This employee was employed.on 04/25/06. The owner will ensure the following; A) The agency's administrative staff developed a I new filing system for the maintenance of records visit observation. " and reports. Statistical reports required by the DON, meeting minutes, personnel records, I grievancesand complaints And or records related I During an interview with the Owner on 07/17107.! to patientcare and services will befiledinatimely at 12:15 PM, the Owner stated that the manner in specific white binders and will nut bu I evaluations were based on in-home visit discarded until three years. The agency's that the obaervation. The Owner acknowledged operator accessed HPN on 09119107 to obtain annualperformance evaluations lacked statistical reports of 200512006 requested bythe documentation of in-home visit observation. The DOH and filed them on 09120107. The agency's I stated that employee #3 and #5 did Owner operator will provide in-service to designed staff rt "onhwtuiizthHPsyem receive their evaluations but they had not on how to utilize the HPN system. B) The operatorand the quality improvemuntsataff returned the signed evaluations to the agency. will submit quarterly statistical reports to the Employee #6 documented an annual cedomntlation ofdateast one257 inhot lacked documentation of at least one in-home I pd 766.12a(3) i H14041 7612(a)(1) Records and reports Quality Improvement Committee starting 1 01 7107. Implementation of a new filing and reporting oC) d r 7 Records and reports. '766.12 R system. D) Reports will be submitted to the Quality IImprovement Committee and administrative staff (a) Thle governing authority or operator shall will perform bi-annual review of the files, which i ensure the prompt submission of all records and I will contain the original notices, agendas and I reports required by the department and that: signed minutes; findings will be discussed in the . I Quality Improvement Committee. I (1) copies of the following records are retained on file at the principal.administrative office in New York State of the home care services agency and available to the department upon 1 request j I H1404 1 $TATE FORM D4JR11 It coninuOn sneel 15 or18 f ' 'A " PRINTED: 08/28/2007 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIERICLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. U (X3) DATE SURVEY COMPLETED B. WING LC0921 A NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 07/17/2007 36 JANICE LANE SELDEN, NY 11784 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE CARING HANDS HOME CARE AGENCY. INC. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULA ORY OR LSC IDENTIFYING INFORMATION) H1404 Continued From'Page 15 (i) the license issued by the department to operate as a home care service agency; (ii) the certificate of incorporation and any amendments thereto, if applicable; (iii) partnership agreement, if applicable; (iv) Certificate of doing business under an assumed name, if applicable; (v) contracts and other agreements related to delivery of patient care entered intol by the operator; (vi) rules and bylaws of the governing authority and quality assurance committees, if applicable; (vii) current written operating policies and procedures; (viii) a current patient roster; and H1404 (ix) listing of all personnel. -This Rule is not met as evidenced by: Based on on-site visit and interview'with the Owner, the Owner provided the Certificate of incorporation papers which revealed that the corporation was still inactive. Findings are: On 07/17/07, review of the Certificate of Incorporation papers, revealed that these were the same documents provided to the surveyor with the Plan of Correction submitted for the survey conducted on 05/17/06. The Owner stated that "the agency's accountant and the Division of Bureau of Taxation are trying STATE FORM D4J1 1 - Ifconnua onsheI 16018 PRINTED: 08/28/2007 FORM APPROVED New York' State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIER/CLLA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION AN BUILDING __________ (X3) DATE SURVEY COMPLETED LCO921A NAME OF PROVIDER OR SUPPLIER B. WING 07117/2007 STREET ADDRESS, CITY, STATE. ZIP CODE CARING HANDS HOME CARE AGENCY. INC. (X4) ID PREFIX TAG 36 JANICE LANE SELDEN, NY 11784 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H1404 Continued From Page 16 to workout a payment plan, but there has been ongoing discussion of how much money is H1404 actually owed by the agency". Online verification on 07/16/07 of corporation status revealed that the corporation is an "Inactive". REPEAT DEFICIENCY FROM 05/17/2006 SURVEY' H1432 766.12(a)(3) Records and reports 766.12 Records and reports. (a) The governing authority or operator shall ensure the prompt submission of all records and reports required by the department and that: (3) at a minimum, the following reports and H1432 records are retained by the home care services, agency and available to the department upon request: (i) minutes of the meetings of the governing authority and the comrhittees thereof which shall be retained for three years from the date of the meeting; (ii) records of all financial transactions directly related to delivery of patient care which shall be retained three years from the date of the transaction; (iii) personnel records, which shall be retained three years from the date of employee termination or resignation; (iv) records of grievances and complaints which shall be retained for three years from the date of STATE FORM V D4JR 1 It continuation sheetoOf 18 PRINTED: 08/28/2007 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDERJSUPPLIERCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED _ _ _ B. WING _ _ _ _ _ _ LCO921 A NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 07/17/2007 36 JANICE LANE SELDEN, NY 11784 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO TIlE APPROPRIATE DEFICIENCY) ((5) COMPLETE DATE CARING HANDS HOME CARE AGENCY, INC. (X4) ID PREFIX TAG SUMMARY STATEMENTOF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H1432 Continued From Page 17 resolution; (v) all records related to patient care and services; and (vi) any other records required to be kept by this Part or Part 765. This Rule is not met as evidenced by: Based on request for the Department of Health Statistical Reports for 2002, 2003, and 2005 and interview with the Owner,the Governing Authority (A) failed to submit and maintain records of the required Statistical Reports prepared and submitted by the agency. Findings are: Upon request for Department of Health Statistical Reports, the Owner was only able to provide the report for 2004. During an interview with the Owner on 07/17/07 at 12:45 PM, the Owner stated that "[ know they were all filed". H1432 REPEAT DEFICIENCY FROM 05/17/2006 SURVEY STATE FORM O~11OO D4JR11 If continuation 18 of 18 sheek PRINTED:- 10/11V2007. FORM APPROVED WSeadmn, e., Heah" ()(l) PROVIDERtSUPPLIER/CLIA' IDENTIFICATION NUMBER: STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (2) MULTIPLE CONSTRUCTION A. BUILDING ____X3__COMPLETED (X3) DATE SURVEY LC0762A LC72A NAME OF PROVIDER OR SUPPLIER ~B. WING___________ 07/27/2007 STREET ADDRESS, CITY, STATE, ZIP CODE ALL METRO HEALTH CARE (X4) ID PREFIX TAG (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 4 WEST PROSPECT AVENUE MOUNT VERNON, NY 10550 SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION PREFIX TAG (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETE DATE CXS) H 000 Initial Comments H 000 A Full survey was conducted on 7/26 &7/27107. A total of nine (9) clinical records were reviewed (#1 through #9). A total of ten (10) personnel records were reviewed (#1 through #10). H 304 766.2(a)(1) Patient service policies and procedures 766.2 Patient service policies and procedures: (a) The governing authority shall ensure for each health care service provided that: (1) written itolicies and procedures consistent with current professional standards of practice are develop, and implemented for each service and are revitwed and revised as necessary. L. This RULE is not met as evidenced by: Based on reiew of the agency's policy and procedure rdanual and Interview, the agency failed to dev lop a policy related to Criminal History Recd.rd Check (CHRC). Findings include: Fining eie aecys(attached), manual, it wdJs noted the agency did not have mnlit s reoted tthe ncy didotveDOH) i l tServices During an int rview with the Administrator on 7/15/07, the idministrator stated that the agency did not have ,I CHRC policy and was not aware that one was hIeeded. Failure to ha an Criminal Background Check Policy has th potential for the agency not having appropriate gbidelines for staff to follow when ATE FORM " DE" . aORATORY DIRECTOR'S OR PVIDERISUPPUER REPRESENTATIVES SIGNATURE ATE FORM H304 766.2(a)(1) Patient Service Policies and Procedures "During an interview with the Administrator on 7/16/07, the Administrator stated that the Agency did not have a CHRC policy and was not aware that one was needed." Branch personnel were confused about this when I spoke to them, as the surveyor did not arrive until 7/26/07, and was presented with our policy in place since 4/07 (updated since to reflect add'l. requirements by and told the Director of Clinical , , , P that this was "just what she was looking for". Please let me know if there is anything additional we need to do regarding this. Addendum 10-30-07 P/ease see attached NYS CHRC Po/icy 4(d) Aprl 2007 and Criminal Background Checks-NYS 2(a) July 2007. l TITLE (X6) DATE hfcontinuation sheet I of 3 f3B611 ' ALL METRO lpt/13/20. 7 is-.!2 NYS r-=H ni DQartment fHa 1 a 22y.. ue -- PAGE"0/0 PRIN-T D:: 10.1/007 -.- 31 46671407 ... :; -______ FORM APPROVED (X3) DATE SURVEY STATEMENT OF DEFICIENCIES AND PLAN OF CORRKCTION ," ---OF -pRO-DEROR SUPPLIER (XI) PROVIDERJSUPUECUIA IDENTIFICATION NUMBER: LCT28. ~LC0762A, (X2)'MULTIPLE CONSTRUCTION A. BUILDING WNG_ -. COMPLETED , -" 071271P2{07 STREET ADDRESS. CITY. STATE. ZJP CODE kALLMETRO HEAO R E ALL METRO HEALTH CARE zO PREFIX -MOUNT 4 WEST PROSPECT AVENUE VERNON, NY 10550 PREFIX TAG to sUMMARY STATEMENT OF DEFICIENCIES sXA (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) TAG (x5) PROVIDERS PLAN OF CORRECTION COMPLETE (EACH CORRECTIVE ACTION SHOULD BE COSS.REFERENCD TO THE APPROPRIATENCY H 304 continued From Page I hiring new employees. H510 766.4(b) Medical orders 766.4 Medical orders. (b)"For purposes of this Part, authorized practitioner shall refer to a doctor of medicine. a doctor of osteopathy,a doctor of podiatry, a licensed midwife or a nurse practitioner authorized under federal and state law and applicable rules and regulations to provide medical care and services to the patient except as may be iUmited by third party contract- Ho34 io .iH 766.4(b) Medical Orders for All Metro Health Care's policy A(1), medical orders [attached - Exhibit (2) & (3) and B(1) & (2)] contains specific language regarding time frames for development of POC's as well as the need for indicating the specific services, plans for implementation as well as type, frequency and duration of visits/shifts.. The Director of Clinical Services is responsible for the completion of POC's at the branch. The DCS shall consult with the Therapist before, writing the orders to determine what specific interventions will be administered, how and for will be reviewed to frequentlycase files how long. All active ctie and for wlll frey assure that this verbiage is present in POC. incoming all forward, Moving be reviewed before documentation will filing to assure that the POC is complete and accurate. Any changes in the therapy type, frequency and duration will be documented in the noles and an Interim Rx shall be sent to the MD for' signature. This is discussed with all DCS's during orientation, and has been reviewed with the Mount Vernon DCS by the VP of Patient Services. . Completion This RULE is not met as evidenced by: Based on clinical record review and staff Interview, the agency failed to include the amount, frequency, end duration for Medical (2) Orders for Physical Therapy (PT) in twote of .Therapy T reeivng at~ntwssevics frm two (2) patient records reviewed, Inwhich the patient was receiving PT services fromthe c #the Failure to include specific amount, frequency and duration in Medical Orders has the potential for the patient to receive inappropriate or Inadequate care. Findings include: Patient# 5 was admitted tot agency on 1117105 with a diagnosis of Cervical Discdated Displacement, The Plan of Care (POC) 6(28/07 ordered a PT evaluation. The PT evaluation was done on 6/129107 and times documented to continue PT for three (3) per week for two (2) weeks. Subsequent PT .ir TATE FORM date 10/31107. Ifco inuation shoet 2 cf 3 3 16B1 ;TATE FOR PRINTED: 10/11/2007 NYSDepartmnent at STATEMENT OF DEFICIENCIE, AND PLAN OF CORRECTION ....... (XI) PROVIDERISUPPLIERICUA IDENTIFICATION NUMBER: FORM APPROVED (X2) MULTIPLE CONSTRUCTION A. BUILDING 0(3) DATE SURVEY COMPLETED B. WING LC0762A NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE. ZJP CODE 07/27/2007 4 WEST PROSPECT AVENUE MOUNT VERNON, NY 10550 I PREFIX TAG ______766;4(b) PROVIDER'S PLAN OF CORRECTION .EACH CORRECTIVE ACTION SHOULD BE COMPLETE DATE ALL METRO HEALTH CARE (X4) IO PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH OEFICIENCY MUST 6E PRECEDED BY FULL RFGULATORY ________________________________ OR L$C IDENTIFYING INFORMATION) Medical Orders All Metro Health Care's policy for H 304 Continued From Page I hirng new employees. ' H 510 766.4(b) Medical orders 766.4 Medical orders, (b) For purposes of this Part, authorized practitioner shall refer to a doctor of medicine, a doctor of osteopathy, a doctor of podiatry, a licensed midwife or a nurse practitioner authorized under federal and state law and applicable rules and regulations to provide medical care and services to the patient except as may be limited. by third party contract H 304 H 510 medical orders (attached - Exhibit A(1), (2) & (3) and B(1) & (2)] contains specific language regarding time frames for development of POC's as well as the need for indicating the specific services, plans for implementation as well as type, frequency and duration of visits/shifts. The Director of Clinical Services is responsible for the completion of POC's at the branch. The DCS shall consult with the Therapist before writing the orders to determine what specific interventions will be administered, how frequently and for how long.. All active Therapy case files will be reviewed to assure that this verbiage is present in Moving forward, all incoming This RULE is not met as Based on cJinical record review and staff Interview, the agency failed to include the amount frequency, and duration for Medical Orders for Physical Therapy (PT) in two (2) of two (2) patient records reviewed, inwhich the patient was receiving PT services from the agency (#5, #9). evidncedby:the POC. Failure to include specific amount, frequency and duration in Medical Orders hasthe potential for the patient to receive inappropriate or inadequate care. Findings include: Patient# 5 was admitted to the agency on 1117/05 with a diagnosis of Cervical Disc Displacement The Plan of Care (POC) dated 6/28/07 ordered a PT evaluation. The PT evaluation was done on 6/29/07 and documented to continue PT for three (3) times per week for two (2) weeks. Subsequent PT rATE FORM rATE FORM documentation will be reviewed before filing to assure that the POC is complete and accurate. Any changes in the therapy type, frequency and duration will be documented in the.notes and an Interim Rx shall be sent to the MD for signature. This is discussed with all DCS's during orientation, and has been reviewed with the Mount Vernon DCS by the VP of Patient Services. Completion date 10/31/07. :Addendum 10-30-07 All medical charts w/I be monitored for is as documentation compiance reviewed by the DCS before filing, as well as during the Utilization Review Process. A random sample of charts is reviewed quarterly by the Department of Clinical Services during routine i internal audits. . SB6B11 S Irnwuafion set 2of 3 . _PRINTED: 10/11/200 FORM APPROVE[ (XO)DATE SURVEY COMPLETE 'YSDer arientof Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION' (Xl.PROVDERISUPPLIER/CLIA IDENTIFICATION NUMBER fX2) MULTIPLE CONSTRUCTION A. BUILDING S. WING ___7/_7/___7 LC0762A NAME OF PROVIDER OR SUI'PLIER STREET ADDRESS, CITY. STATE. ZIP CODE 0712707 ALL METRO HEALTH CARE (X4)ID PREFIX TAG 4 WEST PROSPECT AVENUE 1 " I I MOUNT VERNON,NYI 10550 PROVIDER'S PLAN OF CORRECTION 10" PREFIX TAG CTION CORRE (PAN (EACH CORRECTIVE ACTION SHOULD B CROSS.REFERENCED TO THE APPRDPRIATE DEFICIENCY) (Y' SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (XF1 COMPLETE DATE H510 Continued From Page 2 visits were made on 7/3, 7(6 and 719107, however, there was no order from a Medical Doctor (MD) for the PT visits of 7/3, 6 and 719107. Patient # 9 was admitted to the agency on 10/25/06 with a diagnosis of a Hip Fracture. The POC dated 10/24/06 ordered a PT evaluation. The PT evaluation was done on 10/31/06 and the therapist documented in his notes to continue PT two (2) times per week for six (6) weeks However, there was no evidence that the therapist communicated this to the Medical Doctor (MO) or that a Medical order was obtained for these additional visits. The PT made visits to the home after the evaluation on 11/27 and 12/8/06 and discharged the patient on 12/807. The Medical record lacked evidence of Medical Orders for these additional visits. During an interview on 7/27/07 with the Director H 510 of Patient Services (UPS), the DPS stated that she assumed the physical therapist had obtained the Medical Order from the physician. ,"ATEFORM ;TATE FORM - -- I3611 conitnuatlon sIhaH 3 ar3 .0 CRIMINAL BACKGROUND CHECKS - NYS Following is a list of forms to be used in NYS so, that we may be in compliance with the CHRC regulations. 100 - CHRC Agency Request Form 101 -Authorized Person Designation Form. 102 - Consent Form for Fingerprinting and CHRC 103 - Request for CHRC Instructions (2 pages) 103(a) - CHRC Cover Sheet 103(r) - Resubmission 104 - Expedited Review Request Form 105 - Subject Individual Termination Form 106 Revocation of Authorized Person Designation Form 1. When an associate is hired who is to be the individual primarily responsible for this process, Form 101 isto be completed, notarized and submitted for approval. If/when this person leaves AMHC's employ, or a different person is authorized to manage the CHRC process, Form 106 is submitted. 2. When an applicant is extended a job offer, they are to sign Form 102 documenting their consent for the CHRC. 3. Two sets of fingerprints are taken on the approved FBI fingerprint cards and submitted with Form 103. The employee remains.a provision employee pending the results of the CHRC. 4. If AMHC received notification that the employee must be re-printed, two sets of fingerprints shall be submitted with Form 103(r). 5. If a) prospective employee has been fingerprinted previously since 9/1/06, Form 104 may be submitted with the prints requesting an expedited review... 6. If a letter comes from DOH "Pending Denial", the employee is immediately removed from all cases. If an employeewishes to appeal a negative hiring decision rendered by DOH they may do so, but may not work until a positive decision is returned. 7. If/when the employee is terminated or voluntarily leaves our employ, Form 105 is submitted notifying DOH of same. 8. All CHRC related documents are to be filed in a separate file from the Personnel and Confidential files. 2(a) P Personnel/CrimChecksNYS 7/07. NYS CHRC POLICY AMHC will conduct a criminal history record check on prospective employees who will provide direct care or supervision to patients, residents or clients as per Article 36 of the Public Health Law who are hired or used on or after September 1, 2006 Nurses and other licensed health care providers are excluded from this regulation. AMHC shall designate one or more authorized persons and shall submit the name, position and contact information for each authorized person to the NYS DOH in the form and format required by the Department. ["Authorized person (AP)" means each individual designated by a provider who is authorized to request, receive and review criminal history information] Direct on-site observation is required for the first week the provisional employee or temp staff is used. After the first week, AMHC, may alternate weekly, direct on-site observation with off-site, telephonic evaluation until the CHRC determination is received, Off-site evaluation is conducted via a phone call to the care recipient. The on-site supervision must be completed by a nurse (RN or LPN) and the off-site by either a licensed health care professional or coordinator. AMHC shall: implement the supervision requirements of the temporary employee by utilizing an individual employed by AMHC with a minimum of one year's experience working for a provider certified, licensed or approved under Public Health Law. The results of the observations must be documented in the temporary employee's personnel file and signed by the person providing the supervision. No person who has been previously fingerprinted on or after 9/1/06 and whose fingerprints remain on file with the DOH, shall be required to undergo fingerprinting for purposes of a new criminal history record check. AMHC shall submit a request for an expedited review in lieu of a regular submission for in these individuals and they are subject to the supervision requirements. Recordkeeping. AMHC shall, maintain, and keep current, a record of: (i) a roster of current employees who were reviewed as of 9/1/06 and a list of their staffing assignments; such roster shall be submitted upon -request of the DOH in a form and format specified by the commissioner. Notifications. AMHC will immediately,. but within 14 calendar days after the event, notify the Department, and document such notification occurred, when: (1) any prospective employee who is subject to a criminal history record check withdraws an application for employment or is no longer being considered as a prospective employee.; or (2) any employee who was subject to, and underwent, a criminal history record check is no longer employed by the provider. Retention and disposal of information. AMHC shall maintain information necessary to demonstrate compliance with this regulation (a) of this section, for at least six years after the person ceases to be a subject individual, unless otherwise directed by DOH. P:Personnel/NYS CHRC Pol 4(d) 4/07 PRINTED: 08/14/2007 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDERISUPPLIERCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION . A. ,UILDING (X3) DATE SURVEY COMPLETED 951 L039 NAME OF PROVIDER OR SUPPLIER B.WNG STREET ADDRESS, CITY,STATE, ZIP CODE 08/03/2007 GENTIVA HEALTH SERVICES (X4) ID PREFIX TAG 877 EAST MAIN STREEY RIVERHEAD, NY 11901 . PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) . . SUMMARY STATEMENT OFDEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL o REGULATORY OR LSc IDENTIFYING INFORMATION) (Y5) COMPLETE DATE H 000 Initial Comments H 000 A Full Survey was performed at Gentiva Health Services on August 03, 2007. Five (5) Patient Records were reviewed and are identified as Patients #1 to #5. Seven (7) Personnel Records were reviewed and are identified as Employees #1 to #7. H 204 766,1(a)(1) Patient rights Section 766.1 Patient rights. (a) The governing authority shall establish written .policies regarding the rights of the patient and shall ensure the development of procedures implementing.such policies. These rights, " policies and procedures shall afford each patient the right to: (1) be informed of these rights, and the right to exercise'euch rights, in writing prior to the initiation of care, as evidenced by written documentation in the clinical record.; H 204 (2) be given a statement of the services available by the agency and related charges; (3) be advised before care is initiated of the extent to which payment for agency services may be expected from any third party payors and the extent to which payment may be required from the patient. (i) The agency shall advise the patient of any changes in information provided under this / paragraph or paragraph (2)of this subdivision as soon as possible, but no later than 30 caleinidar The BD /designee will provide the Gentiva Governing Body with a copy of. the approved plan of correction. Additionally, the BD/designee will provide a quarterly update on the status of the plan of correction to Gentiva's Governing! Body for their review and comment. ' 1015/07 days from the date the agency becomes aware LABORATORY DIRECTOR'S OR PR' SIGNATURE TITLE x6 DATIE STATE FORM D2(i1?F JZMG1 I If. continuation4 sheet I ofr13 K PRINTED: 08/14/2007 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDERSUPPUER/CLIA IDENTIFICATION NUMBER: - (X2) MULTIPLE CONSTRUCTION A. BUILDING B. VVNG _ (X3) DATE SURVEY COMPLETED _ _ _ _ _ _ _ _ 9511L039 NAME OF PROVIDER OR SUPPLIER 0810312007* STREET ADDRESS. CITY. STATE. ZIP CODE GENTIVA HEALTH SERVICES (X4) ID PREFIX TAG . 877 EAST MAIN STREEY RIVERHEAD, NY 11901 ID P.REFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD RE CR.OSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) SUMMARY STATEMENT OF DEFICIENCIES . (EACHt DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (XS) COMPLETE DATE H 204 Continued From Page 1 of the change. (ii) All information required by this paragraph shall be provided to the patient both orally and in shallng; to tcorrection . H 204 The BD/ DCM will be responsible to ensure that the action items noted in the submitted plan of correction for H204 are .completed in;. . * . as noted in the plan of submitted 8/27/07 and the amended plan of correction items noted. o (4) be. informed of all services, the agency is to provide, when and how services will be provided, " and the name and . ... of any person and functions affiliated agency met as evidenced by: This Rule is not providing care and services1 .. . T R inmd . Based on patient record review and staff interview. the agency failed to provide their patients with accurate information regarding their rights t5 be advised of the services to be provided in five (5) of five (5) records reviewed (Patients #1 to #5). The agency's.failure to provide accurate information places the patients at risk for not being able to exercise all of their rights. . herein. The specific action items are noted in detail on the correction but a summary of the plan of items action incu: include, 1. BD/dlesigee working with the Gentiva . o .. Forms Committee to approve revisions to the home care consent listing only the services andpayers available through the licensed agency 2. MCP/designee completing a SOC audit for all new admissions ensuring that consents are filled out correctly and that the licensed consent addendum is completed reflecting the cortect licensed agency services and payers. For any incorrectly completed consent and/or I Fining Findings are: arconsent .will Review of the "Patient Rights and Responsibilities" of the "Home Care Consent" form in patient records #1 to #5 under the section noted as "Authorization for Payment/Assignment of Insurance Benefits" documented that "I certify that the information provided by me is correct. I authorize my insurance company (ies) including. as appropriate Medicare, Medicaid, TnCare and other governmental programs to furnish any agency of Gentiva Health Services any and all information : pertaining to my insurance benefits and status of claims submitted by Gentiva Health Services". It should be noted that the licensedt home, care. agency cannot bill Medicare for services. STATE FORM . addendums, the MCP/designee counsel the clinician and any subsequent incorrect consents and/or I consent addendums will result in further disciplinary action up to an including termination. " 3. The DCM/designee will trend the SOC 'audit data and develop and implement a . plan to correct any identified issues: 4. The Branch Director/designee will ensure that patients understand what Specific services and payers are t available through the licensed agency through the inclusion of the licensed i consent addendum (only the specific services and payers available through the licensed agency are noted on the addendum) in the licensed SOC packet. .. . - JLMGi If Continuation sheet 2 of 13 PRINTED: 08/14/2007 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X) PROVIDER/SUPPLIERICLIA. IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A BUILDING B. WING (X3) DATE SURVEY COMPLETED 9511L039 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE. ZIP CODE 08103/2007 877 EAST MAIN STREEY RIVERHEAD, NY 11901 I PREFX TAG - GENTIVA HEALTH SERVICES (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) . PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTON SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (5) COMPLETE DATE 204Continued From Page 2 - H 204 - 5 The.M R/clsi neewill en-ijre that the -homecafe Review of the agency's Admission Information , Packet and patient records #1 to #5 included receipt of the agency's Home Care Consent. through #5 are corrected to reflect only the services-and payers available. through the licensed agency. consent for patients #1 The consent documented that the agency is able -to provide "RN (Registered Nurse), LPN (Licensed Practical Nurse/LVN (Licensed Visiting 6. The MCP/designee will counsel the specific clinicians servicing patients #1 through #5 regarding the specific Nurse), Physical Therapy (PT), Medical Social Pathology (SLP), Home Health Aide (hha), services and payer available through the licensed agency. Further incorrectly ' Services (MSW), Transportation, Housekeeping (or Homemaker) - (HK/HM),.Speech/Language Nutritional Services, Occupational Therapy (OT) and Hospice Services', ' Theconsent form failed to include Personal Care " o completed consents for the clinician, will result in further disciplinary action up to and including termination 7. The DCM/designee will complete an in-service for the clinical staff on the specific servicesand payers available . which is on the agency's license.' : through the licensed agency as well as how. to complete the licensed consent Review of the agency's license does not include Transportation, Nutritional Services and Hospice. Services. These-noted services are not " . approved services that are included on the - addendum. 8. The DCM/designee will ensure that newly hired clinicians are oriented on the " o o - specific services and payers available agency's license # 9511 L039, that was issued by the New York State Health Department on 06/05/01. - through the licensed agency and how to ' "' complete the licensed consent -. addendum. For example:-7, Patient #1 was admitted to the agency on 07/09/07 with diagnoses of Diabetes Mellitus, Ulcer other part of Foot (left). Review of the Home Care Consent dated 07/09/07, the nurse checked on the consent that th6 agency is able to provide: RN, LPN, PT, MSW, DME, and Nutrition. The agency is not. approved for DME (Durable Medical Equipment) and Nutrition services. The nurse failed to check other services that the agency is able to provide such as OT, SLP, and hha (home health aide) services. Patient #3 was admitted to the agency on STATE FORM o 7 / I JZMG11 If conUnuaIIon sheet 3 of13 PRINTED: 08/1412007 FORM APPROVED New York State Department of Health AND PLAN OF CORRECTION STATEMENT OF DEFICIENCIES N PA (XI) PROVIDER/SUPPLERCLIA IDENTIFICATION NUMBER. - (X2) MULTIPLE CONSTRUCTION BUILDING B. WING _ _ _ _ _ _ _ _ (X3) DATE SURVEY COMPLETED 08/0312007 NAME OF PROVIDER OR SUPPLIER GENTIVA HEALTH SERVICES (X4) I0 PREFIX TAG H 204 9511 L039 STREET ADDRESS, CITY, STATE, ZIP CODE " 877 EAST MAIN STREEY RIVERHEAD, NY 11901. ID PREFIX TAG H 204 . SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST RE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From Page 3 06/29/07 with diagnosis of Aftercare Following Total Hip Replacement. Review.of the Home Care Consent dated 06/29/07, the nurse checked on the consent that the agency is able to provide other services such as DME, and Respiratory Therapy (RT). The agency is not approved to provide for DME and RT services. Patient #4 was admitted to the agency on o07/11/07 with diagnoses of Colon Cancer, Dibility, and Chronic Airway Obstruction. Review of the Home Care Consent dated 07/11/07, the nurse checked on the consent that the agency is able to provide DME, Nutrition and RTservices. The agency is not approved to provide for DME, Nutrition and RT services. During an interview on 08/03/07 at 11:20AM with the Director of Clinical Management, the DCM acknowledged that the patients consent forms and the PMatient Information Packet are both Used for the licensed and the certified agency services. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE o CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (XS) COMPLETE DATE H 404 766.3(b) Plan of care 766.3 Plan of care. The governing authority or operator shall ensure that: (b) a plan of care is established for each patient based on a professional assessment of the patient's needs and includes pertinent diagnosis, prognosis, mental status, frequency of each service. to be provided, medications, treatments, diet regimens, functional limitations and STATE FORM H 404 . JZMG11 Ifcontinuation Sheel 4 of13 . PRINTED: 08/14/2007 FORM APPROVED NeW York State Department of Health STATEMENT OF DEFICIENCIES oAND.PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER .(X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED 9511 L039 NAME OF pROVIDER OR SUPPLIER. a. WING STREET ADDRESS, CITY, STATE, ZIP CODE 08/03/2007 o GENIVA HEALTH SERVICES GENTIAHEALH (X4) IO PREFIX TAG . 877 EAST MAIN 11901 -I.IRIVERHEAD, NY STREEY ID PREFIX TAG PROVIDER's PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED.BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H404 Continued From Page 4 rehabilitation potential.I . H 404 A. copy of the tracking tool referenced in the original plan of con'ection dated 8/27/07, is included in this addendum as attachment #1. The tracking tool is entitled, Clinical This Rule isnot met as evidenced by: Based on review, of the patient records and staff interview, the agency failed to ensure that a Plan of Care is established for all patients receiving agency's services. This was evident in One (1) of'. Associate Assignment Tracking Log (attachment # 1). The MCP/designee will. coniplete.the Clinical Associate Assignment five (5) records reviewed.(Patient #5). The agency's failure to establish a Plan of Care for all patients receiving agency's services fails to ensure that the agency provides the required services to meet the patient's n'eeds and has the potential for negative patient outcome. " Tracking Log for all new patients. Upon completion of the patient plan of care the MCP/desighee wilt write a diagonal line through the Patient Name box in red ink and initial and date on the upper right hand corner to indicate that the plan of care was completed, reviewed, signed and processed to' be mailed/faxed to the physician for signature. 'he DCM/designee will audit the Clinical Associate Assignment Tracking Log on a weekly basis to ensure that all patients have.a completed plan of care within 7 days of start of care. rhODCM'designee will take i disciplinary, action for any clinician not . following the process and/or not completing the plan of care within 7 days of stat. Continueddeficiencies with the process may result in further disciplinary action, up to and including'termination. Findings are: . ". Patient #5 was admitted to the agency on 07/03/07 with the diagnoses including Aftercare Following Surgery and Cellulitis. The patient record documented that the patient had an Abscess of the Left Groin. The SN (Skilled Nurse) visit notes from 07/03/07 to 07/1 1/Otocumented that the SN was providing wound care to the patient's left.groin. It should be noted that the patient's record lacked documentation of the Plan of Care. The SN's initial patient assessment that was performed on 07/03/07 documented the patient's wound, the required wound care and the SN visit frequency and duration. The record further lacked documentation of an interim physician order for the SN to provide the wound care and the required wound care regime. During the survey the Manager of Clinical . Practice presented to the surveyor the established Plan of Care, one month after the STATE FORM oz,....JZMG11 , Initiated 8/24107 and ongoing! : .. AA' Ifcontinuaion sheet 5 13 PRINTED: 0814/2007 FORM APPROVED New York State Department of Health STATEMENr OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDER/SUPPLIERCLIA IDENTIFICATION NUMBER: X2) MULTIPLE CONSTRUCTION A. BUILDING B. ViNG __________ (X3) DATE SURVEY COMPLETED 9511L039 NAME OF PROVIDER ORSUPPLIER 08/0312007o STREET ADDRESS, CITY, STATE, ZIP CODE GENTIVA HEALTH SERVICES (4 10 PREFIX TAG .877 EAST MAIN STREEY RIVERHEAD, NY 11901 - SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION ID PREFIX TAG ' PROVIDER's PLAN OF CORRETIO (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE o DEFICIENCY) COMPLETE DATE H 404 Continued From Page 5 start of care date. The Plan of Care was signed and dated "07/03/07" by the nurse when the Plan of Care was. actually established on 08/03/07. H 404 . I The analysis completed by the DCM to ensure that a plan of care was present and signed by the physician and that all orders were signed. within 30 days, as referenced in the original plan of correction submitted 08/27/07, was clone utilizing the "Pient: During interview on 08/03/07 at 12:20PM with the Census for Office 0146" which is included as Manager of Clinical Practices and the Director of Attachment H2. The patients that are crossed Clinica! Management, the Manager stated that " out are Department of Social Service (DSS) know that lam late with the orders". The . Personal Care Aide cases that Gentiva is not not review Manager further stated that she does .. required to have physician orders on since the' .the received SN visit notes. cases belong to the DSS. All other patients are Gentiva licensed agency patients. The H 514 768.4(d) Medical orders +F34,44DCM placed a check mark to the left of each patient upon verification that a plan of care waspresent and signed by the physician and ,, 766.4 Medical orders. , . that all orders for the patient were signed - within 30 days. The DCM signed attachihent . (d) Medical orders Shall reference all diagnoses, /2 to indicate verification and completion of medications, treatments, prognoses, and other -. record audit. .'the pertinent patient information relevant to the agency plan of care; and o"- ., A copy of the signed plan of care for patient . 4 5 is included in this amended plan of " ' (1) shall be authenticated by an authorized - correction. practitioner within thirty (30) days after admission . . 8-24-07 to the aggncy; and -(2) , ... w ci m(The when changes in the patient's medical orders are indicated, orders, including telephone orders,. shall be authenticated by the authorized practitioner within thirty (30) days. oo amended response to tag prefix H404 is continued on a separate page following the since there is not same response formatn sufficient space provided on the form.) A Copy of the signed physician orders for patient #3 and #5 are included in this amended plan of correction. The BD / designee will provide the Gentiva Governing Body with a copy of the approved plan of correction. Additionally, the BDidesignee will provide a quarterly update on the status of the plan of correction to Gentiva's Governing Body for their review and comment. ' / This Rule is not met as evidenced by: Based on patient record revieW and staff interview, the. agency failed to ensure that all . medical orders are authorized and signed by the; physician within thirty (30) days after admission to the agency. This was evidentin two (2) of five (5) records reviewed (Patients #3 and #5). o The agency's failure to ensure that all medical orders are signed by the physician within thirty (30) days, places the patients at risk for receiving unauthorized agencys services and poor quality STATE FORM H514 - 1015/07 I o =itirluation sheut 6 of 13 mJZMG1 ID Pretx Tg rt Tag. H404 Provider Plan of Correction (continued): The BO/ designee will provide the Gentiva Governing, Body with a copy of the approved plan of correction. Additionally, the BD/designee will provide a quarterly update on the status of the plan of correction to Gentiva's Governing Body for their review and comment. The DCM will be responsible to ensure that the action items noted in the submitted plan of correction for H404 are completed as noted in the plan of correction submitted 8/27/07 and the amended plan of correction items noted herein. The specific action items are noted in detail on the plan of correction but a summary of theaction items include: 1. MCP/designee ensuring that a plan of care is completed for all new patients through the utilization of the Clinical Associate Assignment Tracking Log (attachm-ent #1), The DCM/designee completing a weekly audit of the Clinical Associate Assignment Tracking Log to ensure compliance with the process and completion of plan of care within 7 days. DCM/designee taking disciplinary action for non-compliance with the process. 2. DCM/designee completing an inservice for the professional caregivers reviewing the need for a plan of care being completed within 7 days of the start of care and the need for physician signature on such plan of care within 30 days. 3. The DCM/designee ensuring that newly hired professional caregivers are oriented to the requirement that a plan of care being completed within 7 days of the start of care and the need for physiciah signature on such plan of care within 30 days. 4. The DCM completion of an audit of all active licensed cases (excluding DSS cases) to ensure that a plan of care and physician orders were present and signed within 30 days. 5, Verification that a signed plan of care has been received for patient #5. 6. Counseling of MCP and field RN for patient #5 regarding the need for timely UOmpiele Date: 10/5/07 completion of plan of care. Amended x1 PRINTED: 08/14/2007 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION . (X1)..PROVIUER/SUPPLIERJCLIA IDENTIFICATION NUMBER: A. 1 (X2) MULTIPLE CONSTRUCTION A. UILD ING B. AING __________ . (x3) DATE SURVEY COMPLETED 9511L039 NAME OF PROVIDER OR SUPPLIER .. 08/03/2007 " . STREET ADDRESS, CITY. STATE, ZIP CODE GENTIVA HEALTH SERVICES (X4) ID .PREFIX TAG SUMMARY STATEMENT OF DEFICIENcIES 877 EAST MAIN STREEY RIVERHEAD, NY 11901 ID PRE FIX TAG . PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (XS) COMPLETE DATE (EACH DEFICIENCY.MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H 514 Continued From Page 6 of care. Findings are: Patient #3 Was admitted to the agency on 06/29/07 with diagnosis of Aftercare Following Hip %Total Replacement. The Plan of Care dated 06/29 - 08/29/07 lacked physician's signature. During an interview with the Manager of Clinical.: Practices (MCP)'on 08/03/07 at 12:30 PM, the MCP wasinformed of the survey findings. The MCP acknowledged the survey findings and could not provide an explanation why the orders were still not signed. . Patient #5 was admitted to the agency on 07/03/07 with the diagnoses including Aftercare Following Surgery and Cellulitis. The Plan of .been Care dated 07/03/07 to 08/31/07 lacked , physician's signature to authorize the services to H 514 The BD/DCM will be responsible to ensure that the action items noted in the submitted plan of correction for H514 are completed as noted in the plan of correction submitted 8/27/07 and the amended plan of correction items noted herein. The specific action items are. noted in detail on the plan of correction but a summary of the action items include: 1. CTC, under the direction of the MCP, will review the physician order tracking report.on a daily basis and bring any orders over 21 days-old to the MCP for prioritization, The MCP will review the physician order tracking report with the CTC on a weekly basis to ensure that worders are obtained within 30 days and any orders over 21 days have been properly prioritized for follow-up. 2. Administrative and clinical staff have " re-educatedand counseled o ,. regarding the all physician orders being, obtained within 30 days of start of care. Continued non-compliance with the above established process will result in further disciplinary action, up to and including termination. 3. New employees responsible for physician order tracking will be oriented on the established process and the requirement that physician orders be signed within 30 days of start of care. 4. The Clinical Associate Assignment Tracking Log process indicated under tag. H404 to ensure that plans of care are .completed within 7 days of the start of care, will also apply under tag H514 wherein the physician order needs to bef signed within 30 days. The physician order tracking process referenced undert item #1 above will include plans of care.,; be provided by the agency. Refer to 140404 - Plan of Care. During interview with the Director of Clinical Management (DCM) and Manager of Clinical Practices (MCP) on 08/03/07 at 12:30 PM, they .were informed of the survey findings. The MCP ' acknowledged the survey findings, H 722 766.6(a)(10) Patient care record 766.6 Patient care record. .(a) The agency shall maintain a confidential record for each patient admitted to care to " include: ...... . (10) a'discharge summary when the patient is STATE FORM H 722 .. JZMG11 If rlnutI sh 1 t 7of 13 , PRINTED: 08/14/2007 FORM APPROVED New York State Deoartment of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDERJSUPPLIERCLIA DENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED 9511L039 NAME OF PROVIDER OR SUPPLIER " S. WING .0/320 08/03/2007 STREET ADDRESS, CITY. STATE, ZIP CODE 877 EAST MAIN STREEY GENTIVA HEALTH SERVICES (X4) ID PREFIX TAG RIVERHEAD, NY 11901 ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDLD BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE H'722 Continued From Page 7. discharged from the agency including: (i) documentation of discharge planning " preparation; (ii) nQtification to the patient's authorized practitioner; (iii) reasons for discharge and date of discharge; (iv) summary of care given and patient's " progress; H 722 The record review to ensure completion of a discharge summary for every discharged patient referenced in the original plan of correction dated 8/27/07, will be completed by the MCP/designee as each patient is discharged. The DCM/desigriee will ensure compliance with this requirement by' reviewing the comprehensive chart audits for discharged patients on a monthly basis. . 8/30/07 and ongoing " A copy of the discharge summaries for .... including a .(v) patient status upon discharge pa t Spatients description of any remaining needs.for patient care and supportive services; (vi) patient or family ability to selftmanagein relation to any remaining problems; and (vii) recommendations and referral for any follow-up care, if needed. This Rule is not met.as evidenced by: (v) aa ' #2, #3 and #5 are included in trois amended plan of correcti~n. The BD i designee will provide the Gentiva Governing Bodywith a copy of plan approved Ithe of correction Additionally, the BD/designee will provide f quarterly update on the status of the plan of correction to Gentiva's Governing'. 10/51071 Based on patient record review and staff " interview; the agency-failed to ensure that the patient care record documented the patient's discharge plan, reason for the discharge, that the patient and the physician were notified/informed regarding the pending discharge and the discharge summary. This was evident in three (3) of five (5) records reviewed (Patients #2, #3 and #5). The agency's failure to ensure that the patient and the physician have been informed about the patient's discharge, fails to ensure that an appropriate and safe discharge plan has been 'u Body for their review and comment. The 0CMwill be responsible to ensure that the action items noted in thensur submitted plan of correction for H722 are plan anoeintof correction submitted 8/2707 and the amended plan of correction itemsnoted herein. The specific action items ared noted in detail on the plan of correction but a summary of the action items include: 1. MCPdesinee completing a chart ensure completion of a discharge summary. The DCM ensuring discharged patients. I established for the patient and any required follow-up care/referral has been initiated to meet the patient's needsd STATE FORM compliance with this process through a monthly review of the chart audits for JZMG11 Ifcontinuation sheet 8 ol 13 PRINTED: 08/1412007 FORM APPROVED New York State Department of Health STATEMENT OFDEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDERISUPPLIERICLIA IDENTIFICATION NUMBER: (X2) MUI.TIPLE CONSTRUCTION A- BUILDING B. WIG (X3)DATE SURVEY COMPLETED .. NAME OF PROVIDER OR SUPPLIER 9511L039 . 08/03/2007 STREE T ADDRESS, CITY, STATE, ZIP CODE GENTIVA HEALTH SERVICES (X4) ID SUMMARY STATEMENT OF DEFICIENCIES 877 EAST MAIN STREEY RIVERHEAD, NY 11901 ID PROVIDER'S PLAN OF CORRECTION (X5) PREFIX. TAG (EACfH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PREFIX TAG (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THEAPPROPRIATE , DEFICIENCY) COMPLETE DATE H 722 Continued From Page 8 Findings are: H 722 2. DCM/designee completing an inservice for professional caregivers and MCPs identifying the requirements of Patient #3 was admitted to the agency on 06/29/07 with diagnosis of Aftercare Following Total Hip Replacement. The Plan of Care dated 06/29 - 08/29/07 ordered Skilled Nursing (SN) one (1) x week x two (2) weeks and two (2) X week x three (3) weeks. . . discharge planning which include complete documentation, physician notification discharge status, summaryI of care, and identification of continuing needs and supportive services. Caregiver and MOP non-compliance with. this requirement will result in disciplinary action, up to and including termination. 3. Re/education and.counseling of the caregivers identified for patients #2, #3, i and #5 regarding the comprehensive discharge planning requirements and corripletion of discharge-summaries. Continued deficiencies will results in further disciplinary action, up to and including termination. 4. Orientation of newly hired professional" caregivers regarding the discharge planning requirements and completion of discharge Summaries. Review of the record lacked documentation of SN.visit notes after 07/12/07. . During an interview with the Director of Clinical Management (DCM) and Manager of Clinical Practices (MCP)'on 08/03/07 at 12:30 PM, they were informed of the findings and were given an opportunity to provide an explanation. At 2:00 . PM, the MCP stated that the patient was discharged from the agency on 07/12/07 and the discharge summary was done, yet the agency is "' unable to locate the discharge summary. Patient #5 was admitted to the agency on I . - 07/03/07ivith the diagnoses including Aftercare Following Surgery. The Plan of Care dated 07/03/07 to 08/31./07 ordered the SN to prqvide wound care to the patient's left groin. The record documented that the last SN visit 7 note Was dated 07/11/07. The record lacked documentation of the patient care services and the patientIs status from 07/12/07 to 08/03/07. The record also lacked documentation of any discharge planning and if any referral and /or follow-up care was required. The record further lacked documentation of the patient's status upon discharge from the agency's services. During interview on 08/03/07 at 1:50PM with the.A. DCM, the DCM stated that the nurse's last visit STATE FORM 021199 JZMG11 Ifconltinuation sheet 9 of 13 PRINTED: 08/14/2007 FORM APPROVED New York State Department of Health. STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDERISUPPmtFEPJCLA IDENTIFICATION NUMBER (X2) MULrIPLE CONSTrRUCTION (X3) DATE SURVEY COMPLETED A.BUILDINGCOLEE 9511L039 NAME OF PROVIDER OR SUPPLIER B. W1NG _ 08/0312007 STREET ADDRESS, CITY, STATE, ZIP CODE GENTIVA HEALTH SERVICES (X4)ID PREFIX TAG RIVERHEAD, NY 11901 IO PREFIX TAG 577 8 EAST MAiN STREEY PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE -SUMMARY STATEMENT OF OEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H 722 Continued From Page 9 H 722 was on 07/11/07 andthat the nurse failed to document the discharge summary for the patient's. record. Patient #2 was admitted to the agency on 06/18/07 with the diagnosis including Right Total Hip Replacement. The Plan of Care dated 06/18/07 to 08/16/07 ordered SN and PT (Physical Therapy) services. The record documented the last SN visit note was dated 06118/07. The record also documented that the patient refused the SN visit on 06/21/07. The record lacked documentation of the patient care services and the patient's status from 06/22/07 to 08/03/07. The record lacked documentation that the nursing supervisor and/or the nurse had contacted the patient for a subsequent visit and the patient's status after 06/21/07. The recogd also lacked documentation of any discharge planning, if any referral and/or follow-up care required, that the patient and the physician were informed/notified about the discharge and the patient's status upon discharge. During interview on 08103/07 with the DCM at, 1:50PM, the DCM stated that the-nurse failed to document the discharge summary for the patient's record. H1002 766.9(a) Governing authority Section 766.9 Governing authority. The governing authority or operator .as defined STATE FORM 02n o H1002 JZMG11 If.continuation sheet 10 Q 13 PRINTED: 08/14/2007 FORM APPROVED New York State Department of Health (Xl) PROVIUErPJSUPPLIERCLIA STATEMENT OF DEFICIENCIES. IDENTIFICATION NUMBER: AND PLAN OF CORRECTION AND PLAN OF CORRECTION (X2) MULTIPLE CONSTRUCTION . (X3) DATE SURVEY COMPLETED 9511L039 NAME OF PROVIDER OR SUPPLIER A, BUILDING B. VVNG__________ ___________ 08/03/2007 STREET ADDRESS, CITY, STATE, ZIP CODE 877 EAST MAIN STREEY GENTIVA HEALTH SERVICES (X4) ID PREFIX TAG .RIVERHEAD, NY 11901 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACIH CORRECTIVE ACTION SHOULD BE CROSSLREFERENCEO TO THE APPROPRIATE DEFICIENCY) (XS) COMPLETE " DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H1002 Continued From Page 10 . . .. . H10.02 H . The BD/designee will provide the Gentiva Governing Body Wiith copies of the t Committee y G in Part 700 of.thisshall of a licensed home care Improvement Copie thandQualityove services agency Title, se e a c sProfessional Advisory Committee minutes and reports.on a (a) be responsible for the management andJ .meeting () be lr te mquarterly.. operation of the agency; basis in order to update them regarding the agency operations and management. The BD/designeeBody also provide the Gentiva Governing will with! a copy of the approved plan of correction 1015107 and deficiencies and a status update on 1015/07oand the plan of correction, on a quarterly ongoing (b) ensure compliance of the home care services' agency with all applicable Federal, State and local statutes, rules and regulations. This Rule is not met as. evidenced by:. Based on review of the patient records, patient *.basis. admission information packet and staff interview, the Governing Authority failed to be responsible for the'management and operation of the agency.. The Governing Authority's failure to be " responsible for the management and operation of the agency places all patients at risk for poor /4 ., ." patient carepractices. This was evident in the 'following deficiencies: . . ..- . H0204 .H0404 H0514 H0722 - Patient Rights -76601 (a) (1) - Plan of Care - 766.3 (b) - Medical Orders - 766.4 (d) - Patient Care Record - 766.6 (a) (10) H1036 H1036 766.9(l) Governing authority Section 766.9 Governing authority. The governing authority or operator, as .defined in Part 700 of this Title, of a licensed home care services agency shall: (I)appoint a quality improvement committee to establish and oversee standards of care. The quality improvement committee shall consist of a.J, consumer and appropriate health professional STATE FORM " - o . JZMG1 1 If coniJnuation sheet 11 of 13 / 7. PRINTED: 08/1412007 FORM APPROVEQ New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION " (X2) MULTIPLE CONSTRUCTION A. BUILDING a. WUING ______ _____ (X1) PROV1DERSUPPLIEPJCLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED 9511 L039 NAME OF PROVIDER OR SUPPLIER .. B.wING STREET ADDRESS. CITY, STATE. ZIP CODE 08/03/2007 GENTIVA HEALTH SERVICES (X4) io PREFIX TAG 877 EAST MAIN STREEY RIVERHEAD, NY 11901 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION ACTION SHOULD BE (EACH CORRECTIVE TO THE APPROPRIATE CROSS-REFERENCED DEFICIENCY) (XS) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST HE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H1036 Continued From Page 11 . H1036 persons including a physician if professional health care services are provided.The committee shall meet at least four times a year to.' (1) review policies pertaining to the delivery of the health care services provided by the agency. and recommend changes in such policies to the governing authority for adoption; .3. The BD has developed a*ist of items that must be reported and reviewed during the Quality Improvement Committee meetings. so as to ensure that all required .. indicators are addressed. The list of items includes: 1. Active Census Number and date.." 2. Number of Admissions and period reported. Number of Discharges and period reported. - (2) onduct a clinical record review of the safety, adequacy, type and quality of services provided which includes: 4. 5. . NUmber and summirary of Complaints and period reported.. Number and summary of - (i) random selection of records of patients currently receiving services and patients discharged from. the agency within the past three months; and " Incidents and period reported. 6. Number and summary of Adverse Events/Infections and period reported. 7. Chart Audit Findings, Trends, and . (ii) all cases with identified patient complaints as specified in subdivision (j) of this section; (3) prepare and submit a written summary of review fiqdings to the governing authority for necessary action; and (4) assist the agency in maintaining liaison with other health care providers inthe community. This Rule .is 'not met as evidenced by: Based on the review of the Quality Improvement Committee (QIC) Meeting minutes for the year 2006 and staff interview, the Governing Authority times per failed to meet the required fotr (4) year. The Governing Authority's failure to ensure that the QIC meets four times per year, place's the. patients at risk for the agency not being aware of trends/practices that would affect the delivery of . patient care services. Findings are: STATE FORM ' Total Number Completed for the following specific audits: a. Start of Care record audit b. Clinical Record Review, (CRR) audits for active and discharged patients. a' Review of policies and procedures " - 10/5107 and ongoing New and Revised. ' The BD/desighee will provide the Gentiva, Governing Body with copies of the Quality Improvement Committee and Professional Advisory Committee meeting minutes and reports reviewed during such committee meetings, on a quarterly basis. The BD/designee will obtain written acknowledgement and feedback if appropriate from the Gentiva ofGoverning Body, regarding their review of the referenced committee meeting minutes and reports. 10/5/07 and origoing-. A tA oz o10 L 4r1 _ _ J MG11 13 sheet If continuation 12 of - PRINTED: 08/1412007 FORM APPROVED, New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION . N (XI) PROVIDER/SUPPLIERICLA IDENTIFICATION NUMBER (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED 9511 L039 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY. STATE, ZIP CODE 08/03/2007 877 EAST MAIN STREEY RIVERHEAD, NY 11901 I0 PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACll CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE GENTIVA HEALTH SERVICES (X4) IO PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH. DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) .H1036 Continued From Page 12 H1036 Review Of the QIC meeting minutes for 2006, documented that the committee had met on 02/07/06, 04/18/06 and 10/24/06. For the month of July 2.006, the binder' contained a piece of paper thatdue to scheduling the meeting was cancelled documented that conflicts. The section in the binder that Was labeled December 2006, lacked the documentation of the QIC meeting minutes. During interview on 08/03/07.at l140PM with the .Director of Clinical Management (DCM), the DCM stated that she was riot sure if the committee had met after 10/24/06. It should be noted that during the survey, the agency did not provide any additional QIC meeting minutes for the year of 2006. ," . STATE FORM 0211" JZMG1 1 13 sheel 13 of !f cmnlinuation . . , " Cl Feb 2012 schedule z,," Teresa A. Nolan to: Cher l B Phoenix Cc: Mikhail Pankov, Suman Raina, Eileen Warner, Marie S Boyer 01/05/2012 07:24 AM The Cl schedule for Feb is: 2/1/12 Brookhaven Hospice PCV(Prov #33-1537) SR* TN 2/3 SR office/offsite 216 SR office/offsite 2/6 - 2/7 Long Island Healthcare (Lic # 1330L001) EW* MB 2/10 SR office/offsite 2/14 - 2/15 Gentiva PCV TN* EW 2/15 - 2/16 St Mary's (Lic# 1191 L002) MB* SR 2/1.7 SR office/offsite 2/20 Holiday 2/24 SR office/offsite 2/27- 3/2 Brookhaven Hosp Home Health Agency (PrOv #33-7108) SR* TN EW MB DEPAR MENT OF I-EALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES STATEMENT OF DEFICIENCIES ^,ND PLAN OF CORRECTION (Xi) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER; 337301 13. WING PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A.BUILDING (X3) DATE SURVEY COMPLETED 12/27/2007 AMERICAIRE CERTIFIED SPECIAL SERVICES SUB-UNIT STREET ADDRESS, CrY, STATE,.ZIP CODE 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACI- CORRECTIVE ACTION. SIIOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFIENCY) XS) COMPLITION DATE (X4) ID PRrFIX TAG SUMMARY STATEMENT OF DEFIENCIES (EACH DEFIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) G 000 INITIAL COMMENTS An Complaint Survey was initiated at Arnericare CSS on 11/19/07 and the findings resulted in an Extended Survey from 11/19-12/27/07. Americare CSS services a Special Needs Population which are patients with secondary diagnoses involving mental health, the mentally retarded, and/or developmentally disabled that preclude their independence in Activities of Daily Living. Nineteen (19) clinical records were reviewed and identified as Patients #1 - #19. Eight (8) home visits were made to Patients #1, #8, #3, #4, #5, #14, #14, #17 and #18. The patients were visited in there homes which were Adult Care Facilities (ACF). Fourteen (14) personnel files were reviewed and identified as Employees #1 - #14. Certified copies of the clinical records were requested on 11/27/07. The certified records were received in the Central Islip (CI) office on 12/06/07. Record reviews and interviews were conducted fIom the Cl office. The exit conference was conducted on 12/27/07. Based on the Extended and Complairit Survey, the agency was found to be out of compliance with the following Conditions of Participation: 6 000 484.14 Organization, Services, Administration (X6) DATE TITLE LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESF.NTATIVE'S SIGNAIURE deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined o. other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. If cunhinnation sheet Page 1 of 89 Event ID: IRI]I I Facility ID: 4706A FORM CMS-2567 (02-99) Previow Versions Obsolete Amended x I DEPARTMENT OF HEALTH AND H'UMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES ,"ATEMENT OF DEFICIENCIES D PLAN OF CORRECTION (XI) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 337301 (X2) MULTIPLE CONSTRUCTION A.BUILDING B N12/27/2007 B. WING ________ PRINIED 12/26/2007 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED NAMI3 OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE AMERICARE CERTIFIED SPECIAL SERVICES SUB -UNIT S SUWESTBURY, (X4) ID PREFIX "FAG SUMMARY STATEMENTOF I)EFIENCIFS (EACH DEFIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG 900 MERCHANTS CONCOURSE SUITE LL-15 NY 11590 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFIENCY) (X) COMPLETION DATE - G 000 Continued From page I 484.18 Acceptance of Patients, Plan Of Care, Medical Supervision 484.30 Skilled Nursing Services 484.10 PATIENTS RIGHTS G 000 G 101 G 101 G 101 Plan of Rights (StIandard) Educatin: All Niming stiaff have been in-serviced regarding the Patient BOR and Complaint Procedure DOH Jan. 10.2008 (W16t2008 The patient has the right to be informed of his or her rights. The those must protect and promote p ther rise f H]-HA the exercise of those rights. Jan. 16,2008 hotline #. Monitoring: (Suffern) The STANDARD is not met as evidenced by: record review, Policy Based on home visits (HV), and Procedure review, and staff interview, the agency failed to ensure that the patient has access to the information regarding the patient rights. This was evident for six (6) of nineteen (19) records reviewed and four (4) of eight (8) home visits. (Patients #1 IV, #3 1V, #4, #8 11V, #9,and 14 HV) The agency's failure to ensure the patient's access to Americarc CSS Supervising Staff will be visiting, all the AdtiL Care facilities on a weekly as (See attached calendar #2) evidenced by a as #3 written supeivisory note (See attachment at Supervisory Form). The purpose of these visits is to ensure that patients are aware of their BOR, complaint procedure & DOH hotline #.. andto ensure the supervision of skilled nursing services in accordance to the patient's POT.. hotline # is posted in view within the facility. be The Spervisoy reports will reviewedaLndt initialed ona weekly basis by the DPS. On an annual basis the start of the new year all active will be given another copy of their Bill of Ensure that the DOH the information on the patients rights places the patients at risk for not'being able to exercise their rights as needed. opatients The findings include: Patient #1 (HV) was admitted to the agency on 07/03/04 with diagnoses of Diabetes Mellitus and Schizophrenia. A homle visit was made to this patient (who resides in a Adult Care Facility (ACF) on 11/20/07 at 7:05 AM. During the visit, the admission folder (which the agency provides to Riglts & DOI- hotline #. R sposile Person; DPS for each bannch is responsible lr ovw ithlt. the patient during the initial visit) was requested FORM CMS-2567 (02-99) Previous Versions Obsolete Event I): 1RIJ I I Facility ID: 4706A If continuation sheet Page 2 of 89 Amended x 1 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES .ATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDER/SUI'PLIERICLIA II)ENTIFICATION NUMBER: 337301 NAME OF PROVIDER OR SUPPLIER (X2) MUI-IPLE CONSTRUCTION A.BUILDING PRINTE'D: 12/27/2007 FORM APPROVED OMB NO. 0938-0931 (X3) DATE SURVEY COMPLETED 12/27/2007 B. WING cr.'Y, STATE, ZIp CODE 900 MERCHANTS CONCOURSE SUITE LL-15 STREET ADDRESS, AMERICARE CERTIFIED SPECIAL SERVICES SUB UNIT (X4) ID PREFIX TAG " SUMMARY STATEMENT OF DEFIENCIES (EACH DEFIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG WESTBURY, NY 11590 PROVIDER'S PLAN OF CORRECTION (EACH CORRECnVE ACTION SIIOULD BECROSS-REFERENCED TO THE APPROPRIATE DEFIENCY) (X5) COMPLETION DAT, G 101 Continued-From page2 For review. The Nursing Supervisor stated that information would be "kept with the ACF Administrator". The Nursing Supervisor not the, ACF Administrator could locate the patient's admission folder*. G 101 There was no explanation provided by the Nursing Supervisor and/or the Administrator as to the inability to locate the patient's admission folder which includes patient Bill of Rights and a procedure to lodge complaint. Patient #8 (HV) was admitted to the agency on 10/18/07 with diagnoses of Diabetes Meliltus, Long Term Use of Insulin. Congestive Heart 'Failure, Therapeutic Drug Monitoring and Schiiophrenia. A home visit was made to this patient (who resides in an ACF) on 11/2/07 at 9:45 AM. The admission folder that is given to the.patient's during initial visit from the Skilled Nurse (SN) was" requested for review. The Nurse stated that the patient "does not have that information since the SN usually -ives that inm,,ation to the ACT Administrator or the copy is kept in the patient's mini chart which is kept locked in the agency's office". The patient would not be able to get the information on Patient Bill of Rights/Complaint Procedure after hours in case the patient wanted to lodge a complaint with the Department of Health. It places the patient at risk for not able to exercise all her patient rights. Patient #14 (HV) was admitted to the agency on 05/10/07 with diagnoses including Diabetes... Mellitus and Psychosis. FORM CMS-2567I (02-99) Frevious Versions Obsolete Event I): i RIJI 1 Facility ID: 4706A "') If contuuation sheet Page 3 of 89 Amended x I DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVlDER/SUPPIERCLIA IDENTIrICATION NUMBER: 337301 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE. ZIP CODE (X2) MULTIPLE CONSTRUCTION A.BUILDING PRINTED: 12/27/2007 FORM APPROVED OMB NO. 0938-0931 (X3) DATE SURVEYCOMPLETED 12/27/2007 AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNIT (X4) I) PREFIX TAG SUMMARY STATEMENT OF DEIIENCIFS (EACH DEFIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 ID PREPIX TAG PROVIDER'S PLAN OF CORRECTION (EACII CORRECItWE ACTION SHOULD BE CROSS-REFERENCED TO TIE APPROPRIATE DEFIENCY) (XS) COMPLET-ION DATE G 101 Continued From page 3 The clinical record documents that the patient signed his home care consent. The assessment dated 5/10/07 documents: "Materials were given to the ACF (Adult Care Facility) Administrator". During home visit on 10/20/07 at 7:00AM, the patient (who resides in anACF) stated that he did not recall receiving any information on his patient rights. Patient #3 (HV) was admitted to the agency on 02/16/07 with diagnoses of Coronary Atherosclerosis, Congestive Heart Failure, Lower Leg Injury, and Hypertension. During home visit on 11/20/07 at 1 1:00AM, the patient (who resides in an ACF) stated that he "did not receive" any information on his rights. The nursing visit nurse had in her possession the patient's yellow copy of the consent form. The patient was interviewed and stated that he was "not given" a copy of the consent, Bill of Rights and complaint procedure. The agency Director of Patient Services (DPS) was present during the interview and did not, provide and explanation.. Patient #9 was admitted to the agency on 09/04/07 with diagnoses including Mental Retardation and Hypertension. The clinical record documents that the patient signed his home care consent. The assessment dated 09/04/07 documents: "Material were given to the ACF Administrator". G 101 -TA) Event ID:IRIJ I I Facility ID: 4706A It continuation sheet Page 4 of 89 Amended x I .M CMS-2567 (02-99) Previous Verions Obsolete DEPARTMENT OF HEALTH AND HUMAN SERVICES C N'I'ERS FOR MEDICARE AND MEDICAID SERVICES _OMB PRINTED 12/26/2007 FORM APPROVED NO. 0938-0931 (X2) MULTIPLE CONSTRUCrION A.BUILDING STATEMENTOFDEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED 337301 B. WING__ STREET ADDRESS, CITY, STATE, ZIP CODE 12/27/2007 NAME OF PROVIDER OR SUPPLIER AMERICARE CERTfIfED SPECIAL SERVICES SUB-UNIT (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFIENCIES (EACH DEFIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 11) PREFIX TAG 900 MERCHANI'S CONCOURSE SUITE LL-15 WESTBURY, NY 11590 PROVIDER'S PI'AN OFCORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO T4E APPROPRIATE DEFIENCY) (X5) COMPLEHIION DATE - G 101 Continued'Frompage4 During interview with the Director of Patient Services (DPS) of Brooklyn, who was appointed by the parent agency to deal with Department of. Health issues, on 11/27/07 at 11:00AM, the DPS stated that the patients "lose the information" and therefore the "ACF keeps the information for the patient". The DPS could not.verify if the patient was ever given a copy of the patient's rights. Patient #4 was admitted to the agency on 10/06/06 with the diagnosis including Diabetes Mellitus Type fi. The clinical record documents that the Skilled Nurse completed the initial patient assessment on "10/06/06" at which time the SN "discussed with the patient regarding the home care service agreement, State Hotline number and the patient's Bill of Rights". The clinical record documents that the patient signed the consent.for home care services dated "10/06/06". The clinical record and the initial patient assessment lacked documentation that the agency had provided'to the patient in writing, the patient's Bill of Rights and the State lotline number to lodge complaints. The nurse documented "Discussed" under each section regarding this information. During interview on. 11/27/07 at 1:00PM, the agency's Nursing Supervisor and the DPS, were unable to provide explanations. The agency's "Assessment/Reassessment with Medical Supervision" policy which was undated documented on page 2: ...... Upon acceptance G 101 . FORM CMS-2567 (02-99) Previous Versions Obsolete Event ID: 1 JI I Facility ID: 4706A f continuation sheet Page 5 of 89 Amended x I. DEPARTMENT OF HEALTH AND HUMAN SERVICES CENIERS FOR MEDICARE AND MEDICAID SERVICES ,ATEMENT OF DEFICIENCIES AND I-AN OF CORRECTION (XI) PROVIDER/SUPPLIFUCLIA IDENTIFICATION NUMBER: 337301 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A.l UI1J)ING PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X3) DATE SURVEY COMPLETED 12/2712007 13. WING STREET ADDRESS, CITY, STATE, ZIP CODE ." 900 AMERICARE CERTIFIED SPECIAL SERVICES.SUB-UNIT / MERCHANTS CONCOURSE SUITE LL-15 oESTBURY, NY 11591 PROVIDER'S PLAN OF CORRECTION (EACH CORRECMIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFIENCY) (XS) COMPLETION DATE (X4) ID PRE1I-X TAG SUMMARY STATEMENT OF I)EFIENCIBS (EACH DEFIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG G 101 Continued From page 5 into service and advance to providing care, the patient/significant other is provided both verbal and written information and agency and services to be provided. The patient/significant other is given but not limited to the following information: Bill of rights and responsibility...DOH (Department of Health) Hotline #.. Access to care after hours... Complaint grievance process....." T'he agency failed to ensure that the staff provided the patients with the Patient Rights information and that the patients had access to this information as per the agency's Policy and Procedure. G 101 0 121 484.12(c) COMPLIANCE W/ACCEPTED ~Standards PROESSIOAL * PRO FESSIONAL STD The IUA and its staff must comply with accepted G 121 C 121 Complince with Aceptable Professonal (Standard) Montorng: professional standards and principles that apply to professionals furnishing services in an HHA. Thbis STANDARD is not met as evidenced Iby: Based on home visit observations and staff Supervisory staff will make weekly visits to the ACFs to monitor & evaluate the actual staff practices. Are staff members fbllowing the policy and procedure as it is written in the re:muat? interview, the-agency failed to maintain patient confidentiality; based , * Do the staff members need counseling or triaing? Are managers adequately mnonitorng staff practices? on accepted professional . standards and principles that apply to staff providing home care services inthe community as required. This was evident for Patient #8. - m . . Supervisor's will submit weekly summary, DPS will review weekly summaries. Based on the Failure to maintain patient confidentiality in accordance with the accepted professional standards and principles places the patients at risk for unnecessary disclosure of patient information. . Supervisory visit findings in-service cducation will be arranged & provided on an on-going basis as needd. Responsible Person: DIIS for etch branch office will provide oversight and is responsible to enfbree regulation. -Americar The findings include: A home visit was made to Patient #1 (who resides _ ".__ _ _ rORM CMS-2567 (02-99) Previous Versions Obsolete _ CSS Administratoc/Governing Bodv -ensure that the required education and in-services take place and die Agency's have the continued identified deficiencies -nd support tis esolve all T prevent any reoccurTcrces of deficient practices. _ Ifcontinuation sheet Page 6 of 89 Event ID: IRIJ I I Facility ID: 4706A Amended x I DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDER/SUPPLIER/CLIA IDENT11ICA'I'ON NUMBER: (X2) MULTIPLE CONSTRUCTION A.BUILDING PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X3) DATE SURVEY COMPLETED 337301 NAME OF PROVIDER OR SUPPLIER 12/27/2007 B. WING S'REET ADDRESS. crY,STATE, ZIP CODE AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNIT (X4) I) PREFIX TAG SUMMARY STATEMENT OF DEFIENCIES (EACH DEF1ENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 PROVIDER'S PLAN OF CORRECTION (EACII CORRECI'IVE AC71ION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFIENCY) (X5) COMPLETION. DATE G 121 Continued From page'6 In a Adult Care Facility (ACF) on 11/20/07 at 7:05 AM. During the visit, the Nursing Supervisor was observed talking in a loud voice about Patient #8 (who resides at another ACF) in the dining area. There were 3-5 patients in the dinin'g area. - On G 121 11/20/07 at 8:50AM, the nurse and Nursing Supervisor were observed discussing Patient #8. The agency staff used the patient's name several times during the conversation in an open area where other patient's were observed to be sitting around and drinking coffee. On 11/20/07, the Director of Patient Serviceso (DPS) from Brooklyn office who was appointed by the parent agency to deal with Department of Health issues and the DPS from Westbury office were informed of the observations. The administrative staff could not provide and explanations. The agency policy and procedure for "HIPAA PRIVACY NOTICE" which was undated documents that the policy applies to all "Americare workers, contractors, Vendors, ACF staff and other professionals PtII Related Information, in the course of their work. It details pertinent definition, who niay receive PHI Related Information,'in-service education requirements, confidentiality and disclosure...." The policy and procedure further documented That the "Federal law requires us to: Make sure that your medical information is kept private Give you this notice of our legal duties and privacy practices related to your medical information. Follow the terms of the privacy notice that is currently in effect." 484.14 ORGANIZATION, SERVICES & G 122 FORM CMS-2567 (02-99) Previous Versions Obsolete G 122 Event ID: I RII I Facility ID: 4706A If continuation sheet Page 7 of 89 Anmended x 1 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PRINTED: 12/26/07 FORM APPROVED .MB NO. 0938-0931 (X2) MULTI'IA CONS'RIZUCTION A.B U[LDING (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED 337301 NAME OF PROVIDER OR SUPPLIER 12/27/2007 B. WING STREFI' ADDRESS, CITY, STATE, ZIP CODE AMERICARE CERTIFIED.SPECIAL SERVICES SUB-UNIT (X4) ID PREFIX TAG SUMMARY S'TATEMENT OF DEFIENCIES (EACH DEFIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTI-YING INFORMATION) ., ID PREFIX TAG 900 MERCIANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 PROVIDER'S PLAN OFCORRECIION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE . DEFIENCY) (X5) COMPLETION DATE G 122 Continued From page 7 ADMINISTRATION G 122 G122 Organization, Services, Administration (Condition) flow the Governing Authority is going to take responsibility for the corrective action for the Condition: 'This CONDITION is not met as evidenced by: Based on clinical record review, home visits, review of the agency's On Call Log, review of Policies and Procedures, review of the agency's Performance Improvement Committee Meeting oplace P n of the agency. Findings include: minutes, and interviews, the Governing Authority (GA) failed to adequately oversee the management The DPS of each branch is responsible for oversight of Supervisory staff and will provide written weekly suranaric; to the Adtninistrator/Governing Authority. Weekly-meetings (ongoing) will take with the Administrator & DPS to ensure that the POC is being adhered to. On a quarterly basis all findings will be reported to the Professional Advisory Cotnuittee/Board. Ainericare CSS Administaator/Govcirting Body (VP of Operations) will ensure that the equired education and in-services take placeand the Agency's have the continued support to resolve all identified deficiencies arid prevent any t1eoCCuHrencs of deficient practices. The GA failed to ensure the provision of safe and quality care to the agency's special needs population of patients with secondary diagnoses . involving mental health, the mentally retarded, and/or developmentally disabled that prelude their independence in the activities of daily living as evidenced by: Failure to ensure the supervision of the Skilled Nursing Services Failureto ensure that the Skilled Nursing Services were provided in accordance with the patient Plan of Care Failure to ensure that the nursing staff coordinated care with the physician and other staff involved with the patients care including the Adult Care Facility (ACF) staff Failure to ensure that nursing staff reported changes to the physician and revised the patient Plan of Care to reflect the patient needs M CMS-2567 (02-99) Previous Versions Obsolete Event It): IRIJ II Facility ID; 4706A x If continuation sheet Page 8 of 89 Amended x I DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR ME1)ICARE AND MEDICAID SERVICES ATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X2) MULI-n'1LECONSTRUCTON A.BUILDING (Xl) PROVIDER/SUPPLI.ERCLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED 337301 NAME OF PROVIDER OR SUPPLIER B.WING STREET AI)DRESS, CITY, STATE, ZIP CODE 12/27/2007 AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNIT 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 ID PREFIX PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REIERENCED TO THE APPROPRIATE (X5) COMPLETION DATE (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFIENCIES (EACH DEFIENCY.MUST BE PRECEEDED BY FULL REGULATORY OR ISC IDENTIFYING INrORMATION) TAG G 122 DEFIENCY) G 122 Continued From page 8 Failure to ensure that the patients received medications and treatments in accordance with the Patient Plan of Care Failure to ensure supervision of the home health aide services Failure to ensure the patient has access to information on Patient Rights Failure to ensure that the staff respect the confidentiality of patient information during their presence in the ACF Failure to ensure the implementation of the agency's Policies and Procedures Failure to ensure the implementation of the corrective action plan for the Statement of Deficiencies for the Complaint Survey of 06/04/07. Refer to G101, G128, G133, G138, G145, G158, G159, G168, G173, G176,G229, and G236. The cumulative effect of these systems failures resulted in the agency's inability to ensure the provision of safe patient care practices that resulted in poor Diabetic management for patients #1 and #14, poor medication management for the special needs patients serviced by this agency, and places all agency patients at risk for unsafe and poor quality healthcare. 484.14(b) GOVERNING BODY. A governing body (or designated persons so functioning) assumes full legal authority and G128 G128 FORM CMS-2567 (02-99) Previous Versions Obsolete Event I: RL II Facility ID: 4706A If continuation sheet Page 9 of 89 Aineided x I 1t DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES 7"ATEMENT OF DEFICIENCIES D PLAN OF CORRECTION (XI) PROVIDERISUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A.BUILDING PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X3) DATE SURVEY COMPLETED 337301 NAM E OF PROVIDER OR SUPPLIER 12/27/2007 B. WING STREE T ADDRESS. CrrY, STATE, ZIP CODE AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNIT (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEPFIENCIES (EACI DEFIENCY MUST BE PRECLEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATIION) If PREFIX TAG 900-MERCHIANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 PROVIDER'S PLAN OF CORRECTION (EACII CORRECTIVE ACION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFIENCY) G128 Governing Authority (Standard) All Adult Care Facility OwnersAdministrators were given 30-day notice verbally, and in writing. All active patients were provided with a letter and a list alternate providers (patient choice). Atnericare CSS will continue to provide care until the transition to another provider is complete, (Sec. attachment # 5 Letters). Arnericure CSS will maintain a log of the transition of active patients along with the completion date (See attachment 4 6 Termination (XS) COMPLETION " DATE G 128 Continued From page 9 responsibility for the operation of the agency. G 128 This STANDARD is not met as evidenced by: (HV) B nclinical record review, home v Based on cof review of the Performance Improvement (PI) Audit for October 2007, staff interviews, review of the agency's On Call 1..og, and review of the agency's Policy and Procedures, the Governing Authority (GA) failed to ensure and implement the full responsibility fbr the safe delivery of patient care services for the special needs population of patients with secondary diagnoses involving mental health, the mentally retarded, and/or the developmentally disabled that prelude their independence in the activities of daily living which arc serviced by this agency. The findings include: The GA failed to oversee the provision of nursing services to patient #1 HV which resulted in failure Log). DPS provides a written swnmmy with a copy of the transition foe to the Adrniistrator/Governin Authority on a weekly basis. Amencare Supervisory staff will make weekly visits to the ACFs to cnsure services arc rendered in accordance to the POT. The Supervisor will alert the DIS of their findings. Atnericam DPS is responsible to develop and review the nursing schedule (a month in advance) to ensure services are being endered in accordance to the Patien's Plan of Cawe, UPS will report the findings totle Administattor/Goverhna. Authority The IPS submits a copy of the on.all calendar and log to the Administrator on a monthly basis for review. Any problems with staffing are immediately reported by the DIPS to the Administrator for resolution. The VP of Operations has overall responsibility to ensure appropriate staff to inplemnt safe delivery or cae under business agreenent. VP of Oprations is ultimately responsible to ensure the ACFs are appropriately stafled and operating in accordance to the all Federal and State Regulations governing home care. to provide a nursing visit on a weekend, "talking" via telephone to an unlicensed and untrained person at the Adult Care Facility (ACF') through the drawing up of Insulin and riot investigating this incident until two (2) montths later. Refer G 158, G !73, and !76 of this report., The GA failed to ensure the implementation of the. Plan of Correction of the Complaint Survey of 06/04/07. The P1 Audits for October 2007 and Plan of Correction Updates for October 2, 2007 - continue to document the agency's failure to develop a complete Plan of Care, provide care in accordance with the Plan of Care, and supervise the home health aides. The audits documented that the agency had not met the thresholds for compliance to ensure that the corrective actions FORM CMS-2567 (02-99) Previous Versions Obsolete , t, / . -7c ") Event ID: IRIJ I Facility ID: 4706A If continuation sheet Page 10 of 89 Amended x I DEPARTMENT OF HEALTH AND IHUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES kTEMENT OF DEFICIENCIES ,xND PLAN OF CORRECTION (XI) PROVIDER/SUPPLIER/CLIA IDENTIFICAION NUMBER: (X2) MUUIIPLE CONSTRUCTION A.B UnLDING PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X3) DATE SURVEY COMPLETED 337301 NAME OF PROVIDER OR SUPPLIER B.WING S'IREEI' ADI)RESS, CrTY, STATE, ZIP CODE 12/27/2007 AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNIT (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFIENCIES (EACH I)EFIENCY MUST BE PRECEEDED BY FULL REGULATORY OR ISC IDENTIFYING INFORMATION) ID PREFIX TAG 900 MERCIhANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 PROVIDER' S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SIIOUL) BE CROSS-REFERENCED TO THE API'ROPRIAIE DEFIENCY) (X5) COMPLIETION DATE G 128 Continued from page 10 in the Plan of Correction, for the Complaint Survey of 06/04/07 were met. The GA failed to oversee and monitor the PI activities. This was evident by repeat deficiencies in G 158, G 159 and G229. Review of the On Call Log and interviews documented problems with the agency's availability during off hours. During interviews with agency staff, the staff verbalized the problem with nursing availability especially on the weekends. This resulted in missed visits, missed Insulin doses, poor oversight of the patients medication regimen, and poor quality nursing carefor this special needs population. Refer to G158, G159, 173, and G176 of this report. The GA's failure to assume full authority and responsibility for the operation of the agency resulted in the poor oversight of the patients diabetic (patients #1 and #14) and medication management and placed all other patients at risk f'or unsafe and poor quality healtheare. G 128 G 133 484.14 (c) ADMINISTRATOR G 133 G 133 Administrator (Standard) The DIS in each branch provides day to day oversight and management of operations. The Administrator is responsible to ensure the POC is implemented and will report her finding. to te VP of Opcratons/Governing Board. The administrator, who may also be the supervising physician or registered nurse required under paragraph ( d ) of this section,,organizes. and difects the agency's ongoing functions; maintains ongoing liaison among the governing body, the group of professional personnel, and the staff. This STANDARD is not met as evidenced by: *Based on clinical record review, home visits, review of theOn Call Log, review of Policies and VP of Operations is ultimately responsible to ensure the ACFs are appropriately staffed aid operating in accordance to the all Federal and Stale regulations govenlfing home care and corrective actions. Procedures, the identification of repeat deficiencies, review of the agency's Performance Inprovement Committee minutes.and interviews, the Administrator failed to effectively oversee the F1ORM CMS-2567 (02-99) previous Versions Obsolete Event ID: IRI II x Facility ID: 4706A If continuation sheet Page 11 of 89 Amended x I DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES .ATEMENT OF DEFICIENCIFS AND PLAN OF CORRECIION (XI) PROVIDER/SUPPLIERI/CIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X3) DATE SURVEY COMPLETED ABUILDNG 12/27/2007 B. WING STREET ADDRESS, CITY, STAIE, ZIP CODE 337301 NAME OF PROVIDER OR SUPPLIER AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNIT ID PREFIX TAG 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 PROVIDER'S PLAN OF CORRECION (EACH CORRECIIVE ACTION SHOULD BE CROSS-REFERENCED TO TH1E A'PROI'RIATE DEFIENCY) (X5) COMPLETION DATE (X4) I) PREFIX TAG SUMMARY STA'IEMENT OF DEFIENCIES (EACH DEFLENCY MUST BE PRECEEDED BY FULL REGULATORY OR I-SC IDENTIFYING INFORMATION) G 133 Continued From page 1 operation and management of the agency. The failure of the Administrator to effectively manage the services provided by the agency resulted in poor diabetic management for patients #I and #14, poor medication management lor the special needs patients with secondary diagnoses involving mental health, the mentally retarded, and/or the developmentally disabled that preclude their independence in the activities of daily living which are serviced by this agency, and places all patients at risk for unsafe and poor quality care. The findings include: The Administrator failed to: Investigate the failure of the agency to provide a nursing visit to Patient #1 on a weekend and the agency's telephone instruction to an unlicensed and untrained employee of the Adult Care Facility (ACF) Ensure the supervision ofSk"Ie ,i services 1,,. G 133 ing Ensure that Skilled Nursing Services were provided in accordance with the patient Plan of Care Ensure that the agency nursing staff coordinate care with the physician, the ACF staff, and other staff involved in the patient's care Ensure that the nursing staff reported changes to the physician and revised the patient Plan of Care to meet the patient needs I'-NRM CMS-2567 (02-99) Previous Versions Obsolete 7A) Event ID: tRI l I Facility ID: 4706A If continuation sheet Page 12 of 89 Amended x I DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDER/SUPPIJER/CLA IDENTIVICATION NUMBER: "337301 ,B. WING _ PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X2) MULTIPL .CONSTRUCTION A.BUILDING - (X3) DATE SURVEY COMPLETED 12/27/2007 NAME OF PROVIDER OR SUPPLIER SIREET ADDRESS, CITY, STATE, ZIP CODE AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNIT (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEIIENCIFS (EACtl DEFIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 PROVIDER'S PLAN OF CORRECION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED '10 TIlE APPROPRIATE DEFIENCY) (X) COMPLETION DATE G 133 Continued From page 12 Ensure that the patient Plan of Care was complete and addressed all patient needs Ensure that patients received medications and treatments in accordance with their Plans of Care Ensure supervision of home health aide services Ensure the patient's access to the Patient Rights G 133 Protect patient confidentially while providing care to the patients in the ACF Ensure the provision of care in accordance with the agency's Policies and Procedures Ensure the implementation of the corrective action plan for the Statement of Deficiencies issued for the Complaint Survey. of 06104/07. Refer G101, G121, G138, G145, G158, G159, G168, G173, G176, G229, and G236 of this report. 484.14 (d)SUPERVISING PHYSICIAN OR REGIS. NURSE G 138 G 138 G 138 Superv-Lsing Physician or Registered Nurse Arerierc Supervisory staff will make weekly visits to the ACF's to nsu'e services ai renderdxl in to the I'OT. The Supervisor will alen the DPS of their findings. Arnericare DPS is responsible to develop and review the nursing schedule (a month in advance) to ensure services are being in accordance to the Patient's Plan of Care. The DPS develops an in-service and ensures appropriate education is given to the field nurses a- on the Supervisor findings. The DPS will sed report the findings to the Administrator/Govenning Authority on a weekly basis and to the Professional Advisory CinnitteeBoard quarterly. Diabetic Educator will conduct bi-weeklv case conferences on all insulin depetdent patients with Supervisor. ACF ttrse & MD until patient's . stabilizes or becomes independent in insulin administration. Jan. 4In2008 & ono o The s d aaccordance The skilled nursing and other therapeutic services furnished are under the supervision and direction of a physician or a registered nurse (who g "rendered Iy o n p r ay hs at lt y prefrably hs at ls experience and is a publi health nurse). This STANDARD is not met as evidenced by: Based on clinical record review, home visits (HV), review of agency Policies/Procedures, review of review ofthe agency's Mcondition the e C c In PefOn Call Lo, Performance Improvement Committee Meeting i M CMS-2567 (02-99) Previos Versions Obsolete "' Event l): 1RillI Facility ID: 4706A If cotinuation sheet Page 13 of 89 Amended x I DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES STATEMENT OF DEFICIENCIES 'AND PLAN OF CORRECTION (Xl) PROVIDERISUPPIERICLIA IDENTIFCAlION NUMBER: 337301 " (X2) MULTILE CONSTRUCTION PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X3) DATE SURVEY COMPLEI'ED 12/27/2007 A.BUIUDING O.WING ________ NAME OF PROVIDER OR SUPPLIER AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNIT STRETl ADDRESS, CITY, STATE, ZIP CODE 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO T]IE APPROPRIATE DEFIENCY) (X5) COMPLETION DATE (X4) ID PREFIX TAG SUMMARY STATEMENI OF DEFIENCIES (EACH DEFIEINCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDEN'IfYINC INFORMAION) G 138 Continued From page 13 minutes, and interviews, the agency's Supervising Nurse failed to ensure that the Skilled Nursing services provided to the agency's patients were appropriately supervised. This resulted in poor medication management for the special needs patients with secondary diagnoses involving mental health, the mentally G 138 100 % Clinical record audit will be conductx on dependent diabetic patients. insulin all All non-insulin dependent Diabetic patients charts will be reviewed on aquarterly basis. Results will be report d to the DPS/Adm & the PAB on a quarterly basis, Diabetic Educator will provide Quarterly Diabetic ln-srviccs to the ACF staff nuses. ensure VP ofOperations is ultimately restlisible to the ACF's ame appropriately stallf.ed and opra-ating in the accordance to all Federal anud State regulations governing home care and rrectiv actions. Feb. 6, 2008 March 31, 2008 Jan. 10, 2008 &. Ongoing retarded, and/or the developmentally disabled that preclude their independence in the activities of daily living which are serviced by the agency, poor Diabetic managementprovided to patients #1 and #14, and places patients at risk for unsafe and poor quality health care. Refer G 158, G159, G168, G173, G176, and G229. 484.14 (g) COORDINATION OF PAITI2NT SERVICES ,jj / // patients tlO0% Ihe Aency will ensure that all G 145 G 145 chart review of 60- day sRgr iQyare compilee, S V Ewill imely and reflect the patients; true condition. This beevidenced by the review of all re,certification documinieiitatioi nton submission to the A written summary report for each patient is sient to the attending physician at least every 60 days. This SIANDARD is not met as evidenced by: Based on clinical record review and staff "The interview, the agency failed to provide the physician a complete summary of the care agency & Suoervisor/Ol N'usNe/DPS sign off on the documentation checklist. (Se attachment #10)_The Nuising SupRi orlOl Nurse anuor DPS will e ie~wdan d in i v ti.I 6) ()d stu T q A_ _um come into the nurse(s) will be scheduled to office on a weekly basis to review an lupdate the d clinical records as needed based ott the findings on provided to patients. This was evident for six (6) of sixteen (16) clinical records requiring sixty (60) day summaries. (Patients #1, #4,#5,#7, #10, and #14) S1 ,and#14) 0 Sothe caltdar and an attendance record. documentation checklist. D'S wilt develop a The DPS fot each branch have over all responsibility to develop the AC nurses':are staff d ucatiotnand t, enis ongoing in-services, re E docuinetithg itS accordance to the all Federal and The agency's failure to provide the physician with a comprehensive sixty (60) day summary places the patients at risk for poor coordination of care. The finding include: ; regulaions. State A/Y7/1 FORM CMS-2567 (02-99) Previous Versions Obsolete 5' Event ID: IRUI I Facility ID: 4706A If continuation sheet Page 14 of 89 Amended x I DEPAR'TMENT OF HEALT'H AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES (X1) PROVIDER/SUPPLER/CUA IDENTIFICATION NUMBER: 337301 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION PlINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0931 (Xl) DATE SURVEY COMPLETED 12/27/2007 B. WING STREET" ADDRESS, CITY, STATE, ZIP CODE STATEMENT OF DEFICIENCIES .AND PLAN OF CORRECTION ABUILDING_____ ____ AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNIT ID PREFIX TAG 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 PROV IDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFIENCY) (X5) COMPLETION DATE (X4) ) PREFIX TAG SUMMARY STATEMENI OF DEFIENCIES (EACH DEFIENCY MUST BE PRECEEDED BY FULL REGULATORY oR LSC IDENTIFYING INFORMATION) G 145 Continued From page 14 Patient #1 was admitted to.the agency on. 07/30/04 with diagnoses of Diabetes Mellitus and Schizophrenia. The patient currently receives Skilled Nursing (SN) daily and home health aide (hha) services: G 145 The "60 Day Summary/Medical Update" dated 11/08/07 documents that the patient's blood sugar ranged between 116 to 230. The Skilled Nursing visit notes and the Insulin Treatment Log documents that the patients blood sugar ranged between 92 to 392. The summary failed to document the patient's monthly weight and that the patient was receiving hha services as ordered. On 11/26/07 at 2:30 PM, the administrative staff were informed of the survey findings and were given an opportunity to provide an explanation. On 11/27/07, the administrative staff could not provide any explanation. Patient #10 was admitted to the agency on 09/19/07 with diagnoses of Cellulitis of the Legs, Congestive Heart Failure, Dementia, Diabetes Mellitus Type 11, and Depressive Disorder. -The "60 Day Summary/Medical Update" signed and dated by the nurse on 1I/ 6/07 lacked documentation of patient's wound status, and blood sugar levels. The 60 Day Summary also documented that the patient has no peripheral edema. However, the nursing visit notes from 9/20 - 10/24/07 consistently documented that the patient has right lower leg edema of "2+". ,t tD: IRIJI I Facility 1D: 4706A If continuation sheet Page 15 of 89 Amended x I 'M CMS-2567 (02-99) Previous Versions Obsolete DEPARTMENT OF HEALTH AND HUMAN SERVICES CEN'ITERS FOR MEDICARE AND MEDICAID SERVICES -AI'EMEN" OF DEFICIENCIES D PLAN OF CORRECIION (XI) PROVIDEWISUPPLIER/CLIA IDENTIFICATION NUMBER: 337301 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION ABIUILDING PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X3) DATE SURVEY COMPLETED 12/2712007 B. WING STREET ADDRSS, CITY, STATE, ZIP CODE AMERICARE CERTIFIED SPECIAL SERVICES ID PREFIX TAG 900 MERCHANTS CONCOURSE. SUITE LL-15 WESTBURY, NY 11590 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED 'ID THE APPROPRIATE DEFIENCY) (X5) COMPLEiION DATE (X4) I) PREFIX TAG SUMMARY STATEMENTOF DEFIENCIES (EACII DEFIENCY MUST BE PRECEEDED BY FULL, REGULATORY OR LSC IDENTIFYING INFORMAIION) G 145 Continued From page 15 During an interview with the Nursing Supervisor on 11/27/07 at 1:15 PM, the Nursing Supervisor was unable to provide an explanation. Patient #7 was admitted to the agency on 05/19/07 with diagnoses of Diabetes Mellitus Type II, Schizoaffective Disorder, and Hypertension. The "60 Day Summary/Medical Update" dated 11/14/07 lacked documentation of the patient's blood sugar levels despite daily nursing visits to perform this tasks. During an interview with the Director of Patient Services (DPS) of Westbury on 11/27/07 at 1:30) PM,the DPS was unable to provide an explanation. Patient #14 was admitted to the agency on 05/10/07 with diagnoses of Psychosis and G 145 Diabetes Mellitus. The Record lacked documentation of a "60 Day Summary/Medical Update" for the certification period of 09/07 - 11/05/07. The finding was reviewed with the Nursing Supervisor on 11127/07 at 11:00 AM and no explanation for the agency's failure to complete and submit the 60 Day summary was provided. Patient #5 was admitted to the agency on 10/04/05 with the diagnoses including Diabetes Mellitus Type 11and Hypertension. The Plan of Care dated 09/24 -11/22/07 ordered the SN once a week to perform fingerstick and vital signs every Monday. *MCMS-2567 (02-99) Previous Versions Obsolete Event ID: IRU II Facility ID: 4706A A) If continuation sheet Page 16 of 89 Amended x I DEPARTMENI' OF H4EALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES "TEMENT OF DEFICIENCIE1S AND PIAN OF CORRECTION (XI) PROVIDER/SUPPLERCLA TIINTIFICATION NUMBER: 337301 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X3) DATE SURVEY COMPLETED 1227/2007 A.BUILD)ING B. WING STREE' ADDRESS, crI'Y, STATE. ZIP CODE AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNIT 900 MERCIIANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFIENCY) (X5) COMPLETION DATE (X4) I) PREFIX TAG SUMMARY STATEMENT OF DEFIJENCIES (EACH I)E~tENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) G 145 Continued From page 16 The "60 Day Summary/Medical Update" for the' period of 09/24/07 - 11/22/07 lacked documentation of the range of the patient's vital signs and fingerstick test results, During an interview on 11/26/07 at 3:00 PM the Administrative staff were informed of the survey findings. The Administrative staff was unable to provide an explanation. Patient #4 was admitted to the agency on 10/06/06 with the diagnosis of Diabetes Mellitus Typelt The Plan of Care dated 08/02 - 09/30/07 ordered the SN daily to perform fingerstick blood sugar readings and administer Insulin. The "60 Day Summary/Medical Update" for the period of 08/02 - 09/30 lacked documentation of the range of the fingerstick test results. During an interview on 11/26/07 at 3:00PM, the Administrative staff werean opportunitythe survey findings and were given informed of to provide an explanation. On 11/27/07 the agency provided no explanation. G 145 G 156 484.18 ACCEPTANCE OF PATIENTS, POC, MED SUPER (156 Acceptance of Patients, POC. Medical Supervision (Condition) Monitoring: Supervisot , staff will make weekly visits to the ACF's to evaluae the actual suff practices, Are staff members following the policy This CONDITION is not met as evidenced by: Based On clinical record review, horme visits, review of the agency's Policies/Procedures, - and procedure as it is ritea inthe o o review of the agency's Performance Improvement Committee Meeting minutes, and interviews, the manual? Do the staff members need counseling or training? Ae managers adequately monitoring staff pl-actices? Based on the Supervisory visit findings in-service cducation will be alTnged & provided. FORM CMS-2567 (02-99) Previous Versions Obsolete Event ID: IRIJI I Facility ID: 4706A If continuation sheet Page 17 of 89 Amended x I '1 DEPARTMENT OF HEALT1H AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 337301 PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X2) MULTIPLE CONSTRUCTION A.BUIILDING B. WING (X3) DATE SURVEY COMPIETED 12/27/2007 12_27_2007 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CrI'Y, STATE, ZIP CODE AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNIT (X4) tD PREFIX TAG SUMMARY STATEMENT OF I)EFIENCIES (EACH DEFIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENFIFYING INFORMATION). 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 I1) PREFIX 'FAG PROV IDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACIION SHOULD BE CROSS-REFERENCED TO TIlE APPROPRIATE DEFIENCY) (X5) COMPLETION DATE 0 156 Continued From page 17 agency failed to: o G 156 DPS fbr each lranch office will provide oVetsighl and responsible to enforce regtuaiOn. Develop a complete and comprehensive Plan of Care Ancricate CSS Adtinistrator/Govurning Body will ensure that Westbur' & Sufftcrn Develop a complete and comprehensive Plan of Care P Provide care in accordance with the Plan of Care Revise the patient's Plan of Care as needed . Provide care in accordance with the Plan of Care Revise the patient's Plan of Care as needed Ensure effective coordination of patient services Provide instruction to the patient and Adult Care Facility staff Adhere to tile agency Policies/Irocedures Implement the corrective actions for the Statement of Deficiencies for the Complaint Ensure effective coordination of patient services Provide instruction to the patient and Adult Care Facility staff o Adhere to the agency Survey of 06/04/07. Findings include: Refer G 145, G 158, G 159, ( 168, G173, and Policies/Procedures Implement the conective actions for the Statement of Deficiencies for the Complaint Survey of 06/04/07. This wil be achieved by performing ongoing Performance Improvemunl/Quality Assurance clinical record audits on a quarterly basis. Results of these audits will be repotled to the QI AturicareCSS AdttinistrGovening Body will ensure that the required education and in-services take place and the Agency's G 176 The cumulative effect of the agency's failure to develop, implement and revise the Plan of Care have dte cotinued suplpri to resolve all identified deficiencies md prevent any reoetrrences of deficient practices. resulted in poor oversight of patients requiring Diabetic management (Patients #1 HV and #14 P lThe Administnator will report her findings to lte VP of Operations/Govening Board. / '0 HV), poor medication management for the special needs population of patients with secondary diagnoses involving mental health, the nentally retarded, and the developmentally disabled that preclude their independence in the activities of daily living, and places all patients at risk for ,o./ a fd._Y t:1-61 VP of Operations isultimately a'apotlsi to ensure tle ACF's are appropriately accordatce to the stalfed operating in and Fcderal and Stale regulations governing all / /_1 home cre. '/ 158 unsafe and poor quality care with the potential for poor patient outcomes., 484.18 ACCEI'TANCE OF PATIENTS, POC, M.ED SUPER G 158 Medical Supervision (Standard) Facility 1D:4706A G 158 Acceptance of Patients, POC, FORM CMS-2567 (02-99) Previous Versions Obsolete Event ID: IRU I I If continuation sheet Page 18 of 89 Arieded x I )EPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES S&TEMENT OF DEFICIENCIES .DPLAN OF CORRECTION (XI) PROVIDER/SUPPLER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A.BUILDING PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED 337301 B. WING 12/27/2007 STREET ADDRESS, CFI'Y, STATE. ZIP CODE WESTBURY, NY 11590 AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNIT 900 MERCHANTS CONCOURSE SUITE LL-15 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SIOULD 1E CROSS-REV#ERENCiI) TO TIlE APPROPRIATE DEFIENCY) (X5) COMPLETION DAITE (X4) ID PREFIX 'IAG SUMMARY STATEMENT OF DEF1ENClFS (EACH DEFIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG G 158 Continued From page 18 Care follows a written plan of care established and periodically reviewed\by a doctor of medicine, osteopathy, or podiatric medicine. This STANDARDrco~rd review, evidenced by: Based on clinical is not met as home visits (MV), Baseonlini r eview, e vis, the Policy/Procedure review, and staff interview, the agency continued to fail to ensure that care was provided in accordance with the Plan of Care in ten (10) of nineteen (19) records reviewed and two (2) of eight (8) home visits. (Patients #1 HV, #3, #5, #6, #8, #9, #10, #11, #14 I-IV, and ft17) The agency's failure to ensure that the patients receive care in accordance with the Plan of Care resulted in poorr Diabetic and medication pplace management for patients #1 and #14, has the potential for patients to receive inadequate/inappropriate care, places all agency patients at risk for unsafe and poor quality health n a ents parti G 158 The Plan of Care has been reviewed and amended by evidence of physician interim orders in the #3, patient's clinical icord for patient's #1, #5.#6, #sf9.#10,#11 ,#l4.&Hl17 Feb.6,2008 o Staff education and in-srvices will be conducted in both Westbury & Suffern. an 10,2008 & Itin 16.2008 DPS of each branch isresponsible to develop an ongoing staff educatiutt/in-scViCe calendar on quarterly basis. Quarterly clinical record audits will be performed by Supervisor/QI nttrse/DPS to April 14, 2008 & ongoing identify any deficient agency practices. DPS for each branch office will provide oversight and responsible to enforce home care regulations. The Bord/Committee. - DI'S will report her findings on a qnuarterly basis to the QI committee/ Profelional Advisory Amricarc CSS Administrator will ensure that tile audits, educalion and in-services take required chart Agency's have the continued support and the to resolve all identified deficioncies and prevent any -occurronces of deficient practiccs. This will be achieved by meeting with the DPS on a weekly ln pro'enient/Quality Assurance clinical record audit results on a quarterly basis. The Administrator will report. her findings to the VP of Operiations/Goveming Board. VP of Operations is ultimately responsible to ensure basis and reviewing ongoing Performance care, and the potential for negativc patients outcomes. The findings include: Patient #1 (HV) was admitted to the agency on 07/30/04 with diagnoses of Diabetes Mellitus and Schizophrenia./_ the ACFs are appropriately staffed and operating in governing horc care. the accordance to all Federal and State r gulations The Plan of Care dated 05/16 - 07/14, 07/1509/12, 09/13-11/11 and 11/12-01/10/08 documents orders for Skilled Nurse (SN) visits daily to"... Diabetic Regime, S/S (signs and symptoms) of Hypo/hyperglycernia causes and intervention, Foot care/Skin Care. Adm Lantus as ordered Q (every) am, Regular Insulin Coverage AM&PM....fViB/S (blood sugar) > 250". in FORM CMS-2567 (02-99) Previous Versions Obsolete q1 ell ?a En I0 Evenat ID: I RUJI I Facility 1D; 4706A If continuation sheet Page 19 of 89 Amended x I DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES ,L"'ATEMENT OF DEFICIENCIES D PLAN OF CORRECTION (XI) PROVIDER/SUPPLIERICLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION PRINTED 12126/2007 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED A.BUILDING B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 337301 12/27/2007 NAME OF PROVIDER OR SUPPLIER AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNIT 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 I) PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-RrFERENCED TO THE APPROPRIATE DEFIENCY) (XS) COMPLETION DATE (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEF1ENCIES .( EACH DEFTENCY MUST BE PRECEEDED BY 1.JLL REGULATORY OR LSC IDENTIFYING INFORMATION) G 158 Continued From page 19 During the home visiton 11/20/07 at 7:05 AM, the blood sugar log was reviewed. The log documented that the patient tests his blood sugars "twice a day" Interview with the patient during visit, the patient stated that there has been "several days" that the Adult Care Facility staff " drew up the Insul.in" for thehim and he self administered the Insulin. The.Adult Care Facility (ACE) regulations part 487.7 (f) (7) of Title 18 NYCRR (New York Codes, Rules, Regulations) prohibits ACF staff from administering injectable medication. The ACF Standards define the administration of an injectable medication to include the preparation, such as the drawing up and filing the syringe, as part of the administration of an injectable medication. The agency failed to provide SN visits and administer the patient's Insulin'as as ordered-on the Plan of Care. Refer G 176 Patient #14 (HV) was admitted to the agency on 05/10/07 with diagnoses including Diabetes Mellitus, Psychosis, and Hypertenstion. The Plan of Care dated from the start of care to 01/04/08 orders: Skilled Nursing visits daily to administer Lantus Insulin 100 units daily, "diabetic care diabetic regime, S/S (signs and symptoms) of hyper/hypoglycemia:, and included a sliding scale insulin coverage of Humulin R Insulin for blood sugars above 200. G 158 -RM CMS-2567 (02-99) Pr-evious erims Obsolete. Event ID: I RIJI I Facility ID: 4706A If continuation sheet Page 20 of 89 Amended x 1. DEPARTMENT OF HEALTIH AND I-UMAN SERVICES CENTRS FOR MEDICARE AND MEDICAID SERVICES STATEMEN OF DECINCE PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X2) MULTIPLE CONSTRUCIION A.BUILDING j.-A*ND PLAN OF CORRECTION STATEMENT OF DFIiCIiNCES (XI) PROVIDERISUPPUER/CLIA IDENTIFICATION NUMBER: 337301 (X3) DATE SURVEY COMPLETED 12/27/2007 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADI)RESS, CrrY, STATE. ZIP CODE AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNIT (X4) [D PREFIX TAG SUMMARY STATEMENT OF I)EFIENCIES (EACH DEFIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 ID PREFIX PROVIDER'S PLAN OF CORRECTION (EACH CORREC'IVE ACnON SHOULD BE CROSS-REFERENCED TO THE (X5) COMPLETIfON DATE TAG APPROPRIATE DEF1ENCY) G 158 Continued From page 20 During a home visit on 11/20/07 at 7:00 AM, the, blood sugar log (maintained by the patient) was G 158 reviewed. The patient stated he tests his blood sugars "three (3) times a day". The log documented seven (7) blood sugar readings above 200 when the patient tested his blood sugars before lunch and ten (10) blood sugars above 200 when the patient tested his blood sugars before dinner from 11/05 - 11/19/07. The patient stated he "did not get any insulin at these times." During interview with the nurse at 7:50 AM, the nurse stated that she was going to "take the information from the log to the Diabetic Consultant and review them with her". The nurse failed to inform the physician of these elevated blood sugars and case conference with the supervisor to ensure that the patient received the insulin coverage as ordered on the plan of Care. During an interview with the Director of Diabetes Education on 11/21/07 at 8:45 AM, the Educator did "not recall" consulting with the nurse about this patient. On 11/27 the agency provided the surveyor with the "Focus Diabetic Chart Audit Tool" dated 11/14/07. The.tool was completed by the Educator and documented: ..... Many BS (Blood Sugar) out of range for good control needs to be reported to the MD". The agency Skilled Nurse, nursing supervisor, and diabetes educator failed to provide diabetic management of the patient in accordance with ."RM CMS-2567 (02-99) Previous Versions Obsolete Event I): 1RU II Facility ID: 4706A If continuation sheet Page 21 of 89 Amended x I DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES 11 "ArEMENT OF DEFICIENCIES D PLAN OF CORRECI'ION (XI) PROVrDERISUPFI'ERICLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A.BIJII.DING PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X3) DATE SURVEY COMPLETED 337301 A. WING_________ NAME OF PROVIDER OR SUPPLIER STREFI' ADDRESS. CrI'Y, STATE, ZIP CODE 12/27/2007 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVEACTION SHOUILD BE CROSS-REFERENCED TO THE APPROPRIATE DEFIENCY) (X5) COMPLETION DA'ITE AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNIT (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFIENCIES (EACH DEFIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) G 158 Continued From page 21 the Plan of Care. Patient #10 was admitted to the agency on 09/19/07 with diagnoses of Cellulitis of the legs, Congestive Heart Failure, Dementia, Diabetes Mellitus Type I1, and Depressive Disorder. The Plan of Care dated 09/19- 11/17/07 orders: Skilled Nursing (SN) two (2) x day sixty (60) to apply Lotrisone to write lower extremity.., weigh client weekly times four (4) weeks and then every month..., and monitor finger stick blood sugar readings every other week. G 158 The clinical record documents a physician order dated 1/09/07 to "apply Lotrisone to groin and rectal area-twice a day (1ID) for fourteen (14) days, start on 09/22/07 and discontinued on 10/06/07". The nursing visit notes lacked documentation that treatment was rendered according to the Plan of Care and physician's order. The nurse failed to documenctreatment to the groin and rectal area on visit dates of 09/20 PM, 09/25 AM, 09/25 PM, 09/26 PM, and 10/04/07 PM. On 09/30/07, the nurse visited once to administer wound care treatment. The clinical record lacked documentation that the physician was notified of the agency's failure to provide care in accordance. with the Plan of Care. Interview with the Nursing Supervisor on 11/27/07 at 1:30 PM, the supervisor stated that "there has been shortage of nursing and coverage is especially difficult on weekends due to staffing issue." FORM CMS-2567 (02-99) Previous Versions Obsolete Evmt ID: IRIJ I1 Facility ID: 4706A If continuation sheet Page 22 of 89 Amended x I DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES 1ATEMENT OF DEFICIENCIES D PLAN OF CORRECTION (XI) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A.BUILIDING PRINTED: .12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X3) DATE SURVEY COMPLETED 337301 B. WING 12/27/2007 NAME OF PROVIDER OR SUPPLIER . STREEI' ADDRESS. CIFY, STATE, ZIP CODE AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNIT (X4) ID PREIX TAG SUMMARY STATEMENT OF DEFIENCIES (EACH DEFIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENFIFYING INFORMATION) ID PREFIX TAG 900 MERCIIANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 PROVIDER'S PLAN OF CORRECTION (EACH CORRECIVE ACI'ION SHOULD BE CROSS-RE7ERENCED T'ITHE APPROPRIATE DEFIENCY) (X5) COMPLE1ON DATE G 158 Continued from page 22 Further review of the clinical record lacked assessment of the patient's weight weekly for four (4) weeks and then monthly for visits of 09/19 1-1/06/07 as per the Plan of Care. The patient has a diagnosis of Congestive Heart Failure and is on diuretic treatment of Lasix 20mg P0 (by mouth) daily since the start of care of 9/19/07. The visit notes documented that the patient had "persistent peripheral edema 2+ of the lower extremities" and required the increase. of the diuretic On 10/03/07 to Lasix 40mg PO daily. The clinical record lacked docimentation of the assessment of the patients weight as per the Plan of Care. lnteirview with the Nursing Supervisor on 11/27/07 at 1:30PM, the Supervisor could provide no further information or explanation. Further review of the clinical record lacked assessment of the patient's blood sugar as per the Plan of Care which ordered the SN to perform fingerstick blood sugar testing every other week (QOW). The clinical record lacked documentation of the fingerstick/blood sugar levels for nursing visit dates of 09/19-10/08/07. The patient is on oral glycemic agent of Avandia 4mg PO daily since start of care of 09/19/07. Interview with the Nursing Supervisor on 11/27/07 at 1:30PM, the Supervisor could provide no further information or explanation. Upon submission of the certified record to the Central [slip DOH office on 12/06/07, Ihe agency provided Supplemental Documentation of a "Diabetic Flow Sheet" listing fingerstick !evels for the-months of 8/07 -11/07. This flow sheet is maintained in the ACF and was not available at G 158 FORM CMS-2567 (02-99) Previous Versions Obsolete Event ID: 1RIJ11 Facility ID: 4706A If continuation sheet Page 23 of 89 Amended x I DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAfD SERVICES STATEMENT OF DEFICIENCIES [AND PLAN OF CORRECTION PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X2) MULTIPLE CONSTRUC'TION A.BUILDING (XI) 1'ROVIDER/SUPPILIRCLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED 337301 B. WING STREET ADDRESS, Crl'Y, STATE, ZIP CODE 12/27/2007 NAME OF 'ROVIDER OR SUPPLIER AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNIT (X4) ID SUMMARY STATEMENT OF DElENCIES ID 900 MERCIIANTS CONCOURSE SUITE LL-15 ___WESTBURY, NY 11590 -(X5) PROVIDER'S PLAN OF CORREGION PREFIX FAG (EACH DEFIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PREFIX TAG (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFIENCY) COMPLETION DATE G 158 Continued From page 23 time of survey. A telephone call was placed to the agency on 12/17/07 at lO'AM and 12:45 PM to request a copy of the agency Policy/Procedure on the use of the logs/flow sheets by agency staff which are left in the ACF. The DPS returned the call on 12/17/07 at 1PM and stated she would look the policy and call back. The agency faxed the agency's Adult Care Facility Diabetes Patient Care Plan of Protocol which Was not dated to the Central Islip office on 12/17/07. The Protocol documents on page 2 "Nurses or patient/caregiver will complete the Monttly Blood Sugar Montoring Log with available blood sugars and submit a copy each month for the patients record." Patient #3 was admitted to the agency on 02/16/07 with diagnoses of Coronary Atherosclerosis, Congestive Heart Failure, Lower Leg injury, and Hypertension. The Plan of Care dated 10/14 - 12/12/07 orders: Skilled Nursing, 2 Day 60 (twice daily for 60 days) to administer wound care to left leg and home health aide (HH-IA) services were ordered five (5) days per week x two (2) hours a day x nine (9) weeks. The clinical record lacked documentation of Skilled Nursing visits on 10/14 - 10/19 AM and PM visits, 10/20 AM visit, 10/22-10/23 AM visits, 10/24- 10/29 AM and PM visits, 10/3010/31 PM Visits, 11/02 and 11/04 PM visits, and 11/10 AM visit. The clinical record als0acked aide activity sheets G 158 1-A) Event ID: IRIJI I Facility ID: 4706A If continuation sheet Page 24 of 89 Amended x I ,M CMS-2567 (02-99) Previous Versions Obsolete DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES \iMENTI' OF DEFICIENCIES -1) 1LAN OF CORRECTION (Xl) PROVIDER/SUPPLIER/CIIA IDENIFICATION NUMBER: (X2) MULTI'IE CONST'RUCTION . PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X3) DATE SURVEY COMPLETED 12/27/2007 A.BUILDING B.WING 337301 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE. ZIP CODE AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNIT 900 MERCIIANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 (X4) I) PREFIX TAG SUMMARY STATEMENT OF DERIENCIES (EACH DEFIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO TIlE APPROPRIATE DEFIENCY) (X5) COMPLEION DATE 0 158 Continued-From page 24 From 10/11-10/22/07. On 11/27/07 the Director of Patient Services was unable to provide documentation for the missed visits. The clinical record lacked documentation of an explanatioi for the missed SN visits, lack HHA service from 10/11- 10/22/07, and documentation that the physician was notified of the agency's failure to provide care in accordance with the Plan of Care. Upon submission of the certified record to the Central Islip on 12/06/07, the visit notes for 10/28 PM, 11/04 AM, 11/10 PM, and 11/15/07 AM were submitted in a supplemental. folder. (Refer G236). Patient #6 was admitted to the agency on 03/31/05 with diagnoses including Schizophrenia, Diabetes Mel!itus, and Chronic Airway Obstruction. The Plans of Care dated 09/17/07 - 01/14/08 documents orders for the nurse to monitor the symptom patient's weight monthly and .... management hydration/nut rition status". The nurse's visit notes lacked documentation of a weight for the patient in October 2007. The nurse documented on 10/31/07 that "thin lady appears to be wasting away ........ During interview on 11/27/07 at 11:30 AM with the Nursing Supervisor on the case, the supervisor stated that the weight for October was "probably 113 pounds" which was noted in the Progress Note dated 11/08/07. G 158 _M CMS-2567 (02-99) Previous Versions Obsolete Event ID: IRI1 I Facility ID: 4706A If continuation sheet Page 25 of 89 Amended x I I)EPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES STATEMENT OF DEFICIENCIES PLAN OF CORRECTION (XI) PROVII)ER/SUPPLIER/CLIA IDENTItICA'fION NUMBER: (X2) MULIIPLE CONSTRUCTION A.BUILDING PRINTED: 12/27/2007 FORM APPROVED OMB NO. 0938-0931 (X3) DATE SURVEY COMPLETED _AND 337301 NAM E OF PROVIDER OR SUPPLIER B. WING .W1227/2007 STREET ADDRESS. CITY. STATE, ZIP CODE AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNIT (X4) I) PREFIX TAG SUMMARY STATEMENTOFDEFIENCIES (EACH DEFIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ALCION SHOULD BE CROSS-REFERENCED TO TIlE APPROPRIATE DEFIENCY) (X5) COMPLETI ON DATE G 158 Continued From page 25 It should be noted that this was a six (6) pound weight loss and that the nursing visits consistently documented that the visits to this patient were 10 - 15 minutes in duration. (Refer G176) Patient #17 was admitted to the agency on 10/18/07 with the diagnoses of Open Wound of the Lower Extremity and Organic Brain Syndrome. The Plan of Care dated 10/18-12/16/07 orders: Skilled Nursing Visits to perform Normal Saline Wet to Dry dressings twice a day. The clinical record lacked documentation of wound care provided on. 11/10/07 either in the AM or PM. (11/10/07 was a Saturday.) 1 The "Missed .V isit Report" dated I 18/07 documents that a visit was missed on 11/18/07 due to "staff unavailable". The report lacks documentation if the AM, PM, or both visits were missed. The findings were reviewed on 11/27/07 at 11:30 AM with the DPS of Westbury, the )PS of Brooklyn who was appointed by the parent agency to deal with Department of Health issues, and the Nursing Supervisor and no explanation or additional information was provided. Patient #9 was admitted to the agency on. 09/05/07 with the diagnoses of Mental Retardation and Hypertension. The Plans of Care dated from the start of care orders: Home Health Aide (I-IHA) services and included the order for the HHA to weigh the G 158 M CMS-2567 (02-99) Previous Versions Obsolete Event ID: IRIJI I Facility 11): 4706A If couthiuation sheet Page 26 of 89 I Atnended x' DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES - 'IEMENTOF DEFICIENCIES ,DPLAN OF CORRECTION (XI) PROVIDER/SUPPLIER/CLIA IDENTIICATION NUMBER:' 337301 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCIION A,BULDING PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X3) DATE SURVEY COMPLETED 12/27/2007 13. WING STREET ADDRESS, CITY; STA'ITE, ZIP CODE AMERICARE CERTIFIED SPECIAL SERVICES SUMMARY STATEMENT OF DEFIENCIES (EACH DEFIENCYMUST BE PRECEEI)ED BY FULL REGULAIORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 PROVIDER'S PLAN OF CORRECTION (EACH CORREC ITVE ACTION SHOULD BE CROSS-REFERENCED T'O THE APPROPRIATE DEFIENCY) (X5) COMPLETION DATE. (X4) ID PREFIX TAG 158- Continued From page26 patient monthly. The "Aide Plan of Care" dated 09/05/07 documents directions for the I-fl-IA to weigh the patient. The HHA activity sheets dated 09/13 10/27/07 lacked documented evidence that the HHA weighed the patient as per the Plan of Care. The findings was reviewed on 11/27/07 at 11:00 AM with the DPS of Westbury and the DPS of Brooklyn, the DPSof Westbury stated that the "nurses usually weighs the patient and the Plan of care needed to be reviewed with the physician". Patient #8 was admitted to the agency on 10/18/07 with diagnoses including Diabetes Mellitus, Long Term Use of Insulin, Chronic Airway Obstruction, Schizophrenia and Hypertension. The Plans of Care dated 10/18-12/26/07 orders: Home Health Aide (HHA) services five (5) days a week x one (1) hour a day for assist/sipervise personal care, Activities of Daily Living, ensure safety and hygiene and report any status changes to Registered Nurse (RN). From 10/18 - 10/31/07, the clinical record lacked documentation of the patient receiving IHIHA services. On 11/26/07 at 2:30PM, the Administrative staff were informed of the survey findings and were given an opportunity to provide an explanation. On 11/27/07, the Nursing Supervisor could not provide an explanation for the delay of HIIA services. Patient #11 was admitted to the agency with . G 158 M CMS-2567 (02-99) Previous Versions Obsolete Event ID: I RUII Facility ID: 4706A If continuation sheet Page 27 of 89 Amended x I * DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDERISUPPLIER/CIJA IDENTIICATION NUMBER: (X2) MULi'f'E CONSTRUCTION A.BUILDING PRINTED: 12/2612007 FORM APPROVED OMB NO. 0938-0931 (X3) DATE SURVEY COMPLETED 337301 NAME OF PROVIDER OR SUPPLIER 12/27/2007 B.WING, STREE1 ADDRESS, CITY, STATE, ZIP CODE AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNIT (X4) ID PREFIX 'FAG SUMMARY STATEMENT OF DEFIENCIES (EACH DEFIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) I) PREFIX TAG _ 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 PROVIDER'S I'LAN OF CORRECION (EACH CORRECTIVE ACTION SHOULD BE CROSS-RE'ERENCED TO ThE APPROPRIATE DEFIENCY) __ (XS) COMPLETION DATE G 158 Continued From page 27 diagnoses including Schizophrenia, Diabetes and Mellitus Type 11, Hypertension. The Plans of Care dated 08/15-10/13/07 and 10/14-12/12/07 orders: Skilled Nursing every other week to assess weight monthly, and assess medication regime, and supervise the aide every two (2) weeks. The clinical record lacked documentation that the SN monitored the patient's weight form 08/07 11/05/07. the SN visit notes consistently documented the patient had 3 + edema of the lower extremities, yet the SN failed to weigh the patient (luring the visits as pet the Plan of Care. During interview with the Nursing Supervisor on 11/27/07 at approximately 1:40 PM, the Nursing Supervisor acknowledged the findings. Patient #5 was admitted to the agency on 10/04/05 with the diagnoses including Diabetes Mellitus Type It and Hypertension. The Plan of Care dated 09/24-11/22/07 ordered The SN to weigh the client every month and report to MD ten (10) lbs (pounds) weight gain or loss. On 09/19/07, the SN visit note documented the patient's weight as 207 pounds. On 11/05/07, the SN visit note documented the patient's weight as 207 pounds. The record lacked documentation of the patient's G 158 FORM CMS-2567 (02-99) Previous Versions Obsolete Event ID: IRIJ I I Facility ID: 4706A If continuation sheet Page 28 of 89 Amended x I RTMENT OF HEALTH AND HUMAN SERVICES DEPAI CENTERS FOR MEDICARE AND MEDICAID SERVICES ATEMENT OF DEFICIENCIES AND PLAN OF CORRECION (XI) PROVIDER/SUPPLIERiCLIA IDENTIFICAION NUMBER: 337301 B. WING NAME 017 PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCION A.BUILDING PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X3) DATE SURVEY COMPLETED 12/27/2007 STREE ADDRESS, CITY, STATE. ZIP CODE AMERICARE CERTIFIED SI'FCLAL SERVICES SUB-UNIT _ _ _WESTBURY, 900 MERCHANTS CONCOURSE SUITE LL-15 NY 11590 ID PREFIX TAG PROVIDER'S PLAN OF CORRETIION (EACII CORRECIIVE ACI'ION SHOULD BE CROSS-REFERENCED'TO TIlE APPROPIIATE I)EFIENCY) (X5) COMPLETION DATE (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFIENCIES (EACH DEFIENCY MUST BE PRECEEDEI) BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) G 158 Continued from page 28 weight for the month of October 2007. The record lacked documentation to explain why the nurse did not weigh the patient as per the Plan of Care, During interview on 11/26/07 at 2:10 PM with the Nursing Supervisor and the DPS, the agency's staff provided no further. information or. explanation. 484.18(a) PLAN OF CARE The plan of care developed in consultation With the agency staff covers all pertinent diagnoses, 0 158 G 159 G 159 G 159 Plan of Care (Standard) Monitoring: the Supetvisory staff will make weekly visits to ACFs to evaluate the actual staff Practices, and to ensure the POT is being adhered to and changes are ,noted timely. The Supervisor is responsible to review and initial the POT/re-cet for completeness. Based on the Supervisory visit/review findings inservice edctation will he arranged & provided. Nurses will be required to come into tteoffice as needed to update clinical records. Systemic Change Initial POT's/Re-Certs Process: The Westhury office has developed a PCl'/485 workshet (See attachment # 19) to be completed by th ACF RN, the ACF RN submits the completed workaheet to the Supetvisor Assistant. Trte Supetiso: Assistant data enters the infoostatio, into the computer, prints a copy and the designated Nursitg Supervisor for that ACF nurse, reviews, clarifies and approves (initials) the POC/485. If revisions are needed the ACF ttrse is contacted and comtes into the office to make the needed correct ions. Once tlte Supervisor approves she will print acopy maid initial it. The copy is then given to mailing. the Supervisor Assistant for In the Suffern Office the ACF nurse data enters the information into the computer. The designated Nursing Supervisor for that ACF nurse, reviews, cla-ifies and approvcs the POC/485 via computer. If retisions are needed the ACF nurse is contacted and makes the needed corrections within the computer. saproves she will ptrin( a copy Once the Supeviaor iL and initial The copy is then given to the Supervisor Assistant For mailing. Event ID: I RIJ I I Facility ID: 4706A If continuation sheet Page 29 of 89 Amended x I including mental status, types of services and equipment required, frequency of visits, prognosis, rehabilitation potential, functional limitations, activities permitted, nutritional requirements, medicatiorns and treatments, any safety measures to protect against injury. instructions for timely discharge or referral, and . any other appropriate items. This STANDARD is not met as evidenced by: Based on clinical record review and staff interview, the agency continued to fail to develop a complete and comprehensive Plan of Care for all patients. This was evident for eight (8) of reviewed and one (1) of nn )records eight (8) home visits (FIV). (Patients #2,#4, #6 #7,#l0, t14, HV,#16, and #18). This is repeat deficiency from the complaint a survey of 06/04/07. The agency's continued failure to develop . complete and comprehensive Plan of Care places the patients at risk for ttot having their needs met FORM CMS-2567 (02-99) Previous Versions Obsoleto DEPARTMFENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES kTEMENT OF DEFICIENCIES (XI) I'ROVIDER/SUPPLIERCLIA IDENTIFICATION NUMBER: A.BUILDING PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X2) MULTILE CONSTRUCTION (X3) DATE SURVEY COMPLETED 4 -, D PLAN OF CORRECTION 337301 NAME OF PROVIDER OR SUPPLIER 12/27/2007. B.WING STREET ADDRESS, CI?'Y. STATE. ZIP CODE AMERICARE CERTIFIED SPECIAL SERVICES SUB - UNIT (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFIENCIES (EACH DEFIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) I1) PREFIX TAG 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFIENCY) (X5) COMPLETION DATE G 159 Continued From page 29 and possible negative patient outcomes. The findings include: Patient # 14 (HV) was admitted to the agency on 05/17/07 with diagnoses including Diabetes Mellitus and Psychosis. The Plans of Care dated from the start of care to 0 1/04/08 lacked blood sugar parameters for this patient who tests his blood sugars three (3) tirnes a day. The findings were reviewed with the agency Director of Patient Services (DPS) on 11/27/07 at 11:00AM. The DPS acknowledged that an interim order for parameters was not obtained until 11/15/07. During the home visit on 11/20/07 at 7 AM, the patient's blood sugar log documented sixteen (16) blood sugar reading over 200 for the two (2) afternoon testing from 11/05-11/19/07 with no documentation of follow up. The Plan of Care also lacked an order stating that the patient tests his blood sugars three (3) times a day. (Refer Gi73 and G176) Patient #18 was admitted to the agency on. 10/25/07 with diagnoses of Cellilitus and Depressie Disorder. The Plan of Care dated 10/25-12/23/07 ordered the Skilled Nurse (SN) to supervise the Home every two (2) weeks. The Health Aide (HHA) Plan of Care lacked specific orders for the Home Health Aide service to be provided. On 11/26/07 at 2:30 PM, the administrative staff G 159 Responsible Person: DPS for each branch office will provide oversipgh and rdsponsible to enforceregiulation. DPS will report to the Administrator/Govcrning Body on a weekly basis. Antericame CSS Adrainistratot/Govcing Body will ensure that the required education and in-services take place and the Agency's have the continued support to resolve all identified deficiencies and prevent any reoceuTeoces of deficient practices. The Adtinistrator will report her findings to the VP of OpcrtionisGoveming Bored .M CMS-2567 (02-99) Previous Versions Obsolete Event ID:I RJ II Facility ID: 4706A If continuation sheet Page 30 of 89 Amiended x I DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES ATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDERISIPPLIERICLIA IDENTIFICATION NUMBER: (X2) MUIPTI'LE CONSTRUCTION A&BUILDING ________ PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X3) DATE SURVEY COMPLEP1ED 337301 NAME 01 PROVIDER OR SUPPLIER 12/27/2007 B. WING STRE-LT ADDRESS, CITY, STATE, ZIP CODE AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNIT (X4) II) PREFIX TAG SUMMARY STATEMENT OF DEFIENCIES (EACH DEIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATfION) ID PREFIX TAG 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 PROVIDER'S PLAN OF CORREcrION (EACII CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED O TIfE APPROPRIATE DEFIENCY) (X5) COMPLETION I)ATIE G 159 Continued From page 30 were informed of the survey findings. On 11/27/07 the agency provided a Physician Supplemental Order dated 11/24/07 for certification period 10/25-12/23/07, which documented "Please note omission of HIA (Home Health Aide) services on 10/25/07 485. Pt (patient) with HHA services as of SOC 10/25-7D x 2H x 9 weeks to assist with pcrsofial, ADL (Activities of Daily Living) care". The order also included medications which were left out from the 485 dated 10/25-12/23/07 which were Multivitamins with Minerals, Aspirin, Lidocaine, Folic Acid, Thymine HCA, Keflex and Regranex Ointment. Patient #6 was admitted to the agency on 03/31/05 with diagnoses of Schizophrenia, Diabetes Mellitus, and Chronic Airway Obstruction. T1'he Plan of Care dated I 1/16/07-01/14/08 ordered "SN every other week to..... finger stick every other week". The Plan of Care lacked any parameters of the blood sugars to ensure physician notification. The Plans of Care contain conflicting information regarding the patient's diet. The Nutritional Requirements are documented as NCS (No Concentrated Sweets) yet the SN tasks document A "ADA 1800 calorie diet." The findings were reviewed with the DPS of Westbury, the DPS of Brooklyn who was appointed by the parent agency to deal with Department of Health issues, and the supervisors on 11/27/07 at 11:15 AM. No explanation was G 159 -i-Z0 FORM CMS-2567 (02-99) Previous Verions Obsolete Event ID: IRII I ID: Facility 4706A If continuation sheet Page 31 of 89 x A mriended I DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES .ATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVJI)ERISUPPLIERiC.IA IDEN'IFICATION NUMBER: (X2) MULTfLE CONS'TRUCTION PRINTED: 12/27/2007 FORM APPROVED OMB NO. 0938-0931 (X3) DATE SURVEY COMPLETED ABUILDING 337301 B. WING " 12/27/2007 STREET ADDRESS. CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNIT (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFIENCIES (EACH DEFIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIF YING INFORMATION) I) PREFIX TAG 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 PROVIDER'S I'LAN OF CORRECTION (EACl CORRECFIVE ACTION StOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFIENCY) (XJ) COMPLETION DATE G'159 Continued From page 31 Provided for the incomplete Plan of Care. Patient #10 was admitted to the agency on 9/19/07 with diagnoses of Cellitus of the Legs, Congestive Heart Failure. Dementia, Diabetes and Mellitus Type II, Depressive Disorder. The Plans of Care (POC) dated 09/19-11/17/07 and 11/18/07 -01/15/08 lacked blood pressure parameters although the patient is on the antihypertensive medications of Toprol, Vasotec, and a diuretic of Lasix. During interview with the Nursing Supervisor on 11/27/07 at 1:15PM, the Supervisor could not provide any information or explanation. Patient #16 was admitted to the agency on 06/09/07 with the diagnoses including Glaucoma and Schizoaffective. The Plans of Care dated 08/08-10/06/07 and 10/07-12/05/07 ordered the medication "Haldol Decanoate 100mg/ml ampule 200mg Intramuscular; every 4 (four) weeks". The Plans of Care failed to specify the responsible staff person to administer the injectable medication, On 11/26/07 at 2:00PM the Nursing Supervisor, the DPS of Brooklyn and the 1)PS of Westbury were informed of the findings. The agency's staff were not able to provide information on who was the responsible staff member to administer the injectable medication. On 11/27/07 at 1:3013M, the agency's staff presented to the surveyor a "Progress Note" that G 159 FORM CMS-2567 (02-99) Previous Versions Obsolete Event tO: IRI'I I [D: Facility 4706A If contihuation sheet Page 32 of 89 Amnded x I DEPARTMENT OF HEALTH AND HUMAN SERVICES -NTERS FOR MEDICARE AND MEDICAID SERVICES STATEMENTOFDEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A.BUILDING PRINTEI): 12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X3) DATE SURVEY COMPLETED 337301 NAME OF PROVIDER OR SUPPLIER WING B. S'IEt1" ADDREISS, CITY, STATE, ZIP CODE .12/27/2007 AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNIT (X4) ID SUMMARY STATEMENT OF DEFIENCIES ID 900 MERCHANTS CONCOURSE SUITE LL-iS W ESTBURY, NY 11590 PROVIDER'S PLAN OF CORRECTION (X5) COMPLETION DATE PREFIX TAG (EACIH DEFIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PREFIX TAG (EACIH CORRECIVE ACTION SHOULD BE CROSS-REITRENCED TO 11lE APPROPRIATE DEFIENCY) G 159 Continued From page 32 was signed and dated "11/27/07" by the nurse. The note was faxed to the agency from the Audit . Care Facility (ACF) on 11/27/07 at 8:56 AM. The progress note documented, "For the certification period of 08/08/07 - 10/06/07, client received Haldol Decanoate injections from the Dutchess County Mental Health Program Dr. (Doctor) and R.N. (Registered Nurse). They report she has been compliant and tolerates. the medication welW. Patient #4 was admitted to the agency on 10/06/06 with the diagnosis including Diabetes Mellitus Type Ii. The Plans of Care dated 08/02-09/30/07 and 10/01-11/29/07 ordered Insulin sliding scale coverage as 'Novolin-R/Humulin 10nil vial coverage subcutaneous; daily 180-200 =2units, 201-250=4units, 251-300 = 6units" The " Diabetic Flow Chart" that is retained in the ACF documented from "08/10/07 to 11/19/07" the Insulin sliding scale coverage as "Novolin Reg coverage: 180-200=2units, 201-250=4units, 251-300=6units, 301-350=8units, 351-400= 10units" The additional Insulin coverage for the Blood Sugar test results of 301 to 400 were not included in the Plans of Care. The "Diabetic Flow Chart" forms were faxed to the agency from the ACFon 11/20/07 at 7:47 AM. interview on 11/26/07 at 1:30 PM with During art the Nursing Supervisor and the DPS, the G 159 FORM CMS-2567 (02-99) Pievious Versions Obsolete agency's staff could not provide any further _ -70 -__Facility ID: 4706A If continuation sheet Page 33 of 89 Amended x I Event I1): IRIJ11 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES STATM ENT OF DEFICIENCIES -AND PLAN OF CORRECrION PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X2) MULTIPLE CONSTRUCT-ION A.BUILI)ING (Xl) PROVIDERISUPPLIERCLIA IDENTIFICATION NUMBER: (X3) DAIE SURVEY COMPLE1*ED 337301 NAME OF PROVIDER OR SUPPLIER 12127/2007 B.WING STREET ADDRESS. CITY, STATE, ZIP CODE AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNIT (X4) ID PREFIX SUMMARY STATEMENT OF DEPIENCIES (EACH DEFIENCY MUST BE PRECEEDED BY FULL ID PREFIX 900 MERCIHANTS CONCOURSE SUITE LL-15 WESTBURV, NY 11590 PROVIDER'S PLAN OF CORRECTION (EACH CORRECIIVE ACI1ON SHOULD BE (X5) COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DEFIENCY) DATE G 159 Continued From page 33 Information or explanation. On 11/27/07 at I I5AM, the agency's staff presented to the surveyor "Physician Supplemental Orders" signed and dated by the nurse on 12/28/0? (the date is not clear), effective "12/29/05. 'The order from was faxed to the agency from the ACF on 11/26/07 at 5:57PM. The second order form signed by the nurse and not dated for the "certification period 10/01/07 to 11/29/07" was faxed to the agency from the ACF on 11/24/07 at 8:11 PM. Both order forms documented the Insulin sliding scale for the Blood Sugar test results from i80 to 400. The agency staff could not provide an explanation for the agency's failure to ensure that the Plans of Care are complete and comprehensive for [he Diabetic management of this patient. Patient #2 was admitted to the agency on 111//05 with the diagnosis including Diabetes Mellitus Type II. The Plan of Care dated 10/22- 12/20/07 ordered "Flarex 0. 1% drops susp (suspension) ophthalmic; 2 (two) times daily apply to both eyes BED PRN (twice a day and as needed) for dry eyes". The Plan of Care documents that this is a "new medication for the patient". The Plan of Care failed to specify the amount of drops to be administered to each eye and the responsible person to administer the eye drops. G 159 FORM CMS-256'1 (02-99) Previous Versions Obsolete I Event IU:RIJ I" Facility ID: 4706A If continuation shect Page 34 of 89 Amended x I DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES STATEMENT OF DEFICIENCIES .. ND PLAN OF CORRECTION A (XI) PROVIDERJSUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULIIPLE CONS'IRUC flON PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X3) DATE SURVEY COMPLETED A.BUILDING B, WING STREET ADDRESS, CITY, STATE, ZIP CODE 337301 NAME OF PROVIDER OR SUPPLIER 12/2712007 AMERICARE CERTI'IED SPECIAL SERVICES SUB-UN'IT (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFIENCIES (lEAClH DEFIENCY MUST BE PRECEEDED BY FULL, REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAO 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 PROVIDER'S PLAN OF CORRECTION (EACH CORRECIIVE ACYIION SHOULD BE CROSS-REFERENCED TO TI fE APPROPRIATE DEFIENCY) (X5) COMPLETION DAIE G 159 Continued From page 34 During interview on 11/26/07 at 1:30 PM with the Nursing Supervisor and the DPS, the agency's staff acknowledged the survey findings. On 11/27/07 at 11:15AM the agency staff presented "Supplemental Physician Orders" signed and dated by the nurse on "11/26/07". The order form was faxed to the agency from the ACF on 11/27/07 at 10:19 AM. The order form documents "effective dates of service: 10/22/07, certification period: 10/22/07 to 12/20/07" and under the section titled as "other: Clarification on Flarex .1% ophthalmic GTI' (drops), Pt (patient) is self-administering Flarex 1% I (one) gtt to both eyes BID (twice a day) for dry eyes". The agency's staff could not provide an explanation for the agency's failure'to ensure that the Plan of Care is complete and comprehensive regarding the patient's eye drops administration. Patient #7 was admitted to the agency on 05/19/07 with a diagnoses of Diabetes Mellitis Type II, Schizoaffective Disorder, and Hypertension. The Plans of Care dated 09/16-11/14/07 and 11/15/07-01/13/08 documents orders for: Skilled Nursing for fingerstick blood sugar testing and to administer Insulin. The Plan of Care lacked on order for blood sugar parameters for dates of service 09/16/0701/13/08. During an interview with the Director of Patient G 159 -7) Event ID: IRIJI I Facility I): 4706A if continuation sheet Page 35 of 89 Amended x I FORM CMS-2567 (02-99) Previous Versions Obsolete DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES. ANEMENT OF DEFICIENCIES PLAN OF CORRECIION q.,'D (Xl) PROVIDER/SUPPLIERICLIA IDENTI'ICATION NUMBER: PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X2) MULTIPLE CONSTRUCTION ABUILDING (X3) DATE SURVEY COMPLETED I 127/Z007 337301 NAME OF PROVIDER OR SUPPLIER B. WING S'IREET ADDRESS, CrY, STATE. ZIP CODE AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNIr (X4) ID PREFIX TAG' SUMMARY STATMFNTOF DEFIENCIES (EACH DEFIENCY MUST BE PRECEI)EID BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 ID PREFIX TAG PROVIDER'S PLAN OF CORRECtION (EACH CORRECTIVE ACTION SIOUI) BE . CROSS-REFERENCFD TO TIlE APPROPRIATE DEFIENCY) (X5) COMPLETION DATE G 159 Continued From page 35 Services (DPS) on 11/27/07 at 9:30 AM, the DI'S provided the surveyor with a "Physician G 159 Supplemental Orders" dated 11/27/07 which indicates an omission of fingerstick parameters on the 485 and.blood sugar parameters of <60> 400 (less than 60 greater than 400), to notify G 165 physician. 484.18 (c) CONFOIMANCE WITH PHYSICIAN ORDERS Drugs and treatments are administered by agency staff only as ordered by the physician. G 165 C,165 Conformance with Physicians Orders (Standard) Staff Education: All Nursing staff will be itt-serviced regarding the Phn of Contection Stutement of Deficiencies & Action Plan. Wmetbury Jan. 10, 2003 & Suffern Jan. 16, This STANDARD is not met as evidenced by: Based on clinical record review, home visits, review of the agency's Policies/Procedures and to interview, the agency failed e ensure that stafftinrviews idea nre w a gd treatoens s medications and treatents were proviecd as 2001. Monitoring: Ameticare CSS Suoervisia Staff will be visiting all the Adult Can; faciliie5 on a weekly basis. The purpose of these visits is to ensure that services, medication and treatmcms are being ordered in eleven (11 ) of eighteen (1 8) records visits (HV). reviewed and six (6 ) of eight (8) home #6, # 10, # 13, (Patients #IHV, #3HV, #4IV, #51V, #14HV, #16, #17RV, and #19) rendered in accordance to the patient's POT. The Supervisory staff will provide onstn over site of nursing#and homne icalth aide stiff, clauify patient issues. pmblersolve and case conference patinlS as The agency's failure to provide medication and treatments as ordered by the physician resulted it missed visits/Insulin doses and poor Diabetic required. System to measure effectiveness: management fbr Patients #1 HV and #14 I-IV and places all patients at risk for poor quality care and the potential for poor patient outcomes. Findings include: I. On a monthly basis Americatre CSS will obtain a copy of the POTl485 & Adult Ca'e Facility medication admonkisnation r-cord (MAR) for all active patients (inclusive of patients q1,43t14, #5,#6, #10, #13, #14, #16. Refer G 156, G 158, G159, G 168,G 173, and G 176. # 17 & 419). 2. The nurses will cbcck the MAR against the ACF dmitistrtion record on weekly basis for changes to medicatinn i'gime via consultation with ACF snif. * FORM CMS-2567 (02-99) Previous Versions Obsolete Event ID: I RUI I Facility ID: 4706A -7 If continuation sheet Page 36 of ;9 Amended x I DEPARTMENT OF HE ALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES J- TATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (XI) PROVIDESUPPIER/CLIA IDENTIFICATION NUM BER: PRINTED: 12/26/2007 FORM APPROVED OM13 NO. 0938-0931 (X2) MULTIPLE CONSTRUCTION A.BUILDING (X3) DATE SURVEY COMPLETED 12/27/2007 337301 NAME OF PROVIDER OR SUPPIER ,B. WING STREIT ADDRESS, CITY, STATE. ZIP CODE AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNIT (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFIENCIES (EACH DEFIENCY MUST BE PRECEEDED BY FULL REGUI'TORY OR LSC IDENTIFYING INFORMATION) 900 MERCIIANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 ID. PREFIX TAG PROVIDER'S PLAN OF CORRECION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED T) "HE APPROPRIATE DEFIENCY) 3. On a monthly basis the Americare Supervisors/Q will check the ACF MAR against the MD orders (485). and the Medication PRofile in the clinical record. This will be evidenecd by documentation fror vARJ485/Medication Profile audit tool. (See'attachment # 13). Changes will be verified with the MD as evidenced by an interim order. Americare Supervisory staff will provide weekly oversight of the Americare nurses to ensure that rMedication. and treatmnents are rendered in accordance to the POT ad chaugso, are timely noted evidutc. by interim nrders. The Supervisor/QL'DPS will be conduct clinical record audits on a quarterly basis to ensure that deficient practices do ri contintic. Results of these audits will be reporied to the Professional Advisory Committce/Board Adirinistrator/Governing Body on a quarterly basis. (X5) COMPLETION DATE G 165 G 165 4. 5. * Responsible Per.son: DIS for each branch office will provide oversight md rospviiblo to enforce regulaion. DPS will report to the Adninistratr/Goverming Body ott a weekly basis. Ansericase CSS Admninistrator/Governing Body will enure quat the required G168 484.30 SKILLED NURSING SERVICES G 168 / / oA' " Governing Authorily involvement/oversighlt to ensure the agency's compliance: DPS for each branch office will provide oversight and n.sronsible to enforce regulation. I. DPS will repot tracking & trending results to the Administrator/Goverlfing Body on a weekly bxsis. Americare CSS Administratoi/Governing Body will ensure that the required education aud in-setvices take place and the Agency's hase the continued support to resolve all identified deficiencies and prevent any reoccureTneCes of deficient practices. 2. FORM CMS-2567 (02-99) Previous Versions Obsolete I Event 11D:RIJI I Facility ID: 4706A If continuation sheet Page 37 of 89 Amended x I DEPARTMENT OF HEALTH AND HUMAN SERVICES CEN'ITERS FOR MEl ICARE AND MEDICAID SERVICES I)EICIENCIES \,TEMENTOFF .AD PLAN OF CORRECTION (XI) PROVIDEIRSUPPLIERJCLIA II)ENTIFICATION NUMBER: 337301 B. WING PRINTED: 12/262007 FORM APPROVED OMB NO. 0938-0391 (X2) MULTtPLECONSTRUCTION A.3UILDING (X3) DATE SURVEY COMPLETED 12/27/2007 AMERICARE CERTIFIED SPECIAL SERVICES SUB-lJNIT . ID PREFIX TAG STREET ADDRESS. CrI'Y. STATE. ZIP CODE 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 (X5) COMPLETION DATE (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFIENCIES (EACH DEFIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (EACH CORRECI E ACTION SHOULD BE CROSS-REFERENCED TO TIlE APPROPRIATE DEFIENCY) 3. lhe Administrator has ultimate responsibility G 168 Skilled Nursing Services Continued From page 36 This CONDITION is not met as evidenced by: Based on record review, review of agency Policics/Procedurcs, home visits (HV), and staff interviews, the agency's Skilled Nurse (SN) failed G 168 to ensure that Wesbury & Suffcrn: " Develop a complete and comprhensive Plan of Care . to: to: Provide care in accordlance with the Plan of Care Revise the patient's Plan of Care aa; needed Ensure that the patient has access to information on the Patient Rights Protect patient confidentiality Provide patient services in accordance with patient Plans of Care * Ensure effectivc coordiation of patient services to the patient and Provide instruction Adult Cale Facility staff Adhere to ihe agency, Ensure development and revision of patient Plans of Care as necessary Policie,/Predure ims plement the corrective actions for the the Statement of Deficiencies lfr Ensure effective coordination of patient services Provide instruction education to patient/Adult Complaint Survey of 06/04/07. 4. oh wilt be achieved by peforning ongoing Perfonnance Improvemcnt/Qualiiy Assurance clinical record audits on a quarterly basis. Results of these audits will be reported to the Q Dii'eitor/QI Crnmlttee/Professiona Care Facility (ACF) staff Submit SN visit notes Provide effective case management and Diabetic iducator consultation Adequately assess patient conditions and notify the physician of changes in the patient needs and conditiont. Adhere to agency Policies and Procedures Advisory Board 5. Atnericare CSS Administratoi will ensure that the required ettucation and in.scrvices take continued place and the Agency's have ili support to resolve all identified deficiencies and prevent any reoccun-ences of deficient practices. The Administrator will repArt her - findings to te VP of Operations/Goveriog Board. .Westbury Jan 10, 2008 & ongoing * This was evident for eighteen (18).of nineteen" (19) clinical i-ecords reviewed and five (5) of eight (8) home visits, The findings include: needed VP of Operations is ultimately responsible to ensure the ACF's are appropriately staffed and operating in accordance to the all Federal and State regulations governinghioncca're.///~/ as needed Suffern Jan 16, 2008 & ongoing as .M CMS-2567 (02-99) 1revious Versions Obsolete Event ID: IRIJ I1 Facil6 ID: 4706A If continuation sheet Page 38 of 89 Amended x I DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES STrEmENT0; DEFICIENCIES Al) P'LAN OF CORRECTION (XI) PROVIDERISUPPIIERICI.IA IDENTIFICATION NUMBER: (X2) MULTIPLECONSTRUCTION A.BUILDING PRINTED 12/26/2007, FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED . 337301, NAME OF PROVIDER OR SUPPLIER 12127/2007 B. WING S ITREE'I ADD)RESS, crry, STATE, ZIP CODE -UIWSTU SRE CI ERVICES AMEgRICARE CERTIFIED SPECIALSEVCSSSUB-UNIT o Continued From page 37 Refer G101,G121, G145, GI58, G159, G173, G176, G229, and G236 for examples. The cumulative effect of the failure of the nursing staff to prdvide appropriate nursing care to the special needs population of patients with secondary diagnoses involving mental health, the mentally retarded, and/or the developmentally disabled that preclude their independence in the activities of daily living serviced by the agency resulted in missed visits/Insulin administration and poor oversight of patients requiring;Diabetic management (Patients #1 f-V and #14 I-IV), poor management of medications for these patients unable to manage their medication regime, and places all agency patients at risk for unsafe and poor quality nursing care with potential for poor patient outcomes. 173 484.30 (a) DUTIES OF THE REGIS'TiERED NURSE The registered nurse initiates the plan of care and ,NY CONCOURSE SUITE LL-15 900 MERCHANTS 150_ WESTBURY, NY 11590 __ To ensure that all Patien (not linited topatients on the identified statedet of defiientcy) anr the receiving appropriate cue and servicesNursing Supervisor's will make weekly visits to the manors to ensure the ACF nurses: Developing a complete and comprehensive Plan of Care a Provide care in accordance with the Plan necessary revisions. This STANDARD is not met as evidenced by: Based on clinical record review, home visit (HV), and staff interviews, the agency nursing staff failed to ensure that the initial patient Plans of Care were initiated and revised as needed. This of Care needed Plan Revise the patient's of Care as Ensure eflective coordination of patient services was evident for fourteen (14) of nineteen (19) records reviewed and six (6) of eight (8) hone visits. (Patients #1 HV.#2, #3 HV, #4 HV, #5 #7, HV,#6, #9,#10, #11, #13, #14 HV,#16, and #17 I-IV) . and Provide insuction to liepatient Adult Care Facility staff . The agency's failure to ensure that the nursing the Adhere to agency staff initiated the patient Plans of Care and revised the Plans of Care as needed to meet the Policies/Procedures The Supervisor s Will submit Weekly reports to alert the DPS of their findings. Anericare DPS is responsible to develop and-review the nursing ensure services are schedule (a month in advance) to being rendered in accoldance to the Patient's Plan of Care. The DPS develops an in-service calendar and ensui es approptiate education is given to the field nuises based on the Supervisor findings. The DPS is responsible for oversieht and will report the findin&s to the Atlntinistrator/Govemipe the Authority on a Weekly basis and to Professional Advisory Cosnsmitce/Board quartcly Event ID: I RIJ I Facility ID: 4706A If continuation sheet Page 38 of 89 Amended x I FORM CMS-2567 (02-99) Previous Versions Obsolete . DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES \TEMENT OF DEFICIENCIES .4D PLAN OF CORRECTION (XI) PROV1DER/SUPPLIER/CLIA IDENTIFICAI1ON NUMBER: 337301 WING BNAME OF PROVIDER OR SUPPLIER STREFI ADDRESS, CFIY, STATE, ZIP CODE (X2) MULTIPLE CONS'I'RIJCION A.BUILDING PRINTED: 12/27/2007 FORM APPROVED OMB NO. 0938-0931 (X3) DATE SURVEY COMPLETED 12/27/2007 AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNIT (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFIENCIES (FACII DEFIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) . Continued From page 38 patient needs places all agency patients at risk for 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 ID PREFIX TAG PROVIDER'S PLAN OF CORRECION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFIEIENCED TO TiiE APPROPRIATE DEFIENCY) (XS) COMPLETION DATE 6 173 G173 Toprvent deficientpracticesfi'omreccCturring ongoing Performance Improvement/Quality substandard car-e and poor patient outcomes. " The findings include: Patient #1 (HV) was admitted to the agency on 07/30/04 with diagnoses of Diabetes Mellitus and Schizophrenia. The Plan of Care dated 05/16-07/14, 07/1509/12, 09/13 - I1/11 and 1/12 - 01/10/08 documented orders for Skilled Nurse (SN) visits daily to ..... Diabetic Regime, S/S (signs and symptoms) of Hlypo/hypergolycemia causes and intervention, Foot care/Skin Care. Adm Lantus as ordered Q (every) am. Regular Insulin Coverage in AM & PM.... If B/S (blood sugar) > 250." During the home visit on 11/20/07 at 7:05 AM, the blood sugar log was reviewed. The log documented that the patient tests his blood sugars "twice a day". During a interview with the patient during home visit, the patient stated that there has been "several days" that the Adult Care Facility staff drew up the Insulin" for the patient and he self administered the Insulin. During the visit, the patient was observed preparing the Lantus Insulin injection with much instructions from the Skilled Nurse. The blood sugar log and patient record documented the following: On 07/18/07 the staff from ACF drew up the Insulin and the patient self administered. Assurance clinical recbrd audits will be done by he Sulpervisor/QI Nurse/DPS on a quarterly basis. Results of thecse audits will bc reporited to [he QI Director/ QI Committeet Professional Advisor)' Bloard/Commiltee. - April 14,2008 / ,MCMS-2567 (02-99) Previous Versions Obsolete Event ID: i[JI I 1Facility I): 4706A Ifcontinuati6h sheet Page 39 of 89 Amended x I DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES. STATEMENT OF DEFICIENCIES ,"ND PLAN OF CORRECTION (XI) PROVIDER/SUPPLIER/CLIA IDENI-rFiCATION NUMBER: (X2) MULTIPLE CONSTRUC'I'ION A.BUILDING PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X3) DATE SURVEY COMPLEI'ED 337301 NAME OF PROVIDER OR SUPPLIER 12/27/2007 .B. WING STR EET ADDRESS, CYI'Y, STATE, ZIP CODE AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNIT (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFIENCIES (EACH DEFIENCY MUS' BE I'RECEEDED BY FULL REGULATORY ORLSC IDENTIFYING INFORMATION) 900 MERCHANTS. CONCOURSE SUITE LL-15 WESTBURY, NY 11590 I) PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE AC'IION SHOUII) BE CROSS-REFERENCED TO THE APPROPRIATE DHIFIENCY) (XS) COMPLETION DATE Continued From page 39 On 07/29/07 the record documented "missed visit: (no staff). It is unclear whether the patient received the Lantus Insulin or if coverage was needed. The record lacked documentation of a Blood Glucose reading. On 08/02/07 the Blood Sugar was docurnented as "172" at 4:10 PM and "patient self administered with staff assistance". On 08/05107 the Blood Sugar was documented as "269" and "patient self administered with staff" from ACF. The physician order documented that the patient, is to receive Regular Insulin coverage if the blood.sugar is above 250. The record did not include documentation that the patient received the Regular Insulin as per the orders. The agency SN/Nursing Supervisor failed to inform the physician of missed visits until two (2) and a half months later when the agency was called by the Department of Health regarding a patient care issue. The agency failed to ensure that there is a system in place to meet the diabetic care needs of this Insulin Dependent patient. During interview on 11/19/07 at 8:50 AM with the Nursing Supervisor on call on 08/05/07; the Supervisor stated that there was "no nurse available to visit the patient" and "there is a shortage of nurses". The Supeivisor further stated that she called the Adult Care Facility ( ACF) and "talked "and employee of the ACF "through drawing up the Insulin and the patient administered the Insulin". The Supervisor stated the ACF employee has "never been taught or observed drawing up Insulin" and this (ACF staff administering Insulin) has 'occurred two (2) other times" but was "not the agency's practice". G 173 "M CMS-2567 (02-99) Previous Versions Obsolete Event ID: I RUI I Facility ID: 4706A Page if continuation sheet 40 of 89 Amended x I DEPARTMENT OF HEALTH AND HUMAN SERVICES CEN'ITRS FOR MEDICARE AND MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 337301 B. WING_ PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X2) MULTIPLE CONSTRUCTION A.BIJILI)ING ___________ (X3) DATE SURVEY COMPLETED 12/27/2007 STREET ADDRESS, CfTy. STATE, ZIP CODE NAME 01 PROVIDER OR SUPPLIER AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNIT ID PREFIX TAG 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 (X4) i) PREFIX TAG SUMMARY STATEMENT OF I)EFIENCIES (EACtI DEFIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER' S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DFITENCY) (X5) COMPLETION DATE G 173 Continued From page 40 On 11/26/07 at 3:20 PM, a telephone interview was conducted with the evening supervisor of the ACF staff/Medication technician. The ACF staff stated that on 08/05/07, '"the nurse from America-e called while the patient was testing his blood sugar and said the "she could not be there because there was some sort of emergency". .The ACF staff further stated that she "has not been observed/taught by the Americare nurse on drawing up Insulin" and " her parents were both Diabetic and Insulin dependent so she knows how to draw up the Insulin". The ACF Staff stated that she "held the Insulin bottle for the patient and he drew up the Insulin and self administered in his abdomen". During an interview with the Director of Patient Services (DPS) of Westbury on 11/27/07 at 9:45 AM, the DPS stated that she and the Nursing Supervisor were aware that there was a potential for a staffing problem on the weekend of 08/04 and 08/05/07. The DPS stated she was "on vacation that weekend" and the Nursing Supervisor worked the weekend. The DPS further stated that the agency's policy is that "if a nurse is unavailable to make a visit, the supervisor would make the visit. "The MIS stated that " the Supervisor could only do early .morning visits on Sunday and this patient needed his Lantus Insulin in evening." During an interview with the Nursing Supervisor on 11/27/07 at 2:30 PM, the Nursing Supervisor stated that "the Nursing Supervisors have make visits sometimes during the week and on weekends due to staffing issue and not enough nurses to cover the cases. " G 173 FORM CMS-2567 (02-99) Previous Versions Obsolete Event ID: I RU I I Facility ID: 4700A If conthmation sheet Page 41 of 89 Amended x I DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAIl) SERVICES STATEMENT OF DEFICIENCIES 4,ND ILAN OF CORRECTION : (XI) PROVIDERISUPpLIERiCLIA IDENTIFICATION NUMBER: 'IA.BUILDING, (X2) MULTIPLE CONSTRUCTION PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X3) DATE SURVEY COMPLETED 337301 NAME OF PROVIDER OR SUPPLIER B. WING 12/27/2007 STREEI ADDRESS, crrY, STATE, ZIP CODE AMERICARE CERTWIEI) SPECIAL SERVICES SUB-UNIT (X4) ID PREI'IX TAG SUMMARY SIATEMENT OF DEFIENCIt.S (EACH DEFIENCY MUST B E PRECEEDED BY FULL REGUI.ATORY OR [SC [DENTIFYING INFORMATION) ID PREFIX TAG 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 PROVIDER'S PLAN OF CORRECTION (FEACII CORRECTIVE ACTION SHOULD B CROSS-REFERENCED TO TI-E APPROPRIATE DEFIENCY) (X5) COMPLETION DATE G;173 Continued Frompage 41 There is no documented evidence that the nurse Plan Revised tile of'Care until 10/12/07 when the agency received a call from the. Department of Health. G 173 REFER G158 and G176 Patient #14 (TIV)was admitted to the agency on 05/10/07 with diagnoses including Diabetes Mellitus, Psychosis, and Hypertension. The Plan of Care dated from the start of care on 01/04/07 ordered SN visits daily to administer Lantus Insulin 100 units daily, "diabetic care diabetic regime, S/S (,signs and symptoms) of hyper/hypoglycemia",'and included a sliding scale insulin coverage of Hurnulin R Insulin for blood sugars above 200". During home visit on 11/20/07 the blood sugar log was reviewed.. The patient stated that he tests his blood sugars "three times a day". The blood sugar log documents seven (7) blood sugar reading above 200 when the patient tested his blood sugars before lunch and ten (10) blood sugars before dinner from 11/05 - 11/19/07. The patient stated he "did not get any insulin at these times." During and interview with the nurse at 7:50 AM, the nurse stated that she was "going to take the information from the log to the Diabetic Consultant and review them". There is no documented evidence that the nurse informed the physician of the elevated blood sugars and reyise the Plan of Care to address the 'M CMS-2567 (02-99) Previous Versions Obsolete Event ID: IRIJI I 4706A Facility 11): If conlinuation sheet Page 42 of 89 Amenided x I t DEPARTMENT OF HEALTHI AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES "'IATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (XI) PROVIDER/SUPPIJERICLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A.BUILDING PRINTED: 12127/2007 FORM APPROVED OMB NO. 0938-0931 (X3) DATE SURVEY COMPLETED 337301 B. WING__________ 12/27/2007 SIREET ADDRESS. CrTY. STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER AMERICARE CERTIFIED SPECIAL SERVICES (X4) I1) P REFIX 'FAG SUMMARY STA'EMENT OF DEFIENCIES (EACH DEFIIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PRtFIX rAG 900 MERCHANTS CONCOURSE SUITE LL-15 WESTj'BURY, NY 11590 PROVIDER'S PLAN Or CORRECTION (EACH CORRECTIVE ACIlON SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFIENCY) (X5) COMPLETION DATE G 173 Continued From page 42patients needs. (Refer G176) During an interview with the Director of Diabetes Education on 11/21/07 at 8:45 AM* the Educator stated that site "did not recall consulting with the nurse about this patient". The "Focused Diabetic.Chart Audit Tool" dated 11/14/07 completed by the Diabetes Educator documents: ...... Many BS (Blood Sugar) out of range for good control - needs to be reported to the MD". During the home visit, the patient's medications were reviewed and compared to the Plan of Care and agency Medication Sheet. The following discrepancies were noted: Lantus Insulin 100 units daily was not on the Medication Sheet dated 11/05/07 The Plan of Care ordered "Depakote 500 mg, one (1) tablet, at bedtime". The patient's medication bottle and the agency medication Sheet documented that the patient. is to receive "two (2) tablets of Depakote daily". The Plan of Care and the patient's medication bottle documented that the patient is to receive "Glyburide 5mg 2 tablets daily". The agency Medication Sheet documents that the patient is to receive "5mg daily". During an interview with the nurse on the home visit, the nurse stated the ACF staff' administers tile medications" and she was "not sure how often. she was required to review the medications." The nurse failed to initiate the Plan of Care and to G 173 FORM CMS-2567 (02-99) Previous Versions Obsolete ' Event ID: I RIJI I Facility ID: 4706A If coaLuation sheet Page 43 of 89 Amiended x I DEPARTMENT OF HEALTH AND HUMAN SERVICFS CENTEIRS FOR MEDICARE AND MEDICAID SERVICES STATEMENT OF DEFICIENCIES I-"ND PI.AN OF CORRECTION (XI) PROVIDERISUPPI.IERICLIA IDENTJ'IFICATION NUMBER: (X2) MULIPLE CONSTRUCTION A.BUILDING PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X3) DATE SURVEY COMPL.ETIED 337301 NAME OF PROVIDER OR SUPPLIER ), AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNIT (X4) 1I) PREFIX TAG SUMMARY STATEMENT OF DEFIENCIES (EACH DEFIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 12/27/2007 B. WING STREET ADDRESS, CrrY,STATE, ZIP CODE 900 MERCHIANTS CONCOURSE SUITE LL-15 WESTBCRY,NY 11590 PROVIDER'S PLAN OF CORRECIION (EACI ICORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFIENCY) (X5) COMPLEIION DATE - ID PREFIX TAG G 173 Continued From page 43 revise the Plan of Care to reflect the patient's needs. Patient #17 (HV) was admitted to the agency on 10/18/07 with diagnoses including Open Wound of the Lower Leg and Organic Brain Syndrome. During home visit on 11/20/07, the medications on the patients Plan of care, Medication Sheet and the MAR (Medication Administration Record) in the ACF were reviewed. The following medication discrepancies were observed and noted: The Plan of Care and agency medication sheet documents that the patient is to receive "Risperdal 0.5mg twice a day". The Medication Adiinistration Record (MAR) documents that the patient received "Risperdal 0.5 mg at 7;00 AM and 1:00PM and Risperdal 0.5mg 2 tablets at 5:00 PM and at bedtime". The Plan of Care lacked a documented order for Metamucil I packet twice a day. The Plan of Care and the agency medication sheet lacked tat the patient received "Tylenol Extra Strength 500 mg 2 tablets by mouth twice daily." During the home visit the Nursing Supervisor was informed of the medication discrepancies and stated that "the nutrses are required to review the MAR weekly at the ACF." The nurse failed to initiate the Plan of Care and revise the Plan of Care to reflect the changes in the medications. G 173 FORM CMS-2567 (02-99) Previous Versions Obsolete Event ID: I RIJI I Facility ID: 4706A If continuation sheet Page 44 of 89 Amended x I DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES AEMENT OF DEFICIENCIES 4D PIAN OF CORRECTION (Xl) PROVIDER/SUPPLIERJCIA IDENTIFICATION NUMBER: (X2) MULIPLE CONS'IRUCTION PRINTED: 12/26/2007 FORM APPROVEI) OMB NO. 0938-0931 (X3) DAIE SURVEY COMPLETED ABUIILDING 12/27/2007 B.WING STREET ADDRESS, CITY, STATE, ZIP CODE 337301 NAME OF PROVIDER OR SUPPLIER AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNIT (X4) I) PREFIX TAG SUMMARY STATEMENT OF DEFIENCIES (EACH DEFIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG 900 MERCHANTS CONCOURSE SUITE LL-15 -WESTBURY, NY 11590 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SIIOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFIENCY) (X5) COMPLETION DATE G 173 Continued From page 44 Patient #5 (HV) was admitted to the agency on 10/04/05 with the diagnosis including Diabetes Mellitus Type 11. The Plan of Care dated 09/24 to 11/22/07 documents: "Eralapril Maleate 5mg one I tablet oral daily." The Medication Administration (MAR) dated September, October and November 2007 documents that the patient was receiving "Enalapril Maleate 2.5mg I (one) tablet oral daily". During the home visit on 11/26/07 at 7:00 AM, at the Adult Care Facility (ACF) with the Director of Patient Services (DPS), the MAR was reviewed. After being informed of the medication discrepancies, the agency's staff stated that "when there are changes tO the patient's medication regime, the ACF's staff usually faxes a copy of the physician's order and/or inform the nurses regarding the changes." The DPS stated that"the nurses are to review the Plan of Care and the MAR to ensure that the ordered medications are consistent with the Plan of Care." The DPS could not provide an explanation for the nurses and the NursingSupervisor's failure to G 173 ensure that the Plan of Care has been reviewed and revised according to the patient's needs. Patient #4 (-V) was admitted to the agency on 10/06/07 with the diagnosis including Diabetes Mellitus Type 11. The Plan of Care dated 10/01-11/29/07 docurnunts: "Seroquel 100mg 2 (two) tablets oral .4M CMS-2567 (02-99) Previous Versions Obsolete Event ID: I RIJI I Facility ID: 4706A If continuation sheet Page 45 of 89 Amended x I DEPARTMENT OF IEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND A PLAN OF CORRECTION (XI) FROVIDER/SUPPLIERCLIA IDENTIFICATIION NUMBER: 337301 NAME OF PROVIDER OR SUPPLIER (X2) MUI'IIPl.E CONSTRUCTION A.BUILDING PRINTED: 12/26/2007 FORM APPROVED. OMB NO. 0938-0931 (X3) DATE SURVEY COMPLETED 12/27/2007 B. WING STREET ADDRESS, CITY, STATE, ZIP CODE AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNIT (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFIENCIES (EACH DEFIENCY MUST BE PRECEEDED BY FUILL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 PROVIDER'S PLAN OF CORRECTION (.ACtH CORRECTIVE ACTION Sl IOULD BE CROSS-REFERENCED '10 THE APPROPRIATE DETFIENCY) _ W(X) COMPLETION DATE G 173 Continued From page 45 Every AM and PM and Colace 100mg capsule 2 (two) oral QHS (at bed time)". G 173 The Medication Administration Record dated September, October and November 2007 documents that the patient was receiving "Seroquel 200mg I (one) tablet in the morning and 2 (two) tablets at bedtime" and "Colace I00iag (1) one capsule orally at bedtime". A home visit was made on 11/26/07 at 7:00AM, at the Adult Care Facility (ACF) with the Director of Patient Services (DPS). The MAR was reviewed. After being informed of the medication discrepancies, the agency's staff stated that "when there are changes to the patient's medicatioi regime, the ACF's staff usually faxes a copy of the physician's,order and/or inform the nurses regarding the changes." The DPS stated that "the nurses are to review the Plan of Care and the.MAR on a weekly basis to ensure that the ordered medications are consistent with the Plan of Care." The DPS could not provide an explanation for the nurses and the nursing supervisor's failure to Ensure that the Plan of Care has been reviewed and revised according to the patient's needs. Patient #3 (HV) was admitted to the agency on 02/16/07 with diagnoses of Coronary Atherosclerosis, Congestive Heart Failure, and Lower Leg Injury. The clinical record lacked documentation that the nurse revised the Plan of Cate to include the patient's current medication regimen. The Plan of Care dated 10/14- 12/12/07 lacked orders for Ferrous Sulfate 325mg po (orally) daily, -7;0 FORM CMS-2567 (02-99) Previous Versions Obsolete Event ID: I RIJI I Facility ID: 4706A If continuation sheet Page 46 of 89 Amended x I DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X2) MULTIh'LE CONSTRUCT'ION A.BHUIL1ING (X3) DATE SURVEY COMPLETED 12/27/1007 B. WING -"'rATEMENT OF DEFICIENCIES 'DPLAN OF CORRECTION (XI) IROVID3RISUPPLIERCLIA IDEN'IFICATION NUMBER: 337301 NAME OFPROVIDER OR SUPPLIER SIREEI ADDRESS, CITY, STATE, ZIP CODE AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNIT (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEIFINCIES (EACH DEI'ENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 PROVIDER'S PLAN OF CORRECTION (EACII CORRECTIVE ACTION SHOULI) BE CROSS-REFERENCED TO THE APPROPRIATE DEFIENCY) (X5) COMPLETION DATE o 173 Continued from page 46 Multivitamin 1 tab po daily, Xalatan .005% I drop At bedtime. These medications are listed on the Medication Administration Record as being "administered daily" by the staff of the ACF for the months 9/07, 10/07 and 11/07. The Plan of Care dated 10/14-12/12/07 Documents the patient is on "Cipro 500mg 1 tab 2 times daily." During the home visit on 11/20/07 at I 1:00AM, the patient stated that he is "not taking Cipro." The ACF's Medication Administration Record documents that Cipro was 'discontinued on 05/02/07." The Plan of Care was not revised to reflect this change. The Plan of Care dated 10/14-12/12/07 lacked an order for Xalatan .005% 1 drop to left eye at bedtime. The MAR documents the patient has been receiving the "Xalatan eye drops for the months of 9/07,. 10/07, and 11/07." The nursing visit notes for the month 11/07 document the administration of Xalatan eye dr6ps. During interview with the Director of Patient Services (DPS) on 11/27/07, the DPS was unable to provide an explanation for the findings. Patient #10 was admitted to the agency on. 9/19/07 with diagnoses of Cellutis of the legs, Congestive Heart Failure, Dementia, Diabetes Mellitus Type 2, . and Depressive Disorder. The Plans of Care (POC) dated 9/19-11/17/07" G 173 - 'RM CMS-2567 (02-99) Previous Versions Obsolete Event ID: I RIJ II Facilty It): 4706A If continuation sheet Page 47 of 89 Amended x I DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES STNTEMENTOF DEFICIENCIES oAND PLAN OF CORRECTION (XI) PROVIDER/SUPPLIERCLIA IDENTIFICATION NUMBER: 337301 B. WING STREETrADDRESS, CITY, STATE. ZIP CODE (X2) MULTIPLE CONSTRUCTION A.BJILDING PRINTED: 12/26/2007 FORM APPROVED OM3 NO. 0938-0931 (X3) DATE SURVEY COMPLETED 12/27/2007 NAME OF PROVIDER OR SUPPLIER AMERTCARE CERTIFIED SPECIAL SERVICES SUB-UNIT (X4) ID PREFIX TAG SUMMARY STATEMENT' OF DEFIFNC[ES (EACH DEFIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID I'REIPTX TAG 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 PROVIDER'S PLAN OF CORRECTION (EACII CORRECTIVE ACTION SHOUID BE CROSS-REFERENCED TO TilE APPROPRIATE DEFIENCY) (XS) COMPLIuON DA'FE G 173 Continued From page 47 and 1 1/18-01/15/08 orders Skilled Nursing for ,assessment of medication regimen". The agency clinical redord arid the Medication Administration Record (MAR) from the Adult Care Facility (ACF) documents medication discrepancies. The MAR documents: "Oneprazole 20mg 1 tab PO (by mouth) daily" administered 09/2 111/27/07. The agency's clinical record lacked documentation that the nurse revised the Plan of Care to include this medication. On 11/27/07 at 1:15 PM, the Nursing Supervisor was interviewed and was unable to provide an explanation for the noted discrepancies. Patient #13 was admitted to the agency on 08/08/07 with diagnoses of Tear Film Insufficiency, Glaucoma, Depressive Disorder, and an interim order dated 10/22/07 documented new diagnosis of NlDDM(Non-Insulin Dependent Diabetes Mellitus) with an order for Skilled Nursing Visits to perform fingerstick twice a day. The clinical record lacked revision of the Plan of Care to include an order for bloods sugar parameters. The clinical record and the MAR documented that the patient in taking "Micronase/Glyburide 5 mg 13O Daily" 11/01-11/ 11/07. The clinical record lacked documentation that the nurse revised the Plan of Care to include this medication. On 11/27/07 at 1:40 PM, the Supervisor was interviewed and was unable to provide an explanation. ci 173 *Uvl CMS-2567 (02-99) Previous Varsions Obsolete Event ID: IRII I Facility ID: 4706A - 4 If continuation sheet Page 8 of 89 Amended x I DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEI)ICARE AND MEDICAID SERVICES F "ATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (XI) PROVIDER/SUPPLIERJCLIA IDENTIFICATION NUMBER: (X2) MULTIPLtE CONSTRUCTION A.BUILDING PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X3) DATE SURVEY COMPLEI'ED 337301 B.WING STREET ADDRESS, CITY, STATE,. ZIP CODE 12/27/2007 NAME OF PROVIDER OR SUPPUER AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNIT (X4) ID PREFIX TAG SUMMARY STATEMEN't OF DEFIENCIES (EACH DEFIENCY MUST BE PRECEEDED BY FULL REGULATORY OR SC IDENTIFYING INFORMATION) ID PREFIX TAG 900 MERCIIANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 PROVIDER'S PLAN OF CORREC.I'ION (EACH CORRECTIVE ACIION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFIENCY) (X5) COMPLETION DATE G 173 Continted From page 48 Patient #7 was admitted to the agency on 05/19107 with diagnoses of Diabetes MellitUs Type 11,Schizoaffective Disorder, and Hypertension. The Plan of Care dated 09/16-11/014/07 ordered *Skilled Nursing three (3) times a day for sixty (60) days for fingerstick and to administer Insulin. The clinical record documents that the Skilled Nurse (SN) visited the patient three (3) times a. day until 09/25/07. The record further documents thal the SN visited the patient daily from 09/2611/14/07. The record lacked an ordered to decrease SN from three (3) x a day to once a day. On 11/27/07, the Nursing Supervisor was interviewed and was unible to provide and explanation. Patient #19 was admitled to the agency on 08/16/07 with diagnoses including Diabetes Mellitus, Hypertension and Respiratory Neoplasm. The clinical record documents multiple discrepancies in patient's medications on the current Plan of Care dated 10/15-12/13/07. The Medication Administration Record (MAR) dated November 2007 documents: Aspirin 325 mg po daily was discontinued 08/15/07, Hyzaar 100-12.5 tablet daily, Metforim 850 mg three (3) times a day, Colabe 100 mg twice a day, Mirtazepin 7.5 mg at bedtime, Ambien CR 6.25 mg at bedtime, Pamelor 10 mg at bedtime was discontinued 09/13/07, Aggrenox 25-200 mg I G 173 ,RM CMS-2567 (02-99) Previous Versions Obsolete Event II): 1RIJ11 Facility ID: 4706A If continuation sheet Page 49 of 89 .Amended x I DEPART'MENT OF HEALTH AND HUMAN SERVICES CENITRS FOR MEDICARE AND MEDICAID SERVICES "STATEMENT OF DEFICIENCIE.S AND PLAN OF CORRECTION SA.BUILDING___________ (XI) PROVIDER/SUPPLIER/CIA IDENTIFICATION NIUMBER: 337301 (X2) M*ULTIPLF CONSTRUCTION PRINTED: 12/26/2007 . FORMAPPROVED OMB NO. 0938-0931 (X3) DATE SURVEY COMPLETED 12/27/2007 B. WING SI'REE'" ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNIT SUMMARY STNIEMENT OF DEFIENCIES (EACH DEFIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFOdMVATION) ID PREFIX 'rAG 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 PROVIDER'S PlAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO TIlE APPROPRIATE DEFIENCY),, (X5) COMPLETION .DATE (X4) ID PREFIX TAG G 173 Continued From page 49 capsule daily, Zocor 20mg daily, Norvasc 10 mg daily, and Prilosec 20 mg at bedtime. The Plan of Care documents orders for Aspirin and Pamelor although these medications had been discontinued. The dosage of Hyzaar is documented as "100mg -25mg" although the MAR documented "10012.5". Included on the POC was "Oxycodone/APAP 5/325 mg tablet two (2) tablets q 4 It". There is no documentation of this medication on thc MAR. Aggrenox 25 - 200mg" is documented as every "12 hours". The MAR documents "daily." Metforim is documented as administered daily on the POC. The Medication Administration Record documents "three (3) times a day". "Zocor 20 rag" is ordered to'be administered "twice a day." The MAR documents: "daily" administration. "Ambien CR" is ordered to be administered "12.5 mg al bedtime..."The MAR documented that the patient was getting "6.5 mg." "Colace" is ordered to be administered "daily". The MAR documents Colace to be administered" "twice a day," Mirtazepine, Prilosec and Norvasc are included on the POC and not documented on the MAR. The Plan of Care documents: Mutltivilarnin I table and Naprosyn 500 mg twice a day prn and G 173 tM CMS-2567 (02-99) Previous Versions Obsolete Event ID: IRIUI I Facility ID: 4706A If continuation shect Page 50 of 89 Amended x I DEPARTMENT OF HEALT H AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES STATEMENT O" DEFICIENCIES -AND PLAN OF CORRECIION PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X2) MULTIPLE CONSTRUCTION A.BUILDING (Xl) PROV]DER/SUPPLIERICLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETE-D 337301 12/27/2007 B. WING " NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNIT (X4) ID SUMMARY STAI'EMENT OF DI3FIENCIES ID 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 PROVIDER'S PLAN OF CORRECTION (X5) PREFIX TAG G 173 (EACH DEFIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDFNTIFYING INFORMATION) Continued From page 50 to be taken with food. There is no documentation on the MAR. The nurse failed failed to review and revise the Plan of Care to reflect the current and accurate medication regime for this special needs patient (Refer 0176) Patient #6 was admitted to the agency on 03/31/05 with the diagnoses of Schizophrenia, Diabetes Mellitus, and Chronic Airway Obstruction. The Plan of Care dated 09/17/07 to 01/14/08 orders Skilled Nursing visits "every other week to monitor blood sugars, Weights, assess the patient and administer Haldol." The Plan of Care contains conflicting information regarding the patients diet. The Nutritional Requirements are documented as a "NCS (No Concentrated Sweets) "diet. The patient's diet is documented as an "1800 calorie ADA" under the Skilled Nursing tasks. notes dated from 07/31 The Skilled Nursing visit fluctuation in patient's to 11/13/07 documents a weight from 113 to 119 pounds. The Skilled Nursing note dated 10/31/07 does not include documentation ofa weight but documents "Thin Lady appears to be "wasting" away says she eats regularly. MD aware". The record lacked any documentation that the nurse spoke to the physician to regarding any follow up to the patients weigh status and/or revision to the Plan of Care to include measures such as supplements. PREFIX TAG G 173 (EACH CORRECTIVE ACTION SIJOULD BE CROSS-REFERENCED TO TIlIE APPROPRIATE DEFIiNCY) COMPLETION DATE 'M CMS-2567 (02-99) Previous Versions Obsolete Event ID: I R1J II Facility ID: 4706A If continuation sheet Page 51 of 89 Amended x DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES S'TATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDER/SUPPIiERICLIA IDENTIFICATION NUMBER: 337301 B. WING PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X2) MULTIPLE CONSTRUCTION A.BUILDING - (X3) DATE SURVEY COMPLETED 12/27/2007 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, Zi' CODE AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNIT (X4) ID PREFTX TAG SUMMARY STATEMENT OF DEFIENCIES (EACH DEFIENCY MUST BE PRECEEI)ED BY FULL REGULATORY OR LSC IDENTIFYING IINFORMATION) ID PREFIX TAG 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 PROVIVER'S PLAN OF CORRECTION (EACH CORRECTIVE ACI'ION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEMFENCY) (X5) COMPLEIION DATE G 173 Continued From page 51 The findings were reviewed on 11/27/107 at 11:30 -AM with the Nursing Supervisor. The Supervisor stated that when she had a case conference with the nurse on 11/08/07, "the nurse repoted patient's weight as 113 pounds" (this was a 6 pound less from the September weight) and the supervisor discussed what measures the nurse should speak to the physician about. The record lacked any revision of the Plan of Care to address the patient's weigh loss. The agency Medication sheets documents discrepancies in the medications ordered on the Plans of Care. For example: The Medication Sheet daitcd 09/16/07 lacked documentation of the medication, H4aldol 75 rmg IM which is administered by the nurse every four (4) weeks. The Medication Sheet dated 08/17/07 documents Zyprexa 5 mg BID (twice a day) yet the Plan of Care ordered the medication daily. The Medication sheet also documented Haldol 100 mg yet the Plan of Care ordered 75 mg of the medication. The MAR for the ACF.dated 09/01-11/30/07 documents "Zyprexa BID and the Haldo 75 mg." The findings were reviewed on 11/27/07 at 11:00 AM with the Director of Patient Services (DPS) of Westbury, the DPS of Brooklyn who was appointed by the parent agency to deal with Department of Health issues, and the Nursing Supervisor.There was no additional information or explanattion provided. G 173 . 7 -J Event ID: tRUt I Facility ID: 4706A If continuation sheet Page 52 of 89 M CMS-2567 (02-99) Previous Versions Obsolete Amended x I DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES STATEMENT OF DEFICIENCIES ,4NI) PLAN OF CORRECTION (XI) PROVIDERISUPPLIER/CIIA IDENTIFICATION NUMBER: (X2) MULTII'LE CONSTRUCTION A.BUILDING PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X3) DATE SURVEY COMPLEITIED 337301 12/27/2007 B. WING NAME OF PROVIDER OR SUPPLIER STREEF ADDRESS, CITY, STATE, ZO' CODE AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNIT 90 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590. PROViDER'S PLAN OF CORRECTION (EACH CORRECIVE A(7I'ION SHOULD BE CROSS-REFERENCED 'O THE APPROPRIATE DEFIFNCY) (X5) COMPLEIION DATE (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFIENCIES (EACH DEFIENCY MUST BE PRECEED'I)BY FULL REGULATORY OR LSC IDEN'I'IFYING INFORMATION) .ID PREFIX TAG b 173 Continued From page 52 The nurse failed to review the medications with. the physician and revise the Plan of Care as needed. Patient #16 was admitted to the agency on 06/09/07 with the diagnosis including Glaucoma. The Plan of Care date 08/08 - 10/06/07 documents: "Seroquel 200mg tablet orally daily, Seroquel 50mg tablet 2 (two) times daily, Lidoderm'5% (700mg/patch) ADH-topical daily Acetaminophen 650mg tablet oral every 4 (four) hours, Desyrel I 00mg 2 (two) tablets oral bedtime. Synthroid 75mcg tablet oral bedtime, Toprol XL 100mg tablet SR 24hr oral daily, Ultram 50rg tablet oral 2 (two) times daily and Norvasc 5mg oral daily". The Medication Administration Record (MAR) dated September2007 documents: "Seroquc 200mg tablet oral at bedtime" and in addition to "Seroquel 50mg 1 (one) tablet twice a day, Desyrel 100mg 1 (one) tablet daily at bedtime, Synthroid 0.05mg 1 (one) tablet oral daily and Norvase 5mg 2 (two) tablets oral daily". The following medications were not included on the MAR: Lipoderm Patch, Acetaminophen, Toprol and Ultram. The Plan of Care dated 10/07-12/05/07 documents: "Seroquel 200rg tablet oral daily, Seroquel 50mg tablet oral 2 (two) times daily, Synthroid 75mcg tablet oral bedtime and Desyrel 100mg tablet I (one) tablet bedtime". I G 173 The MAR dated October 2007 documents that the patient was receiving "Seroquel 200mg I RM CMS-2567 (02-99) Previous Versions Obsolete Event ID: IRIJII Facility ID: 4706A If continuation sheet Page 53 of 89 Amended x I DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES "'I'AIMENI' OF DEFICIENCIES 'D PLAN OF CORRECTION (XI) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: PRINTED-12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X2) MUI:IIPLE CONSIRUCT"ION A.BUILDING (X3) DATE SURVEY COMPLETED 12/'27/2007 12_27/2007 337301 NAME 01 PROVIDER OR SUPPLIER WING 13. STREET ADDRESS. CITY, STATE, ZIP CODE AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNIT SUMMARY STATEMENT OF I)EFIENCIES (EACII DEFIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 ID 'REFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFIENCY) (X5) COMPLEIION DATE (X4) ID' PREFIX TAG G 173 Continued From page 53 (one) tablet daily bedtime, Synthroid 0.05mg 1 (one) tablet oral daily and Desyrel 100mg 2 (two) tablets oral bedtime". The following medication that was documented on the MAR for October was not included in the Plan of Care of 10/07-12/05/07: Metoprolol 50mg 1 (one) tablet oral daily. The patient record lacked documentation of the physician's order /revision of the Plan of Care and. any explanation regarding the changes in the patient's medication regime. During interview on 11/26/07 at 11:40 AM with the Nursing Supervisor and the DPS, the agency staff was unable to provide an explanation. Patient #2 was admitted to the agency on 11/01/05 with the diagnosis including Diabetes Mellitus Type 11. The PMan of Care dated 08/23-10/21/07 did not include the ordered medication: "Flarex 0.1% ophthalmic drops 5ml instill I (one) drop in both eyes twice a day as needed" The Medication Adminisuation Record (MAR) dated September 2007 documents that the patient was receiving the eye drops per self medication. The Plan of Care lacked revision to include this medication. During interview on 11/26/07 at 11:40 AM with the Nursing Supervisor and the MPS, the agency staff acknowledged the survey findings. Patient #11 was admitted to the agency with diagnoses including Schizophrenia, Diabetes G 173 -'M CMS-2567 (02-99) Previous Versions Obsolete Event ID: IRJI I Facility D: 4706A If continuation sheet Page 54 of 89 Amended x I DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES STATEMEiNT OF DEFICIENCIES PLAN OF CORRECTION (XI) PIROVIDER/SUPI'LIERCL1A IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A.B ULDING_____ ____ PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED --AND 337301 12/27/2007 B. WING STREETADDRESS, CIfY, STATE, ZIP CODE AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNIT " SUMMARY STATEMENT OF DEFIENCIES (EACH DEFIENCY MUST BE PRECEFI)ED BY FULULL REGULATORY OR LSC IDENTIFYING INFORMATION) o ID PREFIX TAG 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 PROVIDER'S PLAN OF CORRECTION (EACH CORRECIVE AC1I'ON SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFIENCY) (X) COMPLETION DATE (X4) ID PREFIX TAG G 173 Continued From page 54 and Mellitus Type U1, Hypertension The Plan of Care dated 08/15 -10/13/07 and 10/14-12/12/07 orders Skilled Nursing "every other week to assess medication regime." The Clinical record documents medication changes of Mobic 7.5mg discontinued on 9/20/07 and that the patient was started on Mobic 15mg po daily. The Plan of Care dated. 10/14-12/12/07 was not revised to reflect these changes. G173 r The Medication Administration Record of the ACF documents the patient was started on Mobic 15mg po daily as of 09/20/07. The Plan of Care lacked revision to include this change. On 11/27/07, the agency staff provided the surveyor with a copy of of a "Physician Supplemental Orders" dated 09/20/07 for certification period 08/15/07 - 10/13/07 and an order dated 10/14/07 for certification period 10/14 -12/12/07 correcting the Plan of Care to include Mobic 15rng PO daily. Patient #9 was admitted to the agency on 09/05/07 With diagnoses including Mental Retardation and Hypertension. The Progress Notes dated 10/30 and 11/02/07 documents the need for the patient to-receive six (6) days of Home Heatlh Aide services. The nurse failed to revise the Plan of Care to reflect the change in patient needs. (Refer G176) The agency "Medication Procedure/Workflow ",M CMS-2567 (02-99) Previous Versions Obsolete Event ID: IRUI I Facility I1): 4706A If continuation sheet Page 55 of 89 Anended x I * DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES STATEMENT OF DEFICIENCIFS AND PLAN OF CORRECTION tA.BUILDING_____ (Xl) PROVIDERISUPPLIERICLIA IDENTIFICATION NUMBER: 337301 (X2) MULTIPLE CONSTRUCTION . ____ PRINTED 12/26/2007 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED 12/27/2007 B. WING STREET ADDRESS, CITY,STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNIT S 0(4) ID pIREF1X TAG SUMMARY STATEMENT OF DEFIENCIES (EACII DEFIENCY MUST BE PRECEEDED BY FUlL, REGULATORY OR LSC IDENTIFYING INtORMATI'ON) ID IREFIX TAG 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 PROVIDER'S PLAN OF CORRECTION (EACII CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFIENCY) (X5) COMPLETION DATE G 173. Continued From page 55. Process" which was undated documents: "I . On SOC (Start of Care), and at each Recertification and PRN (as needed) the nurse must verify all orders with the MD. the 2. If there are changes or discrepancies in G 173 orders, documnent the changes on the interim/supplemental orders after verifying with the MD. 16. All MAR's (Medication Administration Record) must be reviewed bna dated weekly to validate that you have reviewed all orders with the Med. Tech. Sign and date at bottom of the page." The agency staff failed to follow the agency Policy/Procedure regarding the medication management and review for the special needs population of patients with secondary diagnoses involving mental health, the mentally retarded, and the developmentally disabled that prelude their independence in activities of daily living served by this agency. 484.30(a) DUTIES OF THE REGIS'I'ERED.NURSE G 176 G176 'bg Nursing Supervising Stffwill be vistal) the Adult Care facilitics on a weekly basis. The The registered nurse prepares clinical and progress notes, coordinates services, inform the physician and other personnel of changes inthe patient's condition and needs, This STANDARD is not'met as evidenced by: Based on clinical record review, home visits ( Policy and Procedure, and staff interviews, the nurses failed to prepare comprehensive notes, coordinate care and inform the physician and coaNursing t other personnel of patient changes in condition purpose of these visits is to ensure that services, medication and treatments are, being rendered in accordance to the patient's POT. The Suwervisory staff will provide onsite over site of nursing and home health aide staff, clarify issues, patient problet-solve and case conference patients as required. The Nursing Supervisor's will make weekly visits to the tmattor, to ensure the ACF nurses are preparing clinical and progress notes, coordinating services., inforing the physician and other personnel of changes in the patient's condition and needs on a timely basis. The Supervisor will review the ACF mini the record and compare it to patient's clinical record in the agecy. Diserclsaucies in documentadon will be reported to the DPS, The DPS will have the RN come into the office to amnend the rcord with an interimt order (contact the physician) or write'an addendum. Those ), are nurses that found to be deficient will be inserviced and receive a writtenwa nig.. The DPS develops an in-service calendar and ensures appropriate education is given to the field nurses based on the Supervisor findings. "70 FORM CMS-2567 (02-99) Previous Versions Obsolete Event ID: I RUII Facility ID: 4706A If continuation sheet Page 56 of 89 Amended x I DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEI)ICAID sERVICES STATEMNTOF DEFICIENCIES IDPLAN OF CORRECTION (XI) PIROVIDER/SUPPLIERiCI.IA IDENTIFICATION NUMBER: , 337301 (X2) MULTIPLE(CONSTRUCTION A.BUILDING B.' WING PRINTF,D: 12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X3) DATE SURVEY COMPI.FIED 12/27/2007 NAME OF PROVIDER OR SUPPLIER AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNIT (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFIENCIES (EACH DEFiNCY MUST BE PRECEEDED BY FUIl, REGULATORY OR LSC IDENTIFYING INFORMATION) STEETADDRFSS. CrrY, STATE, ZIP CODE 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 II) PREFIX TAG PROVIDER'S PLAN OF CORRECTION (FACH CORRECTIVE ACION SHOULD BE CROSS-REFERENCED TO Ti iE APPROPRIATE DEFIENCY) (WS) COMPLETION DATE G 176 Continued From page 56 and needs. This was evident for twelve (12) of . nineteen (19) records reviewed and four (4) of eight (8) home visits. (Patients #1 H, #2, #6' #8 #9,#10, #13, #14 HY, #16, #17 HV, #18, and dAdvisory 17 H, To pievet deficient practices from reoccurring ongoing Pulonnancc frprovement/Quality Assurance clinical record audits bill be done by the Supet-isor/QI Narse/DPS on a quantcily basis. Results of these audits will he tported to the QI )ire tor/ QI Committee/ Professional Board/Committee. - April 14,2008 qlgrvic jgsht dah~nj ofic DPS forI Liign. DP will i rem osiLteAtlmi ir.G. mid eloi to hG Admnirator/Governing Body on a CSS basis. An ericare #19) The nurse's failure to prepare comprehensive notes, coordinate care and report changes resulted in poor oorwekly ofpatints#1 Diabtic anaemen ad #14, Diabetic management of patients #1 and # 14, poof medication management of the agency's patients, and places all patients at risk for poor quality car and potential forpoor outcomes. The findings include: a Administrator/Govcming Body will ensure that the required education mid in-services take place and die Agency's have the continued support to reoccurrences of deficient practices. The Administrator will report Ier findings to the VP of Operations/Governing Boaid resolve all identified deficiencies and prevent any Patient 31 (WV) was admitted to the agency on 07/03/04 with diagnoses of Diabetes Mellitus and Schizophrenia. The Plan of Care dated 05/16-07/14, 07/15-. 09/12/, 09/13-11/11 and I 1/12-01/01/08 documents orders for Skilled Nurse (SN) visits daily to" ... Diabetic Regime, S/S (signs and symptoms) of I'Hypo/hyperglycemia causes and intervention, Foot car/Skin Care. Adm Lantus as ordered Q (every ) am. Regular insulin Coverage in AM & PM ... if B/S (blood sugar) > 250." During the home visit on 11/20/07 at 7:05 AM, the blood sugar log was reviewed. The log documented that the patient tests his blood sugars "twice a day". During an interview with the patient during visit, the patient stated that there has been "several days" that the Adult Care Facility staff "drew up the Insulin" for the patient and he self administered the Insulin. FORM CMS-2567 (02-99) Previous Versions Obsolete Event ID: I RI I I Facility ID: 4706A If continuation sheet Page 57 of 89 Amended x 1 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CIJA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION ABUILDING PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X3) DATE SURVEY COMPLETED 337301 12/27/2007 B. WING NAME OF IROVIDER OR SUPPLIER STREE" ADDRESS, CITY, STATE, ZIP CODE AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNIT (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFTENCIES (EACH DEFIENCY MUSI' BE PRECEEDED BY tULREGULATORY OR LSC II)EN'IFYING INFORMATION) 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 I) PREFIX TAG PROVIDER'S PLAN OF CORRP.ECTI'ION (EACH CORRECTIVE ACI1ON SHOULD BE CROSS-RFiF'R. CE TI)' TfHE APPROPRIATE DEFIENCY) (X) COMPLETION DATE Continued From page 57 During the visit, the patient was observed preparing the Lantus Insulin injection with much instructions from the Skilled Nurse. The blood sugar log and patient record documented the following: On 07/18/07 the staff from ACF drew up the Insulin and patient self administered. On 07/29/07 the record documented "missed visit" (no staff). It is unclear whether the patient received the Lantus Insulin or if coverage was needed. The record lacked documentation if a Blood glucose reading. On 08/02/07 -Blood Sugar Was documented as "172 at 4:10 PM - patient self administered with Staff assistance". On 08/05/07 - the Blood sugar was documented as "269"- patient self administered with staff' from ACF. The physician order documents that the patient is to receive regular insulin coverage if the blood sugar is above 250. The record did not include documentation that the patient received the Regular Insulin as per the orders. G 176 The agency SN/Nursing Supervisor failed to inform the physician of missed visits until two (2) and half months later when the agency was called by the Department of Health regarding a patient care issue,. The agency failed to ensure that there is a system in place to meet the diabetic care needs of an insulin Dependent patient. During interview on 11/19/07 at 8:50 AM with the Nursing Supervisor on call on 08/05/07, the RM CMS-2567 (02-99) Previous Vesions Obsolete Event ID: IRIJI I Facility ID: 4706A If continuation sheet Page 58 of 89 Amended x I DIEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OFCORRECTION (XI) PROVIDER/SUPPLIERICLIA IDENTIFICAIION NUMBER: 33730:1 B. WING PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X2) MULTIPLE CONSTRUCTION A.BUILDING (X3) DATE SURVEY COMPLETED 12/27/2007 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNIT (X4) U) PREFIX TAG SUMMARY STATEMENT OF DEPIENCIES (EACH DEFIENCY MUST BE PRECEEDED BY IULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 1,1590 PROVIDER'S PLAN OF CORRECTION (EACI I CORRECTIVE ACION SHOULD BE CROSS-REFERENCEID TO TIlE APPROPRIATE DEFIENCY) (XS) COMPLETION DATE Continued from page 58 Supervisor stated that there was "no nurse available to visit the patient" and'"there is a shortage of nurses". The Supervisor further stated that she called the Adult Care Facility (ACF) and "talked "and employee of the ACF "through drawing up the Insulin and the patient administered the Insulin". The Supervisor stated the ACF employee had "never been taught or observed drawing up Insulin" and this (ACF staff administering insulin) had "occurred two (2) other times" but was " not the agency's practice"; On 11/26/07 at 3:20 PM, a telephone interview was conducted with the evening supervisor of the ACF staff/Medication technician. The ACF staff stated that on 08/05/07,." the nurse from Anericare Called while the patient was testing his blood sugar and said that "she could riot be there because there was some sort of emergency". The ACF staff further stated that she "has not been observed/taught by the Americare nurse on drawing up Insulin" and "her parents were both Diabetic and Insulin dependent so she knows how to draw up the Insulin". The ACF Staff stated that she "held the Insulin bottle for the patient and he drew up the Insulin and self adninistered in his abdomen.". During an interview with the Director of Patient Services (DPS) of Westbury on 11/27/07 as 9:45 AM, the DPS stated that she and the Nursing Supervisor were aware that there was a potential for a staffing problem on the weekend of vacation that weekend" and the Nursing Supervisor worked the weekend. The DPS further stated that the agency's policy is that "if a nurse is unavailable to make a visit, the supervisor would make the visit.' The DPS "RMCMS-2567 (02-99) Previous Versions Obsolete G 176 Event ID: IRU II Facility ID:4706A If contimuation sheet Page 59 of 89 Amended x I EPARTMENT OF HEAL'H AND HUMAN SERVICES CEN'TERS FOR MEDICARE AND MEDICAID SERVICES STATEMENTI OF DEFICIENCIES I &.NID PLAN OF CORRECTION (X1) PROVIDERISUPPLIER/CLIA IDENIIIICAfIION NUMBER: 337301 (X2) M UUIPLE CONSTRUCTION PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X3) DIATE SURVEY COMPLE'ED 12/27/2007 UILDING A.I3 B. WING STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNIT (X4) ID PREIX TAG SUMMARY STATEMENT OF DEFIENCIES (EACH DEFIENCY MUST BE PRECEt)EtI) BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 PROVIDER'S PLAN OF CORRECTION (EACII CORRECTIVE ACTION SHOULD BE CROSS-RIFE-RENCED TO THE APPROPRIATE DEFIENCY) (XS) COMPLETION T DAE Continued From page 59 stated that "the Supervisor could only do early morning visits on Sunday and this patient needed his Lantus Insulin in evening. Record review lacked any coordination with the DPS upon return from vacation. During an interview with the Nursing Supervisor on 11/27/07 at 2:30 PM, the Nursing Supervisor stated that " the Nursing Supervisors have to make visits sometimes during the week and on weekends due to staffing issue and not enough nurses to cover the cases." There is no.documented evidence that the nurse revised the Plan of Care until 10/12/07 when the agency received a call from the Department of G 176 Health. The record lacked any documentation that the physician was made aware of the agency's failure to provide care in accordance with the Plan of Care and inability to meet the patient's needs until 10/12/07, more that two (2) months later when the agency was'called by the Department of Health. The agency's failure to coordinate care and case conference with the physician resulted in the patient self administering Insulin which was prepared by an unlicensed and untrained ACF employee. Patient #14 (HV) was admitted to the agency on 05/10/07 with diagnoses including Diabetes Mellitus and Psychosis. The Plans of Care from the start of care to 01/04/08 orders "Skilled Nursing visits every day to administer Lantus Insulin 100mg"; Humulin R XM CMS-2567 (02-99) PreViomS Ver-sions Obsolete Event I); I RUI I Facility ID: 4706A If Confinuatiom sheet Page 60 of 89 Amended x I DEPARTMENT OF HEALTH AND IHRMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN 01 CORRECITON (XI) PROVIDERISUPPLIERICLIA IDENTFICATION NUMBER: 337301 PRINTED: 12/26/2005 FORM APPROVED OMB NO. 0938-0931 (X2) MULTIPLE CONSTRUCTION A.BUILDING B. WING (X3) DATE SURVEY COMPLETED 12/27/2007 NAME OF IROVII)ER OR SUPPLIER STREET ADDRESS. CITY. STATE, ZIP CODE 900 MERCHANTS CONCOURSE SUITE LL-15 AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNIT (X4) ID, PREFIX TAG SUMMARY STATEMENTOF DEFIENCIES (EACH DFFIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INIORMA'ION) ID PREFIX TAG WESTBURY, NY 11590 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO TIlE APPROPRIATE DEFIENCY) (X5) COMPLI 'ION DAT'E Continued From page 60 Insulin coverage for blood sugars over 200. During home: visit on 11/20/07, the nurse observed the patient test his blood sugar. The nurse stated she administers the sliding scale Insulin "if the patient's blood sugar is above 200". During the home visit the patient did not require the insulin coverage. During interview with the nurse during the home visit, the nurse stated she "going to take the log to the Diabetic Teacher". The nursing visit notes dated 11/03, 10/30, and 10/29/07 and Progress Notes dated .11/01/07 documents that the patient is " not able to do his own finger stick or insulin administration due to his mental illness." The nursing visit notes and Progress Notes lack documentation that were was any case conferencing with the supervisor and/or physician regarding the patient inability to do finger sticks and the patient's elevated blood sugars. There is no documented evidence that nurse never addressed the need for insulin coverage or revised the Plan of Care to address these issues. The notes also lack any documentation of follow up with the ACF staff regarding the patient's blood sugar monitoring. The "Focused Diabetic Chart Audit Tool" completed by the Diabetic Educator on 11/14/07 documents the need the blood sugar parameters the lack of coordination regarding the hypo and hyperglycemic readings, the need for teaching of Insulin administration, the need to observe the' patient doing the finger stick, the need to report the blood sugars to the physician, and need for G 176 lab work. ( M CMS-2567 (02-99) Previous Versions Obsolete o .: _--J Event ID: IR1JI I Facility ID: 4706A If contusuation sheet Page 61 of 89 Amended x I DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES ,",ATMEN I' OF DEFICIENCIES IDPLAN OF CORRECTION (Xl) PROV1DER/SUPPLIERICLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONS'I'RUC'ION A.BUILDING PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X3) DATE SURVEY COMPLETED 337301 NAME OF PROVIDER OR SUPPLIER 12/27/2007 H,WING STREET ADDRESS, CITY, STATE, ZIP CODE AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNIT (X4) ID PREFIX TAG SUMMARY STATEMENT OE.DEFIENCIES (.EACH DEFIENCY MUST BE PRECEEDED BY FULL. REGULATORY OR I-SC IDENTIFYING INFORMATION) ID PREFIX TAG 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFIENCY) (X5) COMPLETI ON DATE Continued From page 61 G 176 As of the home visit (11/20/07) these issues had not been addressed and the nurse had failed to effectively coordinate the diabetic care for this patient. The "Draft" Capillary Blood Glucose Monitoring Protocol documents on page 2:....Patient's physician's should be informed in cases of mild to moderate patterns of hypo and hyperglycemia". The nurse's failure to coordinate the care for this patient resulted in uncontrolled blood sugars and poor management of this patient's Diabetes. l)uring home visit medication discrepancies were also evident. Refer G173. The nurse failed to provide effective coordination with the physician and the supervisor regarding the patient's medication regime. Patient # 17 (HV) was admitted to the agency on 10/18/)7 with the diagnoses of Open Wound of the Lower Extremity and Organic Brain Syndrome. The Plan of Care dated 10/18-12/16/07 orders: "SN visits BID (twice a day) to perform dressing change .of Normal Saline Wet/Dry ..... During home visit on 11/20/07 the nurse was observed removing the dressing and applying a Normal Saline wet to dry dressing. After ie change was completed, the surveyor asked the nurse if the w'ound is to be cleansed with Normal Saline (NS). The nurse stated that she "usually splashes the wound with Normal Saline". '-RM CMS-2567 (02-99) Previous Versions Obsolete Event I): IRIJ I Facility ID: 4706A If continuation sheet Page 62 of 89 Amended x I DEPARTMENT O HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES .ATEMENT OF DEFICIENCIES AND PLAN OFCORRECTION (XI) PROVIDERISUPPIJERICLIA RDENTIPCATION NUMBER: (X2) M ULTIPLE CONSTRUCTION PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X3) DATE SURVEY COMPLETED A,BUILDING 337301 .12/27/2007 B. WING STREEP ADDRESS, CiY,STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNIT SUMMARY STATEMENT OF DEFIENCIES (EACH DEFIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) I 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO TIlE APPROPRIATE DEFIENCY) (X5) COMPLETION DATE (X4) ID PREFIX TAG G 176 Continued From page 62 The agency's undated policy and procedure for Wet to Dry Dressing documents in item V#12: Irrigate wound with normal saline or ....... prescribed cleanser". )uring an interview with the DPS of Brooklyn following the home visit, the DPS stated that "the nurses must follow the physician's order and the physician was using this method was being used to debride the wound." The record lacked any documentation that the' physician did not want the wound to be cleansed with NS as per the agency's policy and procedure, The nursing visits notes documented conflicting wound care provided: Nursing visits dated 10/19/07 PM, 10/21/07 AM & AM PM, 11/1 AM, and II. &PM Documented that the wound was "cleansed with NS"(Normal Saline). During interview with the Nursing Supervisor on 11/27/07 at 11:30 AM, the supervisor stated that "the nurse sometimes splashes the wound to the is dressing off because it painful to remove the dressing". The agency nurse and/or Supervisor failed to coordinate the provision of wound care to ensure the that all nurses provided the ordered and G 176 FORM CMS-2567 (02-99) Previous Versions Obsolete Eveit D: 1RUII1 Facility ID: 4706A If continuation sheet Page 63 of 89 Amended x 1 DEPARTMENT OF HEALTH AND HUMAN SERVICES rNJ'I'ERS FOR MEDICARE AND MEDICAID SERVICES PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X2) MULTIPLE CONSTRUCTION A.BUILDING , STAIEMENT OF DEFICIENCIES AND PLAN OF CORRECTION' (XI) PROVIDER/SUPPLIERICLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED 337301 NAME OF PROVIDER OR SUPPLIEILR 12/27/2007 B. WING S'I'REF:r1'ADDRESS, CITY, STATE, ZIP CODE 900 MERCHANTS CONCOURSE SUITE LL-15 AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNIT (X4) ID PRENX TAG SUMMARY STATEENT OF 1DEFIENCI.S (EACII DEFIENCY MUST BE PRECEEDEI) BY FUIl. REGULA'XORY, OR LSC IDENrIF YING INFORMATION) . WESTBURY, NY 11590 PROVIDER'S PLAN OF CORRECTION (EACII CORRECTIVE ACTION SIIOULD BE CROSS-REFERENCED 1O TIlIE APPROPRIATE DEFIENCY) ID PREHIX TAG (X5) COMPLE7I1ON DATE G 176 Cfntinued From page 63 correct vound care. Patient #8 (HV) was admitted to the agency oi 10/ 18/07 with diagnoses in, uding Dia.betes Mellitus, Long Term use of Insulin, Therapeutic Drug Monitoring, Chronic Airway Obstruction, Schizophrenia, and Hypertension. The Plans of Care dated 10/18-12/15/07 documents orders for: Skilled Nursing, two (2) x a day to monitor Fasting Blood Sugar and administer Regular Insulin. The patient is on sliding scale of Humulin R Insulin coverage for sugars over 251. The Plan of Care dated 10/18/07 documents two (2) sets of sliding scale range for this patient. 1. "Regular Insulin coverage 201-300-4. units; 301 -400-8 units; 401 and greater 12 units. 2. Insulin Regular, Human 100 unit/ml vial (N) Injection 2 times daily 0-250 - 0 units; 251-300 - 4 units; 310-400-8 units; 401 greater - 12 units...." During home visit on" 11/20/07 at 10:00 AM, the nurse tested patient's blood sugar. The nurse stated that she administers the sliding scale Insulin "if the patient's blood sugar is above 251 and this morning it's below 251" so "the patient does not require any Insulin coverage today." During the home visit the nurse was interviewed as to how does she know which set or orders to follow. The nurse stated that she "follows the #2 sliding scale Regular Humulin orders because that was on the patient's discharge from the hospital on 10/17/07." During the home visit on 11/20/07, the MAR G 176 I Event ID: IRUI ] Facility ID: 4706A //_ FORM CMS-2567 (02-99) Previous Versions Obsolete If continuation sheet Page 6't of 89 Amended x I DEPARTMENT OF HEAIFTH AND HfUMAN SERVICNS i-NTERS FOR MEDICARE AND MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A.BUILDING PRINTED: 12/26/2007 FORM APPROVED OMB NO: 0938-0931 (X3) DATE SURVEY COMPLETED 337301 NAME OF PROVIDER OR SUPPLIER 13.WING S'TREII' ADDRESS. CITY, STATE. ZIP CODE 12/27/2007 AMERICARE CERTIFIED SPECIAL SERVICES (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFIENCIES (EACI DEFIENCY MUST BE PRECEEDED) BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 PROVIDER'S PLAN OF CORRECTION (EACI I CORRECIIVE ACIION SI IOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEHENCY) (X5) COMPLETIrON DATE G 176 Continued from page 64 (Medication Administration Record) at ACF was reviewed and documents that as of 11/09/07 the ."Tylenol 325 mg 2 tabs every 4 hours for pain" was discontinued. Djuring interview with the nurse, she stated that she was "not aware of the discontinuation of Tylenol." During the home visit on 11/20/07 at 10:00 AM, the MAR at ACF documents that on 11/09/07 Tylenol 325 mg 2 tab PO every 4 hours for pain was discontinued. The clinical record continued to document on the SN visit notes that the patient was taking Tylenol 500 mg tabs 4 x day 1'O on 11/15 PM, 11/21 AM, 11/22 AM and PM, and 11/23/07 AM and PM Visits. The nurse failed to provide effective coordination with the ACF staff, physician and the Nursing Supervisor regarding the patient's mediation G 176 regime. On 11/26/07 at 2:30 PM, the Administrative staff were informed of the survey findings and were given an opportunity provide an explanation. Oi 11/27/07, no explanation was provided by the agency. Patient #18 was admitted to the agency on 10/25/07 with diagnoses of Cellulitus and Depressive Disorder. The Plan of Care dated 10/25-12/23/07 ordered SN daily x nine (9) days and one (1) every other week for wound care on Right Plantar, cleanse and apply Silvadene cream to area and cover with 2x2/4x4 kling. CMS-2567 (02-99) Previous Versions Obsolete FO6kRM Evet ID: I RU II Facility ID: 4706A If continuation sheet Page 65 of 89 Amendd x I DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES OF DEFICIENCIES 'ATEMENT .JD PLAN OF CORRECTION (XI) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUIBER: 337301 B. WING PRINTED: 12/26/2007 FORM APPROVED , OMB NO. 0938-0931 (X2) MUL1[PLE CONSTRUC'ION A.B UILIIN__ (X3) DATE SURVEY COMPLETED 12/27/2007 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. Z1' CODE AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNITS (X4) 11) PREFIX TAG SUMMARY STATEMENT OF DEFIENCIES (EACH DEFIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG 900 MERCIIANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 PROVIDER'S PLAN 0r,CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSSREFERENCED TO THE APPROPRIATE DEFIENCY) (X5) COMPLETION DATE G 176 Continued From page 65 The Progress noted dated 11/09/07 documents: the "patient was seen at the wound care and the wound care to the Right Plantar remains the same-which is cleanse with Norinal Saline, apply Silvadene ointment to dry sterile dressing daily." ( 176 The note further documents that the physician wants "Aquaphor ointment to patient's shin on legs and around wound daily x fourteen (14) days but the medication may not arrive until Monday 11/12/07." The SN visit notes documents that the nurse visited daily and provided wound care to Right Plantar wound. The visit note of 11/10/07 lacked documentation that the nurse applied Silvadene cream after,cleansing the wound with Normal Saline. There is no documented eviden~ce that SN visits from 11/11 to 11/20/07. The Plan of Care dated 10125-12/23/07 documents mulliple medications as follows: Multivitamin with minerals 1 tab daily, Zoloft 50 mg-I tab daily, Zyprexa 2.5 tng J tab daily, Rantidine HCL 75 mg 2 tabs every twelve (12) hours, Zocor 40 mg I tab daily, Keflex 500 mg I tab 4x daily x 5 days, Probiotic Acidophilus Cap I tab daily x 10 days, Aspirin 81 Tog I tab daily, Buspar. 10 mg daily, Folic Acid I mg I tab daily, Thiamine HCL 100 mg 1 tab daily,Regranex 0.01 % gel topical; daily to the right instep, Silvadene 1 % cream topical;daily apply to Plantar. It should be noted that theses medications were listed more then once on the 485. On 11/23/07, the Nursing Supervisor wrote a Physician Supplemental Orders for certification k-ORM CMS-2567 (02-99) Previous Versions Obsolete Event ID: I11 I Faciily ID: 4706A If continuation sheet Pag 66 of Amendecd x I 9 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES ATFMENT OF DEFICIENCIFtS (XI) PROVIDER/SUPPLIEI/CLIA IDENTIFICATION NUMBER: 337301 13.WING PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X2) MUL'ITPLECONSTRUCTION A.BUILDING AND PLAN OF CORREC'ION (X3) I)ATE SURVEY COMPLETED 12127/2007 NAME OF PROVIDER OR SUPPLIER STRE5T" ADDRESS, CrIY, STATE, ZIP CO1)E AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNITS (X4) ID PREFIX TAG SUMMARY STAIEMENI OF DEFIENCIES (EACIH DEFIENCY MUST BE PRECEEI)ED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID I'REFIX TAG 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 PROVIDER'S PLAN OF CORRECIION (EACH CORRECIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFIENCY) (X5) COMPLEI'JON DATE G 176 Continued From page 66 .period for 10/25-12/23/07 which included medications as follows: Augmentin 8.75 Ing twice a day PO (by mouth) discontinued on 11/03/07, Zoloft 50 mg daily PO,Buspar 15 mg P0 daily, Zocor 20mg daily PO,Zyprexa 2.5 mg 10 daily, and Silvadene cream I % to Right 'lantar daily. On 11/24/07, the Nursing Supervisor wrote additional Physician Supplemental Orders that include orders for additional medications such as Mutivitamins with minerals, Aspirian, Rantidine, Folic Acid, Thiamine HCL, Keflex, and Regranex Ointment. The Medication Administration (MAR) from the ACF dated for October 25 and November 2007 documents that the patient was on the following medications: Augmentin 875 mg twice a day PO (by mouth) discontinued on 11/02/07, Zoloft 50 mg daily PO,Buspar 15 mg daily PO,Zocor 20 mg daily PO,Zyprexa 2.5 mg PO daily, Silvadene cream apply to wound daily by agency RN and Regranex 0. 1 ointment apply once a day by agency RN. Further review of the MAR documented thatthe following medications were discontinued on 10/24/07: Folic Acid, Thiaminie HCL, Aspirin, Ascorbic Acid, Multivitamins, Siruvastin 40 mg and Rantidine. The agency SN and/or the Nursing Supervisor failed to review, coordinate and provide effective coordination with the physician regarding the patient's current medication regime. On 11/26/07 at 2:30 PM, the Administrative staff were informed of the survey findings and were given an opportunity to provide an explanation. On 11/27/07 no further information was provided by the agency. G 176 9 Event ID: I RU I Facility tD: 4706A continuation sheet Page 67 of 19 If Amended x I FORM CMS-2567 (02-99) Previous Versions Obsolete DEPARTMENT OF IEAI'fl AND HUMAN SERVICES CIEINTERS FOR MEDICARE AND MEDICAI) SERVICESo VTATEMENT OF DEFICIENCIES -1D PLAN OF CORRECTION (X1) PROVIDER/SUPPLIERVC1A IDENTIFICATION NUMBER: (X2) MULTIPLE CONS-rRUCI71ON A.BUILDING PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X) DATE SURVEY COMPLITED 337301 B.WING 12/27/2007 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE, ZIP CODE AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNITS 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590) (X4) ID PREFIX TAG SUMMARY STATEMENT OF I)EFIENCIES (EACH DEFIINCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMA'I1ON) . ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACII CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFIENCY) (X5) COMPLETION DATE G 176 Continued From page 67 Patient #19 was admitted to the agency on 08/16/07 with diagnoses including Diabetes Mellitus, Hypertension and Respiratory Neoplasm. The clinical record documents multiple discrepancies in patient's medications on the current Plan of Care dated 10/15-12/13/07 and the ACF MAR (Refer to G 173). o The agency Skilled Nurse failed to review, coordinate with ACF staff, inform Nursing Supervisor and with the physician regarding the patient's current and accurate medication regime. On 11/26/07 at 2:30 PM, the Administrative staff were informed of the survey findings and were given an opportunity to provide an explanation. On 11/27/07 no clarification was provide by the Administrative staff. Patient #6 was admitted to the agency on 03/31/05 with diagnoses of Schizophrenia, Diabetes Mellitus, and Chronic Airway Obstruction. The Plan of Care dated September 2007 to 01/14/08 orders: Skilled Nursing services every other week to .... symptom management hydration/nutritional status.... Weigh monthly....-Ialdol 75 ing injection every 4 weeks.... Finger stick every other week." The Nursing Visit note dated 10/31/07 documents that the nurse observed the patient and noted "Thin lady appears to be "wasting" away....". The note lacked documentation of the patient weight and notification of the physician.7A) G 176 FORM CMS-2567 (02-99) Previous Versions Obsolete Event ID: RiJI I Facility ID: 4706A if continuation sheet Page 68 of 89 Amended x I DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES ATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDERISUPPLIERICLIA IDENTIFICATION NUMBER: 337301 B. PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X2) MULTIPLE CONSTRUCTION A.BUILDING A&" (X3) DATE SURVEY COMPLETED 1?i27/2007 WING STREEI' ADDRESS. CITY. STATE. ZI' CODE NAME Of1PROVIDER OR SUPPLIER AME RICARE CERTIFIED SPECIAL SERVICES SUB-UNITS 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEF1ENCIES (EACH DEFIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO TILE APPROPRIATE DEFfENCY) (XS) COMPLETION DATE G 176 Continued From page 68 There was no documentation of how the nurse knew the physician was aware or if the Plan of Care required revision. There is no documented evidence that the nurse spoke to the HHA who provides care to this patient seven (7) days x two (2) hours a day and is to "Remind patient to go to Dining Room.... as per the Aide's Plan of Care. There is no documentation that the nurse case conferenced with the ACF staff regarding the patient's intake and if there has been any changes. During the nursing visits on 10/03/07, 10/10/67, 10/24/07 and 10/31/07, Haldol was administered on 10103/07 and finger sticks were done on 10/10 and 10/24/07. The nursing visits were documented as 10-15 minutes in duration. The Progress Note dated 10/31/07 documents a weight of "113 lbs" which was a 6lbs loss from September. The note documents that the Nursing Supervisor "suggested" that the nurse speak to the physician regarding blood tests. The findings were'reviewed on 11/27/07 at 11:00 AM with the DPS of Westbury, the DPS of Brooklyn appoiited by the parent agency to deal with the Department of Health issues and Nursing Supervisors. No further information was provided. Patient #9 was admitted to the agency on 09/05/07 with diagnoses of Mental Retardation and Hypertension. G 176 FORM CMS-2567 (02-99) Previous Versions Obsolete Event ID: IRIJ I Facility ID: 4706A If continuation sheet Page 69 of 89 Amended x I DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES -TATEMENTOF DEFICIENCIES 'ID PlAN OF CORRECrON (XI) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 337301 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION ABUILDING PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X3) DATE SURVEY COMPLEFED 12/27/2007 B. WING STREET ADDRESS, CFIY. STATE, ZIP CODE AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNITS (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFIENCIES (EACH DEFIENCY MUST BE PRECEDEI) BY FULL REGUIA'ORY OR LSC IDENTIFYING INFORMATION) Il) PREFIX TAG 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 PROVIDER'S PLAN OF CORRECttON (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFIENCY) (X5) COMPLETION DATE G 176 Continued From page 69 The Plan of Care dated 11/04/07 - 01/02/08 orders Home Health Aide (1-f-IA) services "5 days x I hour" for assistance with activities of daily living and personal care. The sixty (60) day summary dated 10/30/07 documents that the patient receives "6 days x 1 hour" and the Progress Note also dated 10/30/07 and 11/02/07 documents that the patient needs six (6) days of hha service and "Must be prompted & encouraged to participate inpersonal hygiene". The record lacked documentation of the change in the patient's needs or that the nurse notified the physician of the patient's need for an additional day of H-A services. The finding was reviewed on 11/27/07 at 1 1:00 AM with the DPS of Westbury, the DPS of Brooklyn, and the Nursing supervisor. No further information was provided. Patient #10 was admitted to the agency on 9/19/07 with diagnoses o1 Cellulitus of the legs, Congestive Heart Failure, Dementia, Diabetes Mellitus Type II, and Depressive Disorder. The Plan of Care dated 9/19-11/17/07 ordered SN two (2) x day x sixt (60) days to "apply Lotrisone to right lower extremity:" The clinical record lacked documentation of coordination of the services for nursing visit times and informing.the physician of changes in the nursing visit frequency. The nursing revisit notes document that the nurse visited on 09/22/07 at 3:30 PM - 3:45PM and again at G 176 FORM CMS-2567 (02-99) Previous Versions Obsolete Event ID: IRU 1I Facility ID: 4706A If continuation sheet Page 70 of 89 Amended x I ,>'PARTMENT OF HEALTH AND HUMAN SERVICES .qTERS FOR MEDICARE AND MEDICAID SERVICES PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X2) MtJI.IPLE CONSTRUCTION (X3) DATE SURVEY COMPLEI'EI) STIATEMENTOF DEFICIENCIES AND PLAN OF COIRECTIION (XI) PROVIDERI/SUPPLIER/CLA IDENTIFICATION NUMBER: A.B UILDING B. WING 337301 12/27/2007 NAME OF PROVIDER OR SUPPLIER S'REET ADDRESS, CITY, STATE, ZIP CODE AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNITS (X4) ID PREFIX TAG SUMMARY STATEMENTOF DEFIENCIES (EACH DEFIENCY MUST BE PRECEEDED BY FUU REGULATORY OR LSC I)EN'I'IFYING INFORMATION) I1) PREFIX TAG 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REPiRENCE) '1 T''IlE AIROPRIA'IE DEFIENCY) (XS) COMPLETION DALE G 176 Continued From page 70 4:00 PM - 5:00 PM. The nursing revisit note dated 9/28 documented a visit from 8:30 AM 8:50 AM. The record lacked documentation of an afternoon visit. On 9/29 visits were made at 3:00 PM - 3:15 PM and again at 4:00PM - 5:00PM. On 9:30 only. one visit was made at 12:00 PM- 12:30 PM. The record lacked documentationi that the physician was notified of the missed visits. On 10/06 visits were made at 2:50 I'M - 3:10 PM and again at 4:00 PM-. 5:00 I'M. The nurse failed to coordinate services to ensure treatment to the patient's leg was administered at appropriate intervals to meet the patient's condition and needs. An interview with the DPS from Wcstbury office on 11/26/07 at 2:30 PM, the DPS stated that the twice a day visits, "the interval for visits should be at least seven (7) hours in between the visits". On 11/26/07 at 3:00 PM the findings were reviewed with the Administrative staff and were given an opportunity to provide and explanation. On 11/27/07 at 1:15 PM, the Nursing Supervisor acknowledged the survey findings. Patient #13 was admitted to the agency on 08/08/07 with diagnoses of Tear Film Insufficiency, Glaucoma, Depressive Disorder, and an interim order dated 10/22/07 documented a new diagnoses of NIDDM (Non-Insulin Dependent Diabetes Mellitus) with an order for SN visits to perforn fingerstick twice a day (BID). An interim order lacked parameters for Blood G 176 sugars. FORM CMS-2567 (02-99) Previous Versions Obsolete Event ID: IRIJI I Facility 11): 4706A If continuation sheet Page 71 of 89 Amended x I DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR ME1)ICAREAND MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION " (XI PROVIDER/SUPPLIERICLIA IDENTIFICAI1ON NUMBER: PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X2) M ULTIPLE CONSTRUCTION A,BUIDING (X3) DATE SURVEY COMPLETED 12/27/2007 B. WING STREEI ADDRESS, CITY, STATE, ZIP CODE 337301 NAME OF PROVIDER OR SUPPLIER AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNITS (X4) ID PREFIX TAG' SUMMARY STATEMENT OF DEFIENCIES (EACH DEFIENCY MUST BE PRECEEDED BY FULL REGULATORYOR LSC IDENTIFYING INFORMATION) 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO TIlE APPROPRIATE DEFIENCY) (X5) COMPLETION DATE G 176 Continued From page 71 The nursing visit notes documents, elevated FS (fingerstick) on the following ovisit notes: 10/24/07 -FS=265; 10/25/07 - FS=227; and 11/02/07 FS=287. The record lacked documentation that the physician as notified of these elevated blood sugar levels. During an interview with the Nursing Supervisor on 11/28/07 at 1:40 PM, the supervisor did not provide an explanation. Patient #16 was admitted to the agency on 06/09/07 with the diagnoses including Glaucoma and Hypertension. The Plans of Care date 08/08 to 10/06/07 and 10/07 to 12/05/07 ordered "SN 2 Day 60 (twice a day for sixty days)" to administer eye drops and to "'report B/P (Blood Pressure) <90/60> or >140/90 to MD" and "RN will monitor C/P (cardio pulmonary), C/V (cardio vascular) status". The Plans of Care ordered the antihypertensive medications. "Norvasc 5mg oral daily (the medication doses was changed to 10mg on 10/07/07) and Tprol XL 100mg tablet SR 24 hr oral daily". The Skilled Nursing visit notes lack documentation that the Skilled Nurse and/or the Nursing Supervisor notified the physician when the patient's BP readings had exceeded the ordered Blood Pressure parameters (report when blood pressure is more than 140/90). For example: On 08/10/07 - (10:00 AM visit note) the Blood G 176 Pressure was documented as 161/83.( FORM CMS-2567 (02-99) Previois Vcisions Obsolete Event ID: I RI II Facility ID: 4706A If continution sheet Page 72 of 89 Amended x I ,1Th)1PARTM.ENT OF HEALITH AND HIUMAN SERVICES *TERS FOR MEI CARE AND MEDICAID SERVICES o __ STATEMNT OF DEFICIENCIES. AND PLAN OF CORRECIION (XI) PROVIDER/SUPPLIER/CI.IA IDENTIFICATION NUMBER: 337301 _ PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X3) DATE SURVEY COMPLETED . (X2) MULITPLE CONSTRUCTION A.BUILDING 12/27/2007 B. WING STREEI- ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNITS 900 MERCHANTS CONCOURSE SUITE 1,L:15 WESTBURY, NY 11590 PROVIDER'S PLAN OF CORRECTION (EACIt CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFIENCY) (X5) COMPLE'ION DATE (X4) ID) PREFIX TAG SUMMARY STATEMENT OF DEFIENCIES (EAC IDEFIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG G 176 Continued From page 72 08/11/07 - (2:30 PM visit note) BP was documnted, as 140/96. 08/12 (10:30 AM visit note) 1P was documented as 159/89 and (1:30 PM visit note) BP was documented as 183/115. The visit note of 08/13 at 3:25 I'M, the note lacked documentation of the patient's vital signs; on 08/16 (8:15 AM visit note) BP was documented as 146/86. On 8/22/07 (3:50 PM visit note) the BP was documented as 156/92 On 8/25/07 (8:25 AM visit note) the BP was documented as 180/79. On 8/26/07 (4:40 PM visit note) the 13P was documented as 130/100. On 09/01/07 (2:40 PM visit note) the BP was documented as 163/95. On 09/03 (9:15 AM visit note) lacked documentation of the patient's vital signs. On09/09 (3:00 PM visit note) the BP was documented as 138/100. On 09/14 (7:15 AM visit note) BP was documented as 160/89. On 09/17 (9:40 AM visit note) 131' was documented as 150/87. On 09/20 (2:15 PM visit note) the BP was documented as 157/96. G 176 7-, Event ID: IRIJI I Facility I): 4706A If continuation sheet Page 73 of 89 Amended x I FORM CMS-2567 (02-99) Previous Versions Obsolete DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES ATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDER/SUPI'PLIERICLIA IDENTIFICATION NUMB ER: PRINTED: 12/26/2007 FORM APPROVED OM13 NO. 0938-0931 (X2) MULTIPLE CONSTRUCTION A.BUILDING o_12_27/2007 (X3) DATE SURVEY COMPLETED 1212712007 337301 NAME OF PROVIDER OR SUPPLIER B. WING STRIEET ADDRESS, CITY, STATE, ZIP CODE AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNITS (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFIENCIES (EACH DEFIIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INt)RMATION) 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 ID PREFIX 'TAG PROVIDER'S PLAN OF CORRECTION (EACII CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFIENCY) (X5) COMPLEION DATE G 176 Continued From page 73 On 09/21 (9:15 AM visit note) lacked documentation Of the patient's vital signs; On 09/23 (10:00 AM visit note) BP was documented as 142/94 and (3:00 PM visit note) BP was documented as 157/107; On 09/25/07 and 09/26/07 (PM visit notes) lacked documentation of the patient's vital signs, On 09/29/07 (9:00 AM visit note) die BP was documented as 159/114. On 09/30/07 (5:00 PM visit note) BP was. documented as 149/99. On 10/02/07 (7:45 AM visit note) the BP was documented as 146/90; On 10/05/07 (8:15 AM visit note) the BP was documented as 146186; On 10/27/07 (6:45 AM visit note) the BP was documented as 157192; On 10/28/07 (6:30 AM visit note) the BP was documented as 147/91: On 10/31/07 (2:30 PM visit note) BP was documented as 150197 On 11/0107 (9:15 AM visit note) BP was documented as 155/88; On 1/02 (8:00 AM visit note) BP was documented as 147/95, G 176 -77(.. Facility ID: 47t6A If continuation sheet Page 74 of 89 Amended x I On 11/04/07 (9:30 AM visit note) FORM CMS-2567 (02-99) Previous Versions Obsolete BP was Event ID: IRUII DEPARTMENT OF HEALTH AND HUMAN SERVICES "NTERS FOR MEDICARE AND MEDICAID SERVICES STATEMENTOF DEFICIENCIS AND PLAN OF CORRECTION (XI) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER; PRINTED: 12/27/2007 FORM APPROVED OMB NO. 0938-0931 (X2) MULTIPLE CONSTRUCTION A.BUIfLDING (X3) DATE SURVEY COMPLE 12127/2007 337301 NAME OF PROVIDER OR SUPPLIER B. WING STREET ADDRESS, CITY. STATE. ZIP CODE AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNITS (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEPTENCIES (EACH DEFfENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 ID PREFIX TAG PROVIDER'S PLAN OF CORRECIION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REIFERENCE "1"I' TIlE APPROPRIATE DEFIENCY) (X5) COMPLETION DATE G 176 Continued From page 74 documented as 147-90 amnd (3:45PM visit note) BP was documented as 154/102. On 11/26/07 at 1:50 PM the Administrative stalf were informed of the survey findings and were given an opportunity to provide an explanation. The Nursing Supervisor stated that the SN should have notified the physician regarding the patient's 11P readings. On 11/27/07 at 11:20 AM, the agency's staff presented a note that lacked the title and the agency's name. The note was typed on a regular piece of paper and was faxed to the agency from the Assisted Living Facility on 11/27/07 at 8:44 AM. The note was signed by the nurse and was not dated. The note documented: "On these dates: 8/26/07, 8/22/07, 9/1/07, 9/9/07 pt (patient) had blood pressure as follows:.8/26-130/100, 8/22-156/92, 9/1-163/95, 9/9- 138/10. As per physician at Assisted Living Facility, she did not G 176 want to be called for any patient on services unless patient was symptomatic and exhibiting symptoms. The Patient was not symptomatic during the dates stated above.:" The Plan of Care dated .11/07 to 12/05/07 and the clinical record lacked documentation of the physician order that documents that the physician did not want to be notified regarding the patient's elevated BP readings. The Plans of Care and the clinical record also lacked documentation that the ordered BP parameters had been revised and/or discontinued. The clinical record lacked documentation of the coordination and management of the patient's cardiovascular o status by the SN and the nursing supervisor. FORM CMS-2567 (02-99) Previous Versions Obsolete Event ID: I RII I I Facility t1: 4706A if coutunation sheet Page 75 of i9 Anien6d x I DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES __OMB PRINTED: 12/26/2007 FORM APPROVED NO. 0938-0931 (X2) MULTIPLE CONSTRUCTION A.BUIIDING - ATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED 12/2712007 337301 NAME OF PROVIDER OR SUPPLIER B.WING STREET ADDRESS, crrY, STATE, ZIP CODE 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECIVE ACTION SHOULD BE CROSS-REPERENCED TO THE APPROPRIATE DEFIENCY) (X5) COMPLEIION DATE AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNITS (X4) II) PREFIX TAG SUMMARY STATEMENT OF DEFIENCIES (EACH DEFIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) G 176 Continued From page 75 The agency staff could not provide an explanation for the SN and/or the nursing supervisor ' failure to notify the physician regarding the patient's BP readings that exceeded the BP parameters as ordered in the Plans of Care. Patient #2 was admitted to the agency on 11/01/05 wotj the diagnosis including Diabetes Mellitus Type II. The Plans of Care dated 08/23 to 10/21/07 and 10/22 to 12/20/07 prdered the "SN 2 Day 60 (twice a day for sixty days) perform FS (finger stick) BI) (twice a day), administer Insulin as ordered BID..... The Plans of Care under the section titled as "Mental Status" documented that the patient is "oriented and forgetful". The SN visit note dated 09/01 (2:15 PM visit) documented that "patient on home leave till 09/04/07". The clinical record and the SN visit notes lacked documentation of the responsible person to perform the twice a day blood sugar monitoring and administration of twice a day Insulin while the patient is on the home leave. The subsequent SN visit notes failed to document how the patient's Diabetic management would be coordinated while on home leave, such as: on 09/13 (PM visit) home visit till 9/15, on 10/12 (PM visit) home visit till 10115 and on 11/11/07 (AM visit) documented that the patient refused the SN visit. The record lacked documentation that the SN had notified the physician that the patient refused the visit aid that the patient did not G 176 receive the ordered AM Insulin dose. FORM CMS-2567 (02-99) Previous Versions Obsolete '- I?1 Event ID: IRUI I Facility ID: 4706A If continuation sheet Page 76 of 89 Amended x I DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES o ,WEMENT OF DEFICIENCIES AND PLAN OF CORRECtiON (XI) PROVIDER/SUPPLIER/CLIA _OMB PRINTED: 12/26/2007 FORM APPROVED NO. 0938-0931 (X2) MULTIPLE CONSTRUCTION A.BUILDING (X) DATE SURVEY COMPLETED 1227/2007 IDENTIFICATION NUMBER: 337301 NAME OF PROVIDER OR SUPPLIER B. WING STREtTI" ADDRESS, crIY,STATE, ZIP CODE AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNIT (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFIENCIES (EACH DEFIENCY MUST BE PRECI3,EDED 13Y FULL REGU'lVATORY OR LSC IDENTIFYING INFORMATION) 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION o (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFIENCY) (X5) COMPLETION DATE G 176 Continued From page "6. During interview on 11/26/07 at 1:00PM with the Nursing Supervisor and the DPS, the agency staff confirmed the survey findings. On 11/27/07 at 11:00 AM the agency's staff presented : "Progress Note" dated "11/26/07" that was documented by the nurse. The Progress Note was faxed to the agency form the ACE on 11/27/07 at 8:59 AM. The note included an "Addendum to certification period from 10/22-10/20/07,'Patient goes On frequent home visits. Americare RN (registered nurse) prefills insulin syringes. Pt (patient) tests FS and administers Insulin with her son supervision and verbal cuing: Pt is unable to independently prefill syringes". The clinical record lacked any documentation of the coordination of the patient's Diabetic status by the SN and the nursing supervisor when the patient was on home visits. G 176 G 229 . 484.36(d)(2) SUPERVISION The registered nurse (or another professional described in paragraph (d) (1) of this section) must make an on-site visit to the patient's home Americure CSS Director or Patient Services ensure will HHA Supervision isbeing done per regulation on all Patients receiving I-IlIA services, the RN must observe HHA skilled in accordance to Conditions of Participation. Patienits receiving non-skilled personal care services will be supervised every 60 days in accordance to NYS 2 e ttding care ev'e, weeks if the case is -no less frequently thai every 2 weeks. o , This STANDARD is not met as evidenced by: Based on clinical record reviews and slaff Home Health Aides (H1-1A) no less frequently that interviews, the agency failed to supervise the every two (2) weeks. This was evident for five (5) of fourteen (14) clinical records of patients receiving Home Health Aide (HHA) services. FORM CMS-2567 (02-99) Previous Versions Obsolete Event ID: I RII I Medicaid Regulations. In-service education reeardino thteIOH renulation HHA sunervision was conducted o 2008 & Suffern on Jan. in Westbury Jan 10, 2008. A corrective memo to all Adult 16, Care Facility nurses to clarify supervisory 1) .i/ea/ahmt cu A /7 _ Facility ID: 4706A if continuation sheet Page 77 of 89 Ameanded x I 7 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES STATEMENT OF DEFICIENCIES A.NI) I'.AN OF CORRECTION (Xl) PROVIDER/SUPPLIERICLIA IDENTIFICATION NUMBER: 337301 PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X2) MULTIPLE CONSTRUCTION A.BUILDING (X3) DATE SURVEY COMPLETED 12/27/2007 1 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUB-UNITS AMERICARE CERTUIFED SPECIAL SERVICES (4) ID 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECIVE ACTION SHOULD BE CROSS-REFERENCED TO TI'tE APPROPRIATE DERENCY). Arnericare CSS Supervisors will make wekly sunervisorv visits to all the Adult Cwe Focilitics to ensure that skillcd tnsing agency's services are providcd to tie patients and to ensure HHA sapervision is being done per regulation. The Supervisory staff will provide onsite over site of nursing and home health aide staff. Agency's System Analyst/Operations '],he Manager developed and will update an IIIIa Supervision Tracking calenda" by ACF on all patient's receiving IIIA PREFIX TAG SUMMARY STATEMENT OF DEFINCIE"S (EACH IEFIENCY MUST BE PRECEEDED BY FULL REGULAIORY OR LSC IDENTIFYING INFORMATION) (X5) COMPLETION DATE G 229 Continued From page 77 #6, (Patients #4, #8, #15, and # 18). (Pt.t G229 This is a repeat deficiency from the survey of 6/4/07 The agency's continued failure to supervise th Iha every two (2) weeks places the patients at risk for receiving poor quality care. The findings include: Patient #6 was admitted to the agency on of SWdtc)sdiy) 03/31/07 with d Schizophr-enia, Diabetes Melldiagnoses Diabetes Mellitus, and Chronic Airway Obstruction. 2007 to Care doffice. The Plan o nof e dated- September present orders: HHA services seven (7) days x two (2) hours a day. The clinical record lacked documentation of HA supervision belween 09/13 - 10/09 and 10/11 - services. The. System Analyst/Operations Manager will run a weekly report (every of un-submitted HHA notes superisory visit by Adult Care Facility Nurse. The ACF nurse will be cotacted and asked to fax the IIlIA supervisory note into the Chronic offenders will be required hand to come to office on a weeklv basis to in their HI-IA supetision notes. Chronic offenders will also receive re-education and a. written disciplinary warning. If noncompliance continues further disciplinary actions will be taken The DPS is responsible to ensure that 100% clinical Charl audits are done on a to ensutre quarterly basisbeing done IIItA per regulation. super"'sion is (See ttachnaenl # 18 IflA Supervisory Audit Tool) 11/12/07. The finding was reviewed with ny agency staff on 11/27/07 at 11:00 AM and no explanation or additional information was provided. f Patient #15 w,-s admitted to the agency on 07/30/07 with the diagnosis including Schizoaffective. The Plans of Care dated 07/30 - 09/27/07 and 09/28 - 11/26/07 orders: I--TA five (5) days a week x one (1) hour a day for nine (9) weeks to assist/direct the patient with activities of daily living. The clinical record lacked documentation that the "r'-RMCMS-2567 (02-99) Previous Versions Obsolete Event ID: I RU II / T/ 6 " / Facility I): 4706A If continuation sheet Page 78 of 89 Amended x I DEPARTMENT OF HEALTH AND HUMAN SERVICES CENIThRS FOR MEDICARE AND MEDICAID SERVICES ['ATEMENT OF DEFICIENCIES ID PLAN OF CORRECI'ON (X1) PROVIDER/SUPPIJERICLIA IDENIlfICATION NUMBER: 337301 NAME OF PROVIDER OR SUPPLIER (X2) MUIJIP'LE CONSTRUCTION A.B3UILDING PRINTED: 12/26/2007 FORM APPROVEI) OMB NO. 0938-0931 (X3) DATE SURVEY COMPLETED 12/27/2007 B. WING STREET ADDRESS. CITY, STATE, ZIP CODE 900 MERCHANTS CONCOURSE SUITE LL-15 AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNITS (X4) 11) PREFIX TAG SUMMARY STATEMENT OF DEFIENCIES (EACH DEFIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC i)ENTIFYtNG INFORMATION) WESTBURY, NY 11590' ID l'REFI'I TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DFIENCY) (X5) COMPLETION DATE Continued From page 78 G 229 G 229 Skilled Nurse (SN) performed Home Health Aide supervision from 10/03 - 10/29/07. On 11/26/07 at 2:00 PM the Administrative staff were informed of the survey findings and were given an opportunity to provide an explanation. On 11/27/07, the agency acknowledged the findings and could not provide an explanation why the SN failed to si pervise,the hha every two (2) weeks. Patient #4 was admitted to the agency on 10/06107 with the diagnosis including Diabetes Mellitus Type 11. The Plan of Care dated 08/20- 09/30/07 ordered IHA seven (7) days two (2) hours a day tr nine (9) weeks to assist tle patient with personal care. The clinical record lacked documentation that the SN had performed Home Health Aide supervision from 08/24 - 09/19/07. During an interview on 11/26/07 at 2:00 PM with the Nursing Supervisor and the DPS from Westbury, and the DPS of Brooklyn who was appointed by the parent agency to deal with department of Health issues, the agency staff did not provide art explanation for the survey findings. Patient #8 was admitted to the agency on 10/18/07 with diagnoses including Diabetes Mellitus, Chronic Airway Obstructive, Hypertension, and Goiter. The Plan of Care dated 10/18 - 12/16/07 ordered hours a day -HHIA five (5) days a week x one (1) for nine (9) weeks to assist the patient with personal care, ADLs, Ensure safety and hyg'iene. FORM CMS-2567 (02-99) Previous Versions Obsolete ____ Event ID: I RIJI I Facility ID: 4706A If continuation sheet Page 79 of 89 Amended x I , DEPAR'MENT OF HEALTH AND HUMAN SERVICES CENTERS FOR ME'DICARE'AND MEDICAID SERVICES ,'ATEMENTOF DEFICIENCIES ID PLAN OF CORRECTION I' PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X2) MULTIPLE CONSFRUCION . A.BUILDING (XI) I'ROVIDER/SUPPLIER/CLA (X3) DATE SURVEY COMPLETED IDENTIFICATION NUMBER: 337301 NAME OF PROVIDER OR SUPPLIER B.WING STREET ADDRESS. 2 1 12/27/204)7 crIry. STATE, ZIP CODE AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNITS (X4) ID PREFIX TAG SUMMARY S'I'AIEMENTOFDEIHIENCIES (EACH DEFIENCY MUST BE PRECEEDED BY FULL REGULATIORY OR LSC IDENTIFYING INFORMATION) 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACII CORRECIVE ACTION SHOULD BE CROSS-REFtERENCEDI TO '1IE APPROPRIATE DEFIENCY) (XS) COMPLETION DATE Continued From page 79 G 229 G 229 The record documentation that the HH4A was placed on the case on 11/01/07. The record lacked documentation of IHA supervision from 11/01 11/27/07. During an interview the with the Nursing Supervisor on 11/27/07 at 11:45 AM, the Nursing Supervisor could not provide an explanation for the lack of bi monthly HHA supervision. Patient #18 was admitted to the agency on 10/25/07 with diagnosis of Cellulitis and Depressive Disorder. The Man of Care dated 10/25 - 12/23/07 ordered SN services for wound care andHHA supervision. The record lacked specific orders for HHA services (Refer G159) yet the record included duty sheets for HHA services on the following days: 10/27- 10/28, 11/03- 11/04 and 11/1011/11/07. The record documented that the HHA was placed on this case on 10/27/07. The record lacked documentation of HHA supervision from 10/2711/27/07. On 11/26/07 at 2:30PM, the Administiative staff were informed of the survey findings and were given an opportunity to provide an explanation. On I1/27/07, the agency provided a Physician Supplemeital Orders dated 11/24/07 (which was after the survey was in progress) for certification period dated 10/25 - 12/23/07 "Please note omission of IlA services 10/25/07 485; Pt Event ID: I RIJI I Facility ID: 4706A !Icotinuation sheet Page 80 of 89 Amended x I FORM CMS-2567 (02-99) Previous Vcrsions Obsolete STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A.BUILDING (X3) DATE SURVEY COMPLETED 337301 ,ME PROVIDER OR SUPPLIER OF 12/2/2007 B. WING STREET ADDRESS, CITY, STNTE, ZIP' CODE 900 MERCTIANTS CONCOURSE SUITE LL-15 AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNITS (X4) ID PREFIX TAG WESTBURY, NY 11590 (X5) COMPLE1ION DATE SUMMARY STATEMENT OF DEFIENCIES (EACII DEFIENCY MUST BE PRFCFEEDED BY FULL REGULATORY OR LSC IDENIIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-RIFERENCED TO THE APPROPRIATE DEFIENCY) G 229 Continued From page 80 (Patient) with HHA services as of SOC (Start of Care) 10/25 7D x 2HI x9 weeks assist with Personal, ADL care". During an interview with the Nursing Supervisor the on 11/27/07 at 11:45 AM, Nursing Supervisor stated that she "picked up the omission of HHA services during record review." The Nursing Supervisor could not provide an explanation for the SN failure to supervise the hha every two (2) weeks as per the Plan of Care. G 229 G. 236 REPEAT DEFICENCY FROM 00/04/07 SURVEY 484.48 CLINICAL RECORDS A clinical record containing pertinent past and (G236 Current findings in accordance with acccpted professional standards is maintained for every The Director of Patient Services for both Westbury & Suffern offices is resptonsible to ensure that all Patient Clinical Records contain pertinent past and curtrt findings in accordance to accepted professional sctadards is maintained for ever' active patient receiving home care seivices. lIn addition to the plan of care, the record patient receiving home health services. In addition to the plan of care, the record contains appropriate identifying information; name of physician; drug, dietary, treatment, and activity orders; signed and dated clinical and progress coitains appropriate identil'iag information: name of the physician; drug. Ireatameti, and activity orders; dictarv sitoed and dated clinical and progress notes; copies of summary reports sent to the attending physician: and a discharge notes; copies of summary reports sent to the. attending physician; and a discharge summary. sutnstary. Te RN in the Adult Facility is responsible to obtain Physician Orders and develop the initial and subsequent Plan of Care (485) in cottjunction with the patient and the primary patient's physician. The Supervisor Assistant will check every new Plan of Cam (485) for completion by: Checking the curreot 485 ttd all .. interit orders generated within the original day period against the Plan of Care 485 generated at the SOC and/or the pivvious 485 for any This STANDARD is not met as evidenced by: Based on clinical record reviews, Policy/Procedure review, and staff interviews, the agency failed to ensure that the clinical records * were complete ad curent. This was evident for (8)of nineteen (19) clinical records reviewed. (8)60#3, (Patients # 1, #5, #7, #8, # 13, # 16, and #18) The agency's failure to ensure that the clinical records are maintained complete and current places the patients at risk for not having their care discrepancies If disccepancies are present. the Supervisor Assistant will immediately notify tte primary nurse ant Nursing Supervisor of the findings. The primary nurse and/or tle Nursing Supervisor will inake the required corrections tud verify the orders with the primary MD. The Supervisor Assistant will print the to or Plan of Care (485) for the nurste obtain the primary physicians signature. if continuation she Page 81 of 89 Amended x I . FORM CMS-2567 (02-99) Previous Versions Obsolete Event ID: I RIJ I I Facility 1D: 4706A DEPARTMENT OF HEAL'H AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X2) MULTIPLE CONSTRUCHION A.BUILDING B.WING STREET ADDRESS, CITYSTNFE. ZIP CODE (XI) PROVIDER/SUPPLIER/CLA. (X3) DATE SURVEY COMPLETED IDENTIFICATION NUMBER: . 337301 NAME OF PROVIDER OR SUPPLIER 12/272007 AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNITS (X4) [D PREFLX TAG SUMMARY STATEMENT OF DEFIENCIES (EACH DEFIENCY MUST.BE I'RECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 ID PREFIX TAG - G 236 Continued From page 81 documented to ensure that quality care is provided. The findings are: G 236 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFIENCY) The ATaeticare CSS Supervisors will make weekly survisory visits to all the Adult Facilities to ensure that skilled nursing eCar: services are provided to the agency's (X5) COMPLEION DATE patients and to supervise Americare CSS staff. clarify patient issues, problem-solve and case conference patients as rquired. Americare Supervisory staff will provide Patient #16 was admitted to the agency on 06/09107.with the diagnosis including Glaucoma. .cdhas, The Plan of Care dated 08/08-10/06/07 documented the medications ''oprolXL 100mg tab SR 24hr oral; daily" and "Liproderm 5 % ADH. Patch topical daily." weekly oversithi of the Americare nurses to ensure that medication and treatment arleOncl noted. Americare CSS Systen AnalyWOpcrations Manager will run a weekly report (every (700mg patch) Wednesday) of un-subttitted clinical visit notes by Adult Care Facility Nurse. Tite nurse will Ibe contacted and asked to fax the clinical note into the office, Chonic The Plan of Care dated 10/07-12/05/07 did not include the above noted medications. The clinical record lacked documentation of the reason for the medications omission on the following Plan of Care dated 10/07 - 12/05/07. The record did not include a documentation of the physician's order to discontinue the medications. , "Improvement/Quality offenders will be reported to the DPS and will be reqtuird to come to office on a weekly basis to hanid in their clinical notes. r o feducation and a w itten disciplinur Chronic offenders will also receive re- If ,warning. non-compliunce cosLinttcS further disciplinary actios will be taken by the DPS. ro prevent deficient practices from reoccurring ongoing Performance Assurance 100 % On 11/26/07 at 1:20 Pm. The Administrative staff the survey findings and were were informed oftbasis. u l unable to provide and explanation. On 11/27/07 at 11:30 AM, the Nursing Supervisor presented to the surveyor 'Physician Supplemental Orders" signed and dated by the nurse on 8/28/07. The order was faxedto the agency form the Adult Care Facility (ACF) on o 11/27/07 at 9:18 AM. Tl'he orders documemnted "certification period 8/8/07 - 10/06/07, effective dates of service 8/28/07, medication change: D/C (discontinue) Toprol XL 100 mg P.O. (by mouth) o(di t ) Topro clinical record audits bill be done by the Supervisor/Q1 Nurse/DPS on a quaitcrly reported to the Q1 Director! QI ongoing DPS for eacti branch office will provide ovcsiealt and responsible to enforce DPS will report to the .s!.ii. AdministratortGoverning Body on a weekly basis. Amocricare CSS Administrator/Governing Body will ensure that the required education and in-services take place and the Agency's have the continued support to resolve all identified of deficient practices. The Aduinistrstor will report her findings to the VP of Operations/Goveming Board. Facility ID: 4706A coninuation sheet Page 82xof 89 u1 Amended I Results of these audits will be Commitlee/ l'rofessional Advisory Bioard/Commiltee. - April 14, 2008 & q.d.(daily) Lipoderrn 5% topical patch q.d." 'The agency's staff could not provide a'n FORM CMS-2567 (02-99) Previous Versions Obsolete ""Event ID: IRIJI I * deficiencies and prevent any reoccurrenees DEPARTMENT OF HEALTH AND HJMAN SERVICES CENTERS FOR MEI)ICARE AND MEDICAID SERVICES V-"ATEMENTOF DEFICINC[ES D PLAN OF CORRECTION PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X2) MULTIPLE CONSTRUCTION A.BUILDING I . (XI) PROVIDER/SUPPI1ERICLIA IDENfI<1ICATI0N NUMBER: 337301 (X3) DATE SURVEY COMPIETED 12/27/2007 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNITS (X4) ID 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 ID PROVIDER'S PILAN OF CORRECTION (X5) PREFIX TAG (EACH DEFIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC II)ENTIFYING INFORMAIION) SUMMARY SI'ATEMENT OF DEFIENCIF-S PREPFIX TAG (EACH CORRECTIVE ACTION SHOUIJ) BF CROSS-REFERENCED T01THE APPROPRIATE DEF1ENCY) COMPI.LION DATE G 236 Continued From page 82 explanation for the nurses/Nursing Supervisor's failure to ensure that the original "Physician Supplemental Orders" were included in the clinical record until the surveyor requested clarification of the findings. G230 c ,3 av / / ll Patient #5 was admitted to the agency on 10/04/05 with the diagnosis including Diabetes ,, 1Ue-i'k.C9 e ;i. t./1C.- Mellitus Type 11.--',.) The Plan of Care dated 09/24 - 10/22/07 ordered Skilled Nurse (SN) to visit the patient every week for nine (9) weeks. The Skilled Nursing visit notes were reviewed from 09/19-10/01/07 and 10/22-11/12/07. The clinical record lacked documentation of the SN visit notes from 10/02 to 10/21/07. On 11/26/07 at I:0) PM, the agency's Administrative staff were informed of the survey findings and were unable to provide an explanation. On 11/27/07 at 1:0011M, the agency provided the missed SN visit notes dated 10/08, 10/15 and 10/22/07. The agency's staff could not provide an explanation for the missing SN visit notes that were not included in the clinical record. Patient #13 was admitted to the agency on 8/08/07 with diagnoses of Tear Film Insufficiency, Glaucoma, and Depressive Disorder. The Plan of Care dated 08/08 - 10/06/07 orders: Physical Therapy (PT) once a week x nine (9) weeks to maintain strength, ROM (Range of CMS-2567 (02-99) Previous Versions Obsolete MJvI Event ID: I Rtil I I): Facility4706A 7-/. If contIinuation sheet Page 83 of 89 Aniended x I DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES (XI) S-A.'EMENT OF DEFICIENCIES PLAN OF CORRECTION D.D PROVIDER/SUPPIJER/CLIA IDENTFICA'ION NUMBER: 337301 (X2) MULTfIPI.E CONSTRUC'ION A.BUILDING. PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X3) DATE SURVEY COMPLETED 12/27/2007 B. WING STREET ADDRESS, CITY, STATE, 7/1P CODE NAME OF PROVIDER OR SUPPLIER 900 MERCHANTS CONCOURSE SUITELL-15 AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNITS. (X4) II) PREFIX TAG SUMMARY STA'IEMENT OF DEFIENCIFS (EACH DEFENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENT'IFYING INFORMATION) WESTBURY, NY 11590 ID PREFIX TAG PROVIDER'S PLAN OFCORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED 110 THE APPROPRIATE DEPIENCY) (XS) COMPLETION DATE G 236 Continued From page 83 Motion), functional & mobility skills. The clinical record lacked Physical Therapy notes for the month of September 2007. On 11/27/07 provided the and 10/4/07. provided for at 10:001AM, the Nursing Supervisor surveyor with 1 T notes for 9/19, 9/27 There were no PT notes were the week of 09/04 and 09/11/07. G 236 On 11/27/07 at 1:40 Pm, the Nursing Supervisor was interviewed and could not provide an explanation for the missed visit notes and notes for two (2) months prior not being included in the clinical record. Patient #1 was admitted to the agency on 07/30/04 with diagnoses of Diabetes Mellitus and Schizophrenia. The Plans of Care dated 05/16 -01/01/08 documents orders for Skilled Nursing daily to administer Insulin. There is no documented evidence of Skilled Nursing visits for the follwing days: 07/18/07.07/29/07, 08/02/07, 10/17/07, 10/19/07 (AM), and 11/02/07. On 11/26/07 at 2:30 PM,the Administrative staff were informed of the survey findings and were provided and opportunity to provide all explanation. On 11/27/07, no explanation was provided by the agency. On 12/06/07 at 1:30Pm, the agency submitted the certified'record to the Central Islip office. The agency included a supplemental documents folder which included SN visit note for 10/18/07 FORM CMS-2567 (02-99) Previous Versions Obsolete Event ID: 1RUII Facility tD:4706A If continuation sheet Page 84 of 89 Amended x I 1*o DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES -"'CATEMENT OF DEFICIENCIES D PLAN OF CORRECTION (XI) PROVIDERISUI'PLARICLIA IDEN1'FICATION NU BER: (X2) MULTIPLE CONS.RUCTION A.BUILDING 'RINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X3) DATE SURVEY COMPLEFED 337301 B.WING NAME OF PROVIDER OR SUPPLIER S'I'REE I'ADDRESS, CITY, STATE, ZIP CODE 12/27/2007 AMERICARE.CERTIEIED SPECIAL SERVICES SUB-UNITS SUMMARY STATEMENT OF DEFIENCIES (EACH DEFIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 900 MERCllANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 (X4) ID PREFEX TAG ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTI]VEi ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFIENCY) (X5) COMPLETION DATE G 236 Continued From page 84 AM. The agency failed to ensure that all SN visit notes were in the clinical record as per the agency policy and procedure. Patient #8 was admitted to the agency on 10/18/07 with diagnoses including Diabetes Mellitus, Long Term Use on Insulin, Chronic Obstructive Airway and Schizophrenia. The Plans of Care dated 10/17 -12/15/07 ordered SN two (2) x day to Monitor Blood Sugars and administer sliding scale Insulin coverage. The orders also included to administer Albuterol nebulizer treatment 2 x day. The record lacked skilled Nursing visit notes for the following days: 10/23/07 AM, 10/24/07 AM,11/03/07 AM, 11/04/07 AM & PM, 11/05/07 PM, 11/08/07 AM & PM, and 11/09/07 AM. On 11/26/07 at 2:30 PM, the Administrative staff wereinformed of the survey findings and were provided an opportunity to provide and explanation. On 11/27/07, the agency provided some of the missing visit notes from October 2007 but could G 236 not provide an explanation for the remainder of the SN visit notes not being in the clinical record. On 12/06/07 at 1:30PM, the agency submitted the certified record to the Central Islip office. The agency included a supplemental documents folder which included Skilled Nursing visit notes for 10/24/07 AM, 11/03/07 AM, 11/04/07 AM & PM. 11/05/07 PM, 11/08/07 AM & PM, and 11/09/07 AM. .(M CMS-2567 (02-99) Previouts Versions Obsolete I Event I): i R.IJ __7 ID: Facility4706A If continuation sheet Page 85 of 19 Amiended x I DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAIID SERVICES STATEMENT OFDEFICIENCIES >-'ND PLAN OF CORRECTION '" (XI)PROVII)ER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 337301 (X2) MULTIPLE CONSTRUCIION A.BUILDING B. WING PRINTED: 12/26/2007 FO1M APPROVED OMB NO. 0938-0931 (X3) DATE SURVEY COMPLETED I " NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODEo AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNITS (X4) I1 PREFIX TAG SUMMARY SIAIEMENT OF DEFIENCIES (IEACI I DEFIENCY MUST BE PRECEEI)EI) BY FULL REGULAIORY OR LSC IDENTIFYING INFORMATION) 900 MEIRCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 ID PRI, IX TAG PROVII)ER'S PLAN OF CORRECTION (EACI CORRECTIVE ACTION SHOULD 3E CROSS-REFERENCED TO TIlE APPROPRIATE DEFIENCY) (X5) COMPLEIION DATE G 236 Continued From page 85 The agency failed to ensure that all SN visit notes were in the clinical record as per the agency policy and procedure Patient # 18 was admitted to the agency on 10/25/07 with diagnoses Celhulitus and Depressive Disorder. The plan of Care date 10/25/07-12/23/07 documents orders for SN daily for nine (9) days and one (1) every other week for wound care on Right Plantar and supervision of aide every two (2) weeks. The record lacked orders for Home Health Aide services yet the record included duty sheets for Home Health Aide services on the following days: 10/27 - 10/28, 11/03-11/04 and I1/10-1l/11/07. The record documented that the Home Health Aide was placed on this case on 10/27/07. On 11/26/07 at 2:30 Pm, the Administrative staff were infbrmed of the survey findings and were given an opportunity to provide and explanation. On 11/27/07, the agency provide a Physician Supplemental Orrders dated 11/24/07 (which was after the survey was in progress) for certification period dated 10/25-12/23/07: "Please note omission of HHA services 10/25/07 485; Pt (Patient) with HI-IA services as of SOC (Start of Care) 10/25 7D x 2H x9 weeks to assist with Personal, ADL (Activities of Daily Living) care". During an interiew with the Nursing Supervisor on 11/27/07 at 11:45 AM. the Nursing Supervisor was unable to provide and explanation. o G 236 tM CMS-2567 (02-99) Previous Versions Obsolete Event ID: IRUtI I ID: acility 4706A If continuation sheet Page 86x of 89 Ansended l DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEI)ICARE AND MEDICAID SERVICES t'TEMFINT OF DEFICIENCIES D PLAN OF CORRECTION . (Xl) PROVIDERISUPPLIER/ CLIAo IDENTIFICATION NUMBER; PRINTED: 12/2612007 FORM APPROVED OMB NO. 0938-0931 (X2) MULTIPLE CONSTRUCION A.BUILDING (X3) DATE SURVEY COMPLETELD 12/2712007 337301 NAME OF PROVIDER OR SUPPLIER B. WING STREET ADDRESS, CITY, STATE. ZIP CODE AMERICARE CERTIFIED SPECIAL SERVICES (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFIENCIES (EACH DEFIENCY MUST BE PRECHEI)ED BY FULL REGULATORY ORLSC IDENTIFYING INFORMATION) 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTfION (EACH CORREC7I'IVE ACTION SHOULD BE CROSS-REFIERENCED TO THE APPROPRIATE DEFIENCY) (X5) COMPLETION DAIE G 236 Continued From page 86 During interview with the Direct of Patient Services (DPS) of Westbury on 11/27/07 at I :(X)AM, the DPS stated that "nursing and therapy notes are required to be submitted to the agency with the week." There was no explanation for the agency's failure to have the Physician's Supplemental Order in the clinical record until the agency was informed of the findings. Patient #3 was admitted to the agency on 02/16/07 with a diagnoses of Coronary Atherosclerosis, Congestive Heart Failure, Lower Leg Injury, and Hypertension. The Plan of Care dated 10/14-12/12/07 orders: "Skilled Nursing", 2 Day 60 (twice daily for 60 days) to administer wound care to leftleg and Home Health Aide (HI-IHA) services were ordered five (5) days per week x two (2) hours a day x nine (9) weeks. The clinical record lacked documentation of Skilled Nursing visits on 10/14-10/19 AM and PM visits, 10/20 AM visit, 10/22-10/23 AM visits, 10/24 - 10/29 AM and PM visits, 10/30- 10/31 PM visits, and 11/02 and 11/04/07 PM visits. On 12/06/07 the agency submitted the certified record to the Central Islip office. The agency included a supplemental folder which included SN visit notes for 10/28 PM and 11/04/07 AM/ The agenicy failed to ensure that SN notes were in the clinical record as per the agency policy and procedure. G 236 FORM CMS-2567 (02-99) Previous Versions Obsolete Event I): 1RIJI I Facility ID: 4706A Ifcontinuation sheet Page 87 of 89 Amended x I I)EPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES ATEMENT OF DEFICIENCIES AND PLAN OF CORRECIION (X1) PROVIDEIUSUPPLIER/CLIA IDENTIFICATION NUMBER: PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X2) MULTIPLE CONSTRUCTION A.BUILDING (X3) DATE SURVEY COMPLETED 12/27/2007 337301 NAME OF PROVIDER OR SUPPLIER AMERICARE CERTIFIED SPECIAL SERVICES SUMMARY STATEMENT Of- DEFIENCIES (EACH DEFIENCY MUST BE PRECEEDED BY FULL REGUIIORY OR LSC IDENTIFYING INFORMATION) B.WING STREET ADDRESS, CITY, STATE, ZIP CODE 900 MERCHANTS CONCOURSE SUITE LL-15 WESTBURY, NY 11590 ID PREFIX TAG PROVIDER'S PL1AN OF CORRECTION (EACH CORRECTIVE ACTION SHOUL.D BE CROSS-REFERENCED TO TIlE APPROPRIATE DEFIENCY) (X5) COMPLETION DATE (X4) ID PREFIX TAG G236 Continued From page 87 Patient #7 was admiteed to the agency on 05/19/07 with a diagnoses of Diabetes Mellitus Type 2 Schizoaffecive disorder, and Hypertension. The Plans of Care dated 09/16 -11/14/17 and 11/15/07 - 01/13/08 ordered Skilled Nursing for fingerstick and to administer Insulin. The clinical record did not include documented evidence of and order for blood sugar/fingerstick parameters for 0916/07 01/13/08. (Refer G158) On 12/06/07, a certified copy of the clinical record was received at the Central Islip DOH office: Upon review, the record contained a - Physician Supplemental Orders" dated 09/16/07 documenting a correction to 485 of 9/16/07 - 11/14/07 ordering" Novolin Regular sliding scale coverage 0-2(X) no coverage, 201-250=2 units, 251-300 = 4 units, etc.." These orders remained unsigned by the physician. The medication profile does not reflect an order for Novolin Regular Insulin coverage. The clinical record lacked documentation that the patient is to receive Insulin coverage. This information was not requested from the agency and there is no explanation for this additional information in the clinical record. The agency Policy and Procedure entitled: "Patient Record Maintenance and Access Policy"effective "6/13/97" documents the following under the area titled "Procedures: Medical Record Maintenance and Storage ." ...... 3. All Clinical documentation will be filled into the patient record within 10 days of receipt G236 by the agency." .M CMS-2567 (02-99) Previous Verions Obsolete Event ID: I RUI I Facility ID: 4706A if continuation sheet Page 88 of 89 Amended x I DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES Fr IfATEMENT OF DEFICIENCIES iD PLAN OF CORRECTION (X1) PROVIDER/SUPPLIERICLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A.BUILDING PRINTED: 12/26/2007 FORM APPROVED 0MB NO. 0938-0931 (X3) DATE SURVEY COMPLETED o 12127/2007 337301 NAME OF PROVIDER OR SUPPLIER . B. WING STREET AI)I)RESS, CITY. STATE. ZIP CODE AMERICARE CERTIFIED SPECIAL SERVICES (X') ID PREFIX TAG SUMMARY STATEMENT OF DEFIENCIES (EACII DEFIENCY MUST BE PRECI-EDED BY FULL REGULATORY OR LSC IDENI'IFYING INFORMATION) 900 MERCHANTS CONCOURSE SUITE L-I15 WESTBURY, NY 11590 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACIt CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFIENCY) (X5) COMPLEI'ON DATE G 236 Continued From page 88 The agency staff could not provide an explanation for the agency's failure to maintain complete clinical records and to follow the agency's Policy and Procedure for Patient Record Maintenance. 484.55 (c) DRUG REGIMEN REViEW G 236 G 337 G 337 that ,Je Americar CSS will eo-stn FOC attd rnrsing staff inioiates the revises the POC as needed to meet all. active pallent needs. Antericare CSS will provide an in-depth in-se-vice to all ACFnrssbyJanuary31,2008. Amcricare CSS has reviewed and revised the Patient's Plan of Care with the patient's physician on ill active paints. including (Patients #1 HV, #3 tIIV, #4 IIV, #5 HIV, #6, #10, #1. #14 H-V, #16, #17 HV, and#19)as evidenced by written progress notes and interim physician orders in the clinical record. This was done to ensure that the patient isreceiving current care, medications Fcb. 6, 2008 The comprehensive assessment must include 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 STANDARD.is not met as evidenced by: Based on clinical record review, home visits, review of agency Policies/Procedures ind staff interview, the . Feb. 6,2008 agency failed to ensure that the comprehensive assessment included a complete and accurate assessment of the patient medication regimte in eleven (11) of nineteen (19) records reviewed and six (6) of () recormedication inete ho me eight) eight (8) home visits (HV). ( and treatment. The agency's failure to ensure that the comprehensive assessenent included a review of the patient medication regime places all patients at risk for poor patient On a monthly basis Americare CSS will obtain a copy of the Adult Care Facilify administration recore (MAR) for all active patienis. thenurseswill the ACF heckthMARaginsA administration record, 485 and medication profile on weekly basis for charwe to medication regime Changes consultatign with ACF staff. via Will be verified with the MD as evidenced by an interim oider. Americare CSS Supervisors will make weekly supervisory visits to all (he Adult Care Facilities to ensure that h outcomes. Findings include: Refer G156, G158, G168, G173, and G176 Antericare nursea are reviewing mettdication and rcatmentordcrs and enrstrinp that chanres are timely noted. FORM CMS-2567 (02-99) Previous Versions Obsolete Ement ID: I RIJI I Facility ID: 4706A If continuation sheet Page 89 of 89 Amneaded x I DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES STATEMENT OF DEIICIENCIES A ND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIERICLIA IDENTIFICATION NUMBER: 3373011 PRINTED: 12/26/2007 FORM APPROVED OMB NO. 0938-0931 (X2) MUI:I'IPI.F, CONSI'RUCTION A.BUILDING_ E (X3) DATI SURVEY COMPLETED 12/27/2007 B. WING .. NAME OF PROVIDER OR SUPPLIER STREIT ADI)RESS, CIY, S.ATE, ZIP COI)E AMERICARE CERTIFIED SPECIAL SERVICES (X4) ID" PREFIX TAG SUMMARY S'IATEMENT OF DEFIENCIES (EACH DEFIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 900 MERCHIANTS CONCOURSE'SUITE LL-15 WESTBURY, NY 11590 ID PREFIX TAG PROVIDER;S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE API'ROPRIATE DEFIENCY) (X5) COMPLETION. DATE ,Continued From page 89 G 337 484.55 (c) DRUG REGIMEN REVIEW G 337 Americare CSS Supervisors will review 10% of each Adult Care Facility pat records on a monthly basis. Based on the finding's ongoing education will take place and the audit results will be placed in the nurses personnel record to be reflected on their aninual perfornsance evaluation. l)l'S for each branch office will provide oversitht and responsible to enforce regulation and to ensure that deficiencies do not re-occur. DPS will report to the Administrator/Governing Body on a weekly basis. Americare CSS Administrator/Goveming Body will ensure that the requirel education and in-services take pjacie and the Agetcy's have the continued support to identified deficiencies and resolve kill prevent any reoccorrenes of deficient practices. The Administator will report her findings to the VP of Operations/Governing Board Feb. 6,2008 FORM CMS-2567 (02-99) Previous Versions Obsolete Event ID: I RIJI I Faciliiy I): 4706A if continuation sheet of Page 89 of 89 Amended x I Man Richard F. Daines ,ommissioner STATE OF NEW YORK DEPARTMENT OF HEALTH Metropolitan Area Regional Office 90 Church Street, New York, NY 10007 December 27, 2007 er YamjIle Di'-ecpr of atient Services Mejroda~e Givers, Inc \ 32 Gold\Street, 3 rd Floor \Bro klyn NY 1.1201 - .. Re: Response to Plan of Corrections Survey Date: October 2 4 th 2007 License: 9773L001 Dear Ms. Singer: Please be advised that the plan of correction relating to the recent Article 36, survey of your agency have been reviewed by this office. All items were found to be acceptable and it is expected that you will implement this plan within the time frames thatwere submitted. A post approval review will be conducted to verity the correction of deficiencies. If you have any questions regarding this matter, please contact (212) 417-5888. Sincerely Cheryl Phoenix-Tannis, RN. MSN, CS Program Manager Home Health and Hospices Services Metropolitan Area Regional Offices PRINTED: 12/07/200.. New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION FORM APPROVE( (X2) MULTIPLE CONSTRUCTION A. BUILDING (XI) PROVIDERISUPPUER/CLIA IDENTIFICATION NUMBERCOMPLETED W) DATE SURVEY COMPLETED 9773L001 NAME OF PROVIDER OR SUPPLIER . ING STREET ADDRESS, CITY. STATE, ZIP CODE 10/24/2007 METRO CARE GIVERS. INC. (X4) ID PREFIX TAG . 325 GOLD STREET BROOKLYN, NY 11201 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (Xh) COMPLETE DATE H 000 Initial Comments H 000 A Full survey was conducted on 10/24/07 at MetroCare Givers Inc. Six (6) Patient records were reviewed and are identified as Patients #1-#6. Six (6) Personnel Records were reviewed and I are identified as Employees #1- #6. H 222 766.1 (a)(8) Patient rights H 222 Corrective action to be accomplished for those patient! found to'have been affected by the deficient practice. r Immediatiey following the October 24, 2007 survery by the New York State Department of Health (NYS DOH), the Director of Patient Services (DPS) contacted the (NY9 DOH) to verify the correct information for patientsfcaregivers want to voice complaints or recommend change in policies to the NYS DOH. The information was verified as follows: NYS DOH complaint hotilne telephone .' # (212) 417-5888; available 10am to 4pm on all state business days. The UPS also reviewed the Patient Bill of Rights to ensure I it includes accurate contact information for the NYS DOH complaint hotfine. See Patient Bill of Rights (enclosure 1). The Client Manual' has been updated to reflect the correct information to contact the NYS DOH. See page 2-3 Client Section 766.1 Patient rights. (a) The governing authority shall establish written Trwho policies regarding the rights-of the patient and shall ensure the development of procedures implementing such policies. These rights, the right to: policies and procedures shall afford each patient (8) voice complaints andaecymmed changes in p8)oliceand semvics tod recommend hae s iManual sa policies and services to agency staff, the New York State Department of Health or any outside representative of the patient's choice. The ' expression of such complaints by the patient or his/her designee shall be free from interference, Al active clients and clients dischar d after the date of the NYS DOH's complaint hotline te ephone number change will be mailed aletter of explanation along with acopy of the Bill of Rights and the revisions to the Client Manual. The DPS will call all clients to ensure they received the (enclosure 2) documents and answer any uestions. This contact will be documeno~-aTZtrt're rds andwll be teo coercion, discrimination or reprisal.,r This Rule is not met as evidenced by: Based on record review and staff interview, the agency failed to provide the patients accurate to lodge a f complaint with the New York State Department telephone contact information .corrective I rn cate contact information for the NYS DOH complaint hotline (December 18, 2007). The Registered Nurse Field Supervisor (RNFS) will review the patient Bill of Rights and the Client Manual for accurate contact information for the NYS DOH complaint hotline during the client's next scheduled visit. The RNFS will answer any questions the client has regarding the To be completed within 3 months (March complaint processi 20. 2008) 2. How other patients having the potential to be affected by the same deficient practice will be identified and what Janua 4,200 action will be taken. of Health. Failure to provide accurate contact information places patients at risk for not being afforded their right to lodge a complaint with the New York LABORATORY DIRECTOR'S OR PROVIDERJSUPPLIER REPRESENTATIVE'S SIGNATURE New patient packets will be reviewed by the DPS to ensure they contain accurate NYS DOH complaint hotline contact information. The RNFS will insure accurate NYS DOH complaint hotline contact information is provided to all new admissions by reviewing the Client Manual and the Patient Bill of Rihts with all new admissions. Effective immediate y and ongoing. aorh 3.What measures will be put inplace or what systematic , changes will be made to ensure that the deficient practice TITLE . (/, . I(X6)DAT tATE FORM , 6 1 0GIX11 V if continuation sheet 1of 1 New York State Department of Health STATEMENt OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDER/SUPPLIERICLLA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTI6N A.BUILDING. _ _ _ PRINTED: 12/07/2( FORM APPROV (X3) DATE SURVEY COMPLETED B. WING 9773L001 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10124/2007 METRO CARE GIVERS. INC. (X4) ID PREFIX TAG 325 GOLD STREET BROOKLYN, NY 11201 ID PREFIX TAG i SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) I PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) " (X5) COMPLE" DATE H 222 Continued From Page 1 H 222 State Department Of Health. The findings are: The agency: "Client Manual" documents the following information on page 2-3: " "Should you not be satisfied with the outcome, you may file your complaint or grievance with the The DPS is responsible to ensure all information in the Patient Bill of Rights and the Client Manual is updated as needed. When an update is indicated i the DPS will update the appropriate form (i.e., Bill of Rights or Client Manual, etc.) and archive the out of date form. The DPS will educate the RNFS and establish an implementation date. The RNFS will be responsible to educate the clients to the new information and pmvice them with updated forms. During the quarter following lhe implementation date the DPS will conduct an audit to ensure that the accurate information is being provided to the clients. This will occur immediately and ongoing. u 4. How the corrective action will be monitored to ensur the DPS will conduct an audit of 100% of active client rost on a quarterly basis to ensure all records have been updated to include the accurate telephone contact information for clients to lodge a complaint with the NYS DOH. The results 1of the audit will be reported by the DPS to the Performance Improvement (PI) Committee at the quarterly PI meetinb. immediately and ongoing. This information will Rective be reported to the Governing Authority. 5. Responsible Party (s): Director of Patient Services, R.N. Field Supervisor deficient practice will not recur. New York State Department of Health, (212) 268-6406. The documented number is not the correct information to contact the New York State Department of Health.' The agency" Bill of Patient Rights "documents the following information on page 1, item #11: ...... your complaints heard, reviewed, and Have if possible resolved and recommend changes in policies and services to the agency staff, the governing authority and the New York State Department of Health (xxx-xxx-xxx)... There is no documented evidence of the current telephone number. On 10124/07 at 3:50PM, the Director of patient services was interviewed and stated that she was not aware we moved. H 408 766.3(d) Plan of care 766.3 Plan of care. The governing authority or operator shall ensure . p H 408 1. Corrective action to be accomplished for those patie Is found to have been affected by the deficient practice. Patient #5. An RN visit will be performed to assess i the patient and the need for PTIOT therapy. - The result of assessment will be phoned to patient's MO for appropriate referrals. that: ...... (d) the plan of care is reviewed and revised as frequently as necessary to reflect the changing care needs of the patient, but no less frequently than every six months; .$"rkTE FORM 2. How other patients having the potential to be affected by the same deficient practice will be ]identified and what corrective action will be taken. -.All patient records will be reviewed to ensure all ordered services are addressed and reflected in the medical orders assessments and care plans where appropriate. A nursing visit will be performed if the patent record ha!. 'any discrepancies inwhat is ordered and what is docui ented. J.By Director of Nursing and Field nurse supervisor. pJo 1, 15", 0G1X11 It continuation-sheel-"" 021199 PRINTED: 12/07/200 FORM APPROVEI New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDERISUPPLERICLA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A.BUILDING B. WING __________ (X3) DATE SURVEY COMPLETED 9773L001 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1012412007 325 GOLD STREET BROOKLYN, NY 11201 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) What measures will be put inplace or what systematic changes will made to ensure that the.deficient practice, does not recur. - At METRO CARE GIVERS. INC. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (XS) COMPLETE DATE H 408. Continued From Page 2 H408 (1) each review shall be documented in the (1adassessment clinical record; and (2) agency professional personnel shall promptly alert the patient's authorized practitioner and dcare pto other a need to alter the plan of care. a acpv s y changes in the patient's condition that indicate a. '! This Rule is not met as evidenced by: the Based on record review and interview, agency failed to ensure that the plan of care reflected all the ordered services that the patient was receiving. This was evident for one 91) out Of six (6) patient charts reviewed. (Patient #5). the times of admission, RN 3 month assessment and RN as needed assessments the RN performing the will review all ordered services and ensure they are reflected and followed-up patients record. 4. How the corrective action will be monitored to ensure the deficient practice will not recur. The Director of patient services or RN field supervisor will review all charts of newly admitted patients, patients who have had a 3 month or prn assessment oneweek after the Rn has made the visit to ensure compliance with the above plan of correction. On November 15th, 2007 and ongoing. The results of the audit will be reported by the DPS (PI) -,'-,/.Improvement .. Committee to the Performancemeeting. at the quarterly Fl ,,, l -hqur, PI meein g. a include all ordered of care. Failure to risk for poor quality services places the patient at The findings are: Patient #1.has diagnoses which include Seizure Disorder, Osteoporosis and Hypothyroidism. The medical order dated 2110/06 documents:".... Continue physical therapy in patient' s home 2 x a Week for gait balance, strengthening. Physical Therapy to evaluate again for above on 2/20/06." 1 There is no documented evidence that Physical Therapy was initiated. On 10/24/07 at 4PM, the Director of Patient Services was interviewed and was unable to ['provide an explanation for the finding. H 514 766:4(d) Medical orders H 514 ,. I - ' 766.4 Medical orders. STATE FORM 21199 1. Correction action to be accomplished for those patients ifound to be have been affected by the deficient practice. 1- Physican of patient #1 will be telephoned and the NYSDOH regulation of thirty day MD signatures will be discussed.and reviewed to ascertain ways VID orders can be signed OGIX 11 Ifcontinuation sheet 3of 1 PRINTED: 12/07120 FORM APPROV New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING __________ (X3) DATE SURVEY COMPLETED 9773L001 NAME OF PROVIDER OR SUPPLIER . 10/24/2007 STREET ADDRESS, CITY, STATE, ZIP CODE METRO CARE GIVERS. INC. (X4) ID PREFIX TAG 325 GOLD STREET BROOKLYN, NY 11201 ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) I PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) t (X5) COMPLET DATE 514Continued From Page 3 ...... H 514 (d) Medical orders shall reference all diagnoses, medications, treatments, prognoses, and other . and returned in.a timely manner by 1/10/2008. 2. How other patients having the potential to be affected by the same deficient practice will be identified and t what corrective action will be taken. - All patient active records will be reviewed for outstan ing MD sinatUres. All outstanding orders will be faxed to the and re-faxing. If there is one week remaining for order to be . signed, an RN will personally visit the phsycians office I to obtain the md's signature. By the Director of Patient Services and RN field supervisor.. By 1/4/08.. or what systema ic put in 3. What measures will beensure placethe deficient that changes will be made to does not recur. t - Starting immediately all physician's office for timely signatures within 30 days. If there is one week remaining for orders to be signed an RN will personally visit ithe physicians office to obtain the signature after calling to be sure the physician is there. If physician is not in the office at that time an appointment will physician's office with a request for an immediate signing pertinent patient information relevant to the and yplan of c care; agency (1) shall be authenticated by an authorized practitioner within thirty (30) days after admission (practice whnc; ty pttier . (2) when changes in the patients medical orders are indicated, orders, including telephone orders, shall be authenticated by the authorized practitioner within thirty (30) days. This Rule is not met a eidncd Thi Rleisno mt as evidenced by: y:- be made. 14. How the corrective action wilt be monitored to ensure the deficient practice will not recur. The Director of Nursing will formulate a list. . By Director of patient services and RN field supervisor.= Based on record review and interview, the were ensure ha mdialorer failed toagecyfale t orders wrein esue that medical signed within 30 days. This was evident for one (1) out of six (6) records reviewed. (Patients #1). Failure to ensure that medical orders are signed within 30 days place the patient at risk for poor quality of care. The findings are: Patient #1 has diagnoses which include: Pigmentation Retinitis, History of bilateral Inguinal Hernia, Asthma and Bilateral lower leg Varicosities. The agency: " Home Health Certification and Plan of Treatment " from 5/3/06-11/3/06 was signed by the physician on 6/27/07. On 10/30/07 at 4PM the Director of Patient I found Services was interviewed and stated that it was not done." of MD orders to be signed within 30 days and will revie w i it daily to be sure orders are received and signed a timely manner. ay Dinrctor-ofPatien Lervc s and RN field supervisori ., s By Decmber 7 ecember 17th 20 Tirestilts-ef-tils review will be reported by the DPS. . to the Performance (.OC,._,EURquarterly PI meeting,Improvement Committee (PI)t,at the qt Pt m , _ " STATE FORM 0211GX99 Ifcontnuation sheet 4, PRINTED: 12/07/200 New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDER/SUPPLIERCLIA. IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION BUILDING FORM APPROVEC (X3) DATE SURVE .Y O.PLETED - 9773LOl NAME OF PROVIDER OR SUPPLIER [ B,WING STREET ADDRESS, CITY, STATE, ZIP CODE 10124/2007 METRO CARE GIVERS, INC. _ 325 GOLD STREET ID PREFIX TAG BROOKLYN, NY 11201 PROVIDER's PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE ( .X5) COMPLETE DATE (X4) ID PREFIX TAG __ SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) _ _DEFICIENCY) H616 ContinuedoFrom'Page 4 I H 616 H 616 H 616 (766.5 (b) (2) Clinical Supervision I:Corrective action to be accomplished for those employees found to have been affected by the deficien practice. - Bi-weekly RN visits notes and daily telephone call logs for employees 1 & 6 were requested of the RN field super isor and the staffing coordinator. Bi-weekly RN visit notes nd telephone logs are now (copies attached). Policy in theProcedure for employees lory and personnel of Criminal H' &6 .Background checks was reviewed by the DPS and alsc and reinforced with RN field supervisor and staffing 1coordinator. 2.How other patients having the potential to be affected by the same deficient practice will be identified and what corrective action wili be taken. a w -Recordshistoryemployees who have not had their criminal of all background check will be reviewed by QPS. Any lapses in RN visits or phone calls will be remedied . immediately. An RN will schedule the needed visit withlthe tpatient the next day and a telephone will be made bV DPS for the patient's home. Effective: Immediately by November 161h, 2007 RN field supervisor and DPS -All employees with criminal history'background I 616 766.5(b)(2) Clinical supervision " authority Shall ensure for all health care Services that: (b) all staff delivering care in patient homes are 766.5 Clinical supervision. The governing adequately supervised. The department shall consider the following factors as evidence of Careviewed adequate supervision: (2) staff are assigned to the care of patients in accordance with their licensure, and their training, orientation, and demonstrated skills. This Rule notd met as evidenced by: his Rled is not meties evidnd yto Based on record reviews and interview the .by faild toensue agency failed to ensure tht supervision was that was evident for two (2) out of six (6) employee records. (Employees# 1 and #6).. provided for employees while the results of the ,and criminal history record check are pending. This checks outstanding will continue to have an RN visit bi-weekly alternately a telephone call by the staffing to the patient's home until a disposition is madecoordinator with th6 return of their criminal history background check. Effective: Immediately and ongoing by Failure to ensure that supervision was provided as required place the patient at risk for unsafe and poor quality of care. 3.1JWhat measures will be put in place or what systematic changes will be made to ensure that the deficient practice does not recur. immediately documentation of RN field nurse supervisors. RN Field supervisors will be ir -serviced on this new procedure by November 16, 2007. If RN supervisory visits are not submitted weekly RN Field Supervisor wili be telephoned, Policy & Procedure will be reinforced bytho DPS RN will be requested to do supervisory ! Supervisory note can either be faxed or RN visit imme, iately. must bring to the to the All by the end must have original submittedagency.DPS faxed notesof the week.th ' Telephone logs will be reviewed by the DPS to satisfy ff site observation requirements weekly. If required telep one call to patient's home are found to be lacking, staffing coordinator will have Policy & Procedure reinforced and* 1 call will be made to patient's home by DPS. lmmediate( (and on-going by DPS and RN Field Supervisor. . :4.i How the corrective action will be monitored to / ensure the deficient practice will not recur. supervisory visits will be submitted weekly to the DPS ty The findings are:' 1) The personnel record for Employee #1 (Home Health Aide) documents a'hire date of "6/5107", opersonally The personnel record documents evidence of a" fingerprint rejection" letter dated 7/10/07 and a Criminal History Record Check Resubmission Form" dated 7/17/07. There is no documented evidence of weekly supervision from the time of hire to the date of the rejection letter and from the resubmission of the fingerprints to the present date. STATEFOR__ STATE FORM _IcontinuaiosheeI o=Ilgo i-L ]Employee records will be audited weekly to ascertain timely documentation is placed in the employie records. Immediately and ongoing by DPS and field nurse supervisor. 0GiXi 1 Ifcontinuation sheet 5 of 13 5 o 13 New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X ) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: -A. PRINTED: 12/07A20 FORM APPROVI (X2) MULTIPLE CONSTRUCTION BUILDING B. WING (X3) DATE SURVEY COMPLETED COMPLETED______ 9773L001 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE ZIP CODE 10/2412007 325 GOLD STREET BROOKLYN, NY 11201 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCEDTO THE APPROPRIATE DEFICIENCY) b The results of the audit will be reported by the DPS to the performance improvement (PI) Committee. At the quarterly PI meeting. Effective immediately and ongoing. This information will be reported to the METRO CARE GIVERS, INC.. (X4) ID PREFIX TAG " SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) . J (X5) COMPLET . DATE H 616 Continued From Page 5 2) The personnel record for Employee #6 ( Home Health Aide) documents a hire date of "6/7/07'. .The personnel record documents evidence of a "fingerprint rejection" letter dated "7/10/07" and a. "Criminal History Record Check" resubmission form dated "7/24/07". The personnel record does not include documented evidence of weekly supervision from the time of hire to the date of the rejection letter and from the resubmission of the finger prints to the present date. On 10/24/07 at 4 PM, the Director of Patient Services and the Human Resource Supervisor verified .the findings. H 616 governing authority. H1036 766.9(1) Governing authority Section 766.9 Governing authority.. The governing authority or operator, as defined in Part 700 of this Title, of a licensed home care ...... a H1036 quality improvement committee shall consist of a consumer and appropriate health professional persons including a physician if professional health care services are provided.The committee shall meet-at least four times a year to: (1) review policies pertaining to the delivery of the health care services provided by the agency governing authority for adoption; (1)appoint a quality improvement committee to/ aall ei establish and oversee standards of care. The n ay es* agncy oet H1036 766.9(1) Governing Authority Section 766.9 1.Corrective action to be accomplished for area found to have been affected by the deficient practice. -Metrocare Givers has identified the consumer and a back-up consumer (should the consumer not be available to attend a scheduled meeting). to attend all P1meetings. The DPS has discussed attendance and role of the Consumer at Performance Improvement meetings, lVice President's Administrative Assistant will contact the Consumer and back-up Consumer to review the schedule of upcoming meetings and the need of their attendance by Novembe r-12;-2007. Ses .sign-in sheet for PI meeting of iDecember 10th, 20072-. 2.How the poten o be affected by the same deficient identified and what corrective action will be taken. hence forth. Two weeks before quarterly PI meeting Vice President's Administrative Assistant I call the Consumer and verify attendance at the meeting. IfConsumer cannot attend the back-up Consumer will be immediately contacted. By VP Administrative Assistant month ly and on-going. -The agency will assure the presence of a consumer at Pi meetings 3.What measures will be put inplace or what systematic changes will be made to ensure that the deficient practice does not recur. -All members of the PI meeting have been provided with .a calendar of 2008 PI meetings by VPs Administrative Assistant on January 31st, 2008 and will be contacted one month before the date of the next PI meeting. If Consumer tcannot attend the back-up Consumer will be immediately deficient practice will not recur. and recommend changes in such policies to the (2) conduct a clinical record review of the safety, STATE FORM OV1w contacted. If back-up Consumer cannot attend PI meeting, the meeting will be re-scheduled by Administrative Assistant I to Vice President and DPS. By November 12th 2007 and ongo ng. 4.How the corrective action will be monitored to ensure the -Attendance at Performance Improvement Committee will continue to be monitored for the attendance of the consumer. .By the Vice President and DPS. This information will be reportd .Lto the Governing Authority. o 0GIX1 1 If continuation sheet 6 0 PRINTED: 12/07/200 New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIERJCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDINCOMPLETED B.WING________ __ FORM APPROVEI (X3) DATE SURVEY 9773L001 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10/2412007 325 GOLD STREET METRO CARE GIVERS. INC. I (X4) ID PREFIX TAG BROOKLYN, NY 11201 ID * PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H1036 Continued From Page 6 adequacy, type and quality of services provided which includes' (i) random selection of records of patients currently receiving.services and patients discharged from the agency within the past three months; and (ii) all cases with identified patient complaints as specified in subdivision (j) of this section; (3) prepare and submit a written-summary of review findings to the governing authority for H1036 H1036 766.9 (o)Governing Authority Section 766.9 Governingauthority 1 .Corrective action to be accomplished for those areas foi nd to -DPS will review policy procedure and practice of quarterl, chart reviews. Director of Patient Services (DPS) will review 3 r ndom charts and 1 discharge chart (if applicable for that quarter necessary action; and have been affected by the deficient practice. (4) assist the agency in maintaining liaison with other health care. providers in the community. This Rule is not met as evidenced by: Based on record reviews and interview, the agency failed to ensure that the Quality Improvement Committee meetings included a consumer, a random record review of patients for the list quarter. " 2.How the potential to be affected by the same deficient actice will be identified and what corrective action will be taken. as well as safe and adequate care are incorporated into tt e each month. Chart review for quarterly last quarter Perforn ance reflected in minutes of meeting. There were no dischar es -Starting immediately the Director of Patient Services will nsure chart reviews of random patients to ensure quality service s, the quarter will be reviewed and a so be discussed. By DIs 3.What measures will be put inplace or what systematic changes will be made -Going forward in2008 the minutes of all PI meetings and ongoing in 2008. minutes of the quarterly PI meetings. All Discharging with n to ensure the deficient practice do( s not recur, that are currently receiving services and a review of patients discharged from the agency within the past three (3) months were discussed, mboth Failure to ensure that tlhe Quality Improvement Committee performs the required functions places patients at risk for poor quality services, unsafe . will be monitored for the presence of random chart review for as well as safe and adequate care provision. Quarterly in ?08 by Vice President and DPS. 4.How the corrective action will be monitored to ensure active and discharged patients for quality of services and, inadequate care. the deficient practice will not recur. -The results of the audit will be reported by the OPS to thE Performance Improvement Committee. Effective immediately and ongoing. This information will be reported to the Governing authority. The findings are: The agency " Quality Improvement Committee Meeting " minutes dated "3/28/06, 6/28/06, 9/14/06", does not include documented evidence of a consumer at the meetings. On the cover sheet of the minutes dated "12/19/06, 3/8/07 and 6/27/07', it was documented- that the consumer was absent. STATE FORM OG1X11 If continuation sheet 7 of" PRINTED: 12/07/201 FORM APPROVE New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDERISUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION .BUILDING B. WING __________ ___ ____ (X3) DATE SURVEY COMPLETED 9773L001 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY. STATE. ZIP CODE 10/24/2007 325 GOLD STREET BROOKLYN, NY 11201 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION . (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETI DATE METRO CARE GIVERS, INC. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H1036 Continued From Page 7 H1036 The QI meeting minutes documents statistics for Accidents/Incidents, Patient Complaints/ Grievance Statistics, Plan of Care/ Duty Sheets, Doctors orders, PPD Testing Pain Management, Competency Testing, Quality Indicator (Fall Risk) and patient satisfaction. There is no documented evidence of random patient record review. There is documented evidence of 11 patient discharges from 1/07- 6/07. There is no documented evidence of discussion of these discharges at the 3/8/07 or 6/27/07 meetings. On 10/24/'07 at 3:50 PM, the Director of Patient Services was interviewed and stated that they "have not replaced the consumer" and that "after the meetings" the Director of Patient Services and the physician discuss patient records. H1142 766.9(o) Governing Authority I H1142 H1142 76.9 (o)Governing Authority Section 766.9 Governing authority 1.Corrective action to be accomplished for those areas found to have been affected by the deficient practice. practice of the Health Provider Network (HPN) in 2006 and a Policy & Procedure was formulated. Attached is a Section 766.9 Governing authority (o) Health Provider Network Access and V.P. and DPS reviewed the regulations'and agency Reporting Requirements. The governing authorty or operator of an agency shall obtain from the Department' s Health Provider Network PNHPN accounts for each agency that it (HPN), operates and ensure that sufficient, knowledgeable staff will be available to and shall maintain and keep current such accounts. At a minimum, twenty-four hour, Seven-day a week c t ei oof contacts for emergency ommunication ' ocopy of our Policy and Procedure for the Health Provider Network (HPN). This Policy and Procedure was presented o at the quarterly meeting 2006 for review and approval. This policy and procedure was also submitted to the Governing Authority that month for review approval. 2. How other areas having the potential to be affected by the same deficient practice will be identified and what corrective action will be taken. -The DPS will access the Health Provider Network (HPN) by logging on to the official HPN Network to be informed HPN Communications Directory. A policy defining the agency' s HPN coverage consistent with the agency' s hours of operation shall be STATE FORM 02119 and 'to alerts, must be designated by each agency in the alerts, Letters To The Administrator, changes and revisions the Criminal History Background Check Policy's and Procedures, information concerning licensed home caie agencies and for communication during emergency situations 24hrs a day / 7 days a week. That would be 10/31/07 and ongoing. To Metrocare Givers will continue to follow our Policy and Procedure for the HPN. Immediate and ongoing. By Vice President and DPS. OGIX11 Ifcontinuation sheet 8 of PRINTED: 12107/2001 New York State Deartment of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION . FORM APPROVEE (X2) MULTIPLE CONSTRUCTION A. BUILDING A.BUIING.COPEE (X3) DATE SURVEY COMPLETED (X1) PROVIDERISUPPLIERCLIA IDENTIFICATION NUMBER: 9773L NAME OF PROVIDER SUPPLIER o B.WING 10/2412007 1 METRO CARE GIVERS. INC. (4 (x4) D PREFIX. TAG STREET ADDRESS, CITY, STATE, ZIP CODE 1BROOKLYN, "SUMMARY STATEMENT OF DEFICIENCIES 325 GOLD STREET NY 11201 ID PREFIX TAG (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) _______________________________________DEFICIENCY) I 1 i PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE . (XS) DT CMLT CDATE H11421 Continued From Page 8 created and reviewed by the agency no less than annually. Maintenance of each agency's HPN accounts shall consist of, but not be limited to, the following: (1) sufficient designation of the agency' s HPN coordinator(s) to allow for HPIN individual user application; (2) designation by the operator of an agency governing authority or of of sufficient staff users the HPN accounts to ensure rapid response to requests for information by the State and/or local Department of Health; H3. What measures will be put inplace or what systemalic changes will be made to ensure that the deficient prac!ice Itdoes not recur. The Director of Patient Services will access the HPN; daily to be informed of alerts, on. Arequirements or changes, by using her password to log new log will be to record daily access. The DPS will develop anddeveloped log. keep the The Vice President will review the logs quarterly. Begining 2008 and ongoing. HPN policy will be revised as new or different requirements are identified and will be brought before quarterly Performance Improvement meetings for discretion, review, and implementation as these changes immerge. The Policy and Procedure for the Health Provider Network (HPN)Iwill be reviewed yearly by the Vice President and Director of Patient Service (DPS) and all proposed changes and additions will be, discussed at the quarterly Performance Improvement meetings. By December 30, 2007. 4.How the corrective action will be monitored t ensure the deficient practice will not recur. to I - All revisions or changes to the HPN policy will be bro[Ight (3) adherence to the requirements of the HPIN user contract; and .(4) current and complete updates of the Communications Directory reflecting changes that include, but are not limited to, general information and personnel role changes as soon as they occur, and at a minimum, on a monthly, basis. forward to the Governing Authority for approval. 2008 and ongoing by Vice President and DPS to the attention of the Quarterly Performance Committee for discussion and implementation. And This Rule is not met as evidenced by: Based on record review and interview, the agency failed to develop and policy and procedure for the Health Provider Network (HPN). Failure to develop policy and procedures for the .agency' s HPN account fails to direct the agency staff in how to respond to requests for information by the local health department, management in emergency situations and failed to ensure the maintenance of the agency' s HPN program. STATE FORM 021199 OGlX11 If continuation sheet 9of 13 New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDERISUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION SB. PRINTED:, 12107/200 FORM APPROVE F CO MPETED RE COMPLETED______ A. BUILDING WING___________ 9773L001 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10/2412007 325 GOLD STREET BROOKLYN, NY 11201 i ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE (XS) COMPLETE DATE METRO CARE GIVERS. INC. (X4) ID PREFIX TAG I SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY. MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) '. H1142 EFICIENCY) D H1,1421 Continued From Page 9 The finding is: The agency policy and procedure manual did I not include documented evidence of a policy and procedure for the Health Provide Network. On 10/24/07 at. 3:30 PM, the Director of Patient Services was interviewed and stated that the agency "does not have the HPN policies". H13381 766.11(g) Personnel 766.11 Personnel. The governing authority or operator shall ensure Sfor health care personnel: all "obtaining i (g)that personnel records include verifications of ...... H1338 Page 10 H1338 766.11 (g) Personnel 1. Corrective action to be accomplished for those patients found to have been affected by the deficient practice. - Files of employees 1and 5 reviewed by DPS and HR Personnel for correct process in employment verification (see attached). Process was reviewed and reinforced to HR Personnel by DPS: By October 26, 2007. Re-verification of these 2 employees was done on 10/26/07 by Human Resources Personnel. 2.How other patients having the potential to be affected by the same deficient practice wil be identified and what dorrective 766.11 Personnel employment history and qualifications for the duties assigned and, as appropriate, signed and dated applications for employment; records of of physical examinations and health status action will be taken. professional licenses and registrations; records -HR staff will review all current records to ensure correct process for verification of employment is documented in their records. By HR personnel by January 31, 2008. 3. What measures will put in place or what systematic 9*hanges will I A quarterly audit of all new employees will carried Out be by DPS and HR personnel to ensure employment verification process is-follow-up and reflected in records. By DPS and HR Personnel in March the and ongoing. 2008 4. How the corrective action will be monitored to ensure the deficient practice will not recur. results of the audit will reported by DPS be Performance Improvement Committee. Effective at the quarterly immediately and ongoing. This information will be reported to the employment, resignations, dismissals, and other ' pertinent data provided that all documentation and information pertaining to an employee's I medical condition or health status, including such recordsrThe of physical examinations and health status assessment shall be maintained separate I and apart from the non-medical personnel record confidential treatment given patient medical records under section 766.6 of this Part. This Rule is not met as evidenced by: Based on record reviews and staff interview the agency failed to ensure that all personnel records included verification of employment history. This was evident for two (2) out six (6) STATE FORM oGgg assessments; performance evaluations; dates of- that the deficient practice does not recur. governing authority. information and shall be afforded the same i 0G1Xl1 Ifcontinuation sheet 10 of 1: PRINTED: 12/07/20 of Health New York State Department STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION [(Xl) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING __________ FORM APPROVI - (X3) DATE SURVEY COMPLETED 97731001 NAME OF PROVIDER OR SUPPLIER B.WING STREET ADDRESS, CITY, STATE, ZIP CODE . 16/24/2007 METRO CARE GIVERS. INC. (X4) ID PREFIX TAG 325 GOLD STREET BROOKLYN, NY 11201 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) . SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X5) COMPLET DATE H13381 Continued From Page 10 records reviewed.(Employees #1, and #5). Failure to ensure that all employment history is verified places the patient at risk for poor quality of care. The findings are: 1) Employee #1 is a Home Health Aide (HHA) hired with a documented hire date of"6/5/07'. The personnel record includes (1) agency " Employee Reference Inquiry " form and 1. verified personal reference. The personnel the employment reference was verified. 2) Employee #5 is a HHA with a documented H1338 I record.did not include documented evidence that hire date of "2/29/00". The personnel record included (2) agency "Employee Reference Inquiry" forms, The personnel record did not include documented evidence that the references were verified: On 10/24/07 at 4:15PM the Director of Patient Services and the Human Resources Administrator were interviewed. The Human Resource Supervisor stated that the "reference Page 11 H1354 766.11 (1)(1) Personnel inquires were faxed and returned faxed". H1354 766.1 1(1)(1) Personnel . H1354 766.11 Personnel. The governing authority or operator shall ensure for all health care personnel: ...... . 766.11 Personnel 1. Corrective action to be accomplished for those pat ents found to have been affected by the deficient practice. - Employee number 2will have infection control traini g in Standard Precautions/HIV Confidentiality Law, Empic yee will also sign the HIV letter at the time of her in-servic 12/311/07. By DPS or RN Field Nurse supervisor. -Employee number 3 has been inservi on__ Precautions/HIV Confidentiality Law and has sign d e HIV letter. By DPS. Date of inservi el2f 1_7/0l Standards for Licensed Home Care Age cies require ents were reviewed for Personnel Records (see attached). As per this regulation all employees will be inserviced on Standard Precauions/HIV Confidentiality Law at orientation and then yearly. At the time of mandatory inservice or Standard PrecautionsHIV Confidentiality Law; the letter will be signed by employees and documentItion of signing will be placed in their employee record. November 2007 and ongoing. The DPS accessed the HPN Net. The nimu (I) that a program is implemented and enforced (1) ) t pdHIV for the prevention of circumstances which could STT 0 021199 STATEFORM 0GIX1I Ifcontinuation sheet 11 of New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIERICLIA IDENTIFICATION NUMBER: - PRINTED: 12/07/20( FORM APPROVE (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING 9773L001 NAME OF PROVIDER OR SUPPLIER B. WING __________ 10124/2007 STREET ADDRESS, CITY, STATE, ZIP CODE BROOKLYN, NY 11201 METRO CARE GIVERS, INC. (X4) ID PREFIX TAG 325 GOLD STREET ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) . PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE -___ DEFICIENCY) (X5) COMPLET DATE H1354 Continued From Page 11 H1354 t in a- result in an employee or patient/client becoming exposed to significant risk body substances which could put them at significant risk of HIV or 2. How other patients having the potential to be affected by the same deficient practice will be identified and what corrective action will be taken. wsscheduled for training to December 2007. At that time' for Standard Precautons/HIV Confidentiality Law, had been HIV Confidentiality will be discussed and employees wilt sign the HIV Confidentiality letter. Employees. Documentation of signing will be placed in their employee record. By DPS, Field Nurse Supervisor by 12/31/07. All employees who have not had in-service this year 2007 other blood-borne pathogen infection during the of services, as defined in sections63.1 proviiond and 63.9 of this Title. Such a program shall Sinclude:- 3.What measures will put in place or what systematic changes I that the deficient practice does not recur. - will be made to ensure (i) use of scientifically accepted protective I barriers during job-related activities which involve, or may involve, exposure to significant risk body substances. Such preventive action shall be taken by the employee with each placed inemployee files for all professional and para-irofessional will assure that all professional and para-professional personnel are in compliance with yearly mandatory Infection Control Training by checking their in-service status monthly when calendars are formulated. Aides and Nurses may also be called inand trained on one-to-one basis to accommodate their work schedules personnel. By DPS and RN Field Nurse Supervisor. ! - The Director of Patient Services with the aide of HR Personnel Beginning in January 2008 the HIV Confidentiality letter will be signed at annual Infection Control Training, andwillfbe patient/client and shall constitute an essential element for the prevention,of bi-directional spread of HIV or other blobd-borne pathogen; o (ii) use of scientifically accepted preventive beginning 2008. -4. How the corrective action will be monitored to ensure the deficient practice will not recur. - practices during job-related ach involve the use of contaminated instruments or equipment which may cause puncture injuries; e minformation year to insure Infection Control Training is documented inall professional and para-professional personnel. The results of this yearly audit will be reported by the DPS to the Performance Improvement Committee at the quarterly PI meeting. Effective 2008 and on-going this; will be reported to the governing authority. I DPS will perform a final record audit in December of each (iii) training at the time of employment and yearly staff development programs on the use of protective equipment, preventive practices, and circumstances which represent a significant risk for all employees whose job-related tasks involve, or may involve; exposure to significant risk body substances; (iv) provision of personal protective equipment for employees which is appropriate to the tasks being performed; I (v) a system for monitoring preventive programs to assure compliance and safety. This Rule is not met as evidenced by: Based on record reviews and staff interview, the agency failed to ensure that all employees receive the required annual training on HIV STATE FORM 0GIX11 Ifcontinuation sheet 12 of New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVDERISUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING - PRINTED: 12/0712007 FORM APPROVEC 9773L-Ul " 973L00 NAME OF PROVIDER OR SUPPLIER . [ "_" 10/2412007 METRO CARE GIVERS, INC. (X4) ID PREFIX TAG STREET ADDRESS. CITY, STATE, ZIP CODE 325 GOLD STREET ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL BROOKLYN,,NY 11201 PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE REGULATORY OR LSC IDENTIFYING INFORMATION) H1354 Continued From Page 12 Confidentiality and Universal Precautions. This was evident for two (2) out of six (6) personnel records reviewed. (Employees #2, #3). Failure to ensure that employees receive the required annual in-services places the patients at., risk for receiving poor quality care. The findings are: 1) The personnel record.for Employee #1( Home Health Aide) documents a hire date of "3/18/03". The personnel record does not include evidence of annual HIV Confidentiality and Universal Precautions training. 2) The personnel record for Employee #2 (Registered Nurse) documents a hire date of" 8/11/05". The personnel record does not include evidence of annual HIV Confidentiality training. The last HIV training in the personnel record is dated "7/15/05". On 10/24/07at 4:30 PM the Director of Patient o services was interviewed and stated: "....... in reading the regulations, it was not clear that HIV was required annually however it would be done." Hi354 STATE FORM 0211" 0GIX11 Ifcontinuation sheet 13 of 13 P.M Richard F. Daines M. D. Commissioner November 1, 2007 STATE OF NEW YORK DEPARTMENT OF HEALTH.... Metropolitan Area Regional Office 90 Church Street. New York, NY 10007 Catherine .Giandurco Executive Vice Presid'ent Premier Home Health Care Services, Inc 8002 Kew Gardens Rd, Ste 402 Kew Gardens, NY 11415 License: LC0584A Onsite Visit: June 21 2007 Dear Ms. Giandurco: Please be advised that the Plan of Correction relating to the Article 36 survey of your agency has been reviewed by this office. All items were found to be acceptable and it is expected that you will implement this plan within the time frames that were submitted. A post approval review will be conducted to verify the correction of deficiencies. If you have any questions regarding this matter, please contact (212) 417- 5888. Since ly Cheryl Phoenix-Tannis, RN, MSN, CS Program Manager Home Health and Hospice Services Metropolitan Area Regional Office home health care services, inc. October 25, 2007 Ms. Patricia Jones, RN, MN Deputy Regional Director Metropolitan Area Regional Office New York State Department of Health 90 Church Street New York, N.Y. 10007 :j Dear Ms. Jones: branch location was audited by The agency's 8002 Kew Gardens Rd, Kew Gardens N.Y., of Deficiency as a result of the NYSDOH back on 6/21/07,and has received a Statement the audit. address the deficiencies documented in Enclosed please find the corrective action plan to the S.O.D. Please contact me with any questions regarding the enclosure at 914-428-7722. Most Sincerely, -- I:,. -U: L 'IU Catherine Giandurco Executive Vice President OCT 2 9 2007 H 2-::'360'f:" A n S 1'0 W 360 Hamilton Avenue, Suite 120, White Plainls, New YorkiO 601 Phone 914428-77 2 7 Fax 914-428-2 404 . /,t,.: PRINTED: 1Q/11/2007 FORM APPROVED "ew York State Department of HealthA 3TATEMENT OF DEFICIENCIES kND PLAN OF CORRECTION (X1) PROVIDERSUPPLIERCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING _ _____ _ _ _ _ _ _ _____ _ _ _ (X3) DATE SURVEY COMPLETED LC0584A AME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 06/21/2007 PREMIER HOME HEALTH CARE SERVICES. INC. (X4) IO PREFIX TAG 8002 KEW GARDENS RD STE 402 KEW GARDENS, NY 11415 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) . H 000 Initial Comments H 000 In an effort to identify other Premier Home A full survey was conducted atJune21, 2007. Health Care Services, Inc. on Two (2) Patient Records were reviewed and are identified as 'Patients #1 and #2. Five personnel records were reviewed and are identified as employees 1 - 5. . branch offices that may be agency reviewed all of its NYS impacted by this deficiency the licenses and identified 3 additional licenses that list Physical and Occupational therapy as services provided by o . H 108 'the branch. H 108 765-2.2(c) Amendment of a License, 765-2.2 Amendment of a license, (c) After issuance of an initial license, a licensed home care services agency shall notify the department in writing at least30 days prior to commencing or discontinuing physical therapy, occupational therapy, speech/language . pathology, nutrition services, social work, respiratory therapy, physician services, or medical supplies, equipment and appliances. The agency has Corrected this deficiency by. submitting a letter to the Metropolitan,, Area Regional Office of the NYSDOH requesting an amendment to the licenses that list theseservices. (Please see enclosed letter dated 10/24/07). The agency has Pot provided Physical or Occupational Therapy, nor has it marketed verballyor in its written or electronic materials to its clients, community or contracts, that such seryices are provided by the agency. o This Rule is not met as evidenced by: the Based on review of the agency's license; agency failed to notify the.department in writing at least thirty (30) days prior to discontinuing Physical Therapy and Occupational Therapy services, The agency's failure to ensure that the operating license is current, complete and accurate places all patients at risk for.not being aware of care services provided by the agency. The finding is: The agency's.operating license documents that ABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVES IGNA iTATE FORM 021999 . " .X6) I T 9,.$CZ11 continualion sheet 1 of 5' If PRINTED: 10/11/2007 FORM APPROVED New York Stat Qe artment of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION :M FPOIE I RSPLE. NAME OF PROVIDER OR SU PPLIER.. (X1) PROVIDER/SUPPLIERICLIA IDENTIFICATION NUMBER: .. -STREET (X2) MULTIPLE CONSTRUCTION A. BUILDING A.BULDING B. WING ZIP 402 CITY, ADDRESS, D8002 RD STE CODE KEW GARDENSSTATE, . ..... D -(X3) C OMP LETE DATE SURVEY . . ~ 06/21/2007 LC0584A REI ER HOA / FICSINC IES CARE S E YMENTEALTH KEW GARDENS, NY 11415 ID PREFIX TAG PROVIDER's PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X(5) .COMPLETE DATE. (X)DSUMMARY STATEMENT OF DEFICIENCIESFULL (EACH DEFICIENCY MUST BE PRECEDED BY PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION) TAG H 000 Initial Comments HO survey was conducted at Premier Home full Health Care Services, Inc. on June 21, 2007. Two (2) Patient Records were reviewed and are identified as Patients #1 and,#2, f aof Five personnel records were reviewed and are identified as employees 1 - 5. 10 765-2.2(c) Amendment of a License 765-2.2 Amendment of a license: (c) After issuance of an initial license, a licensed home care services agency shall notify the department in writing at least 30 days prior to commencing or discontinuing physical therapy, occupational therapy, speech/language pathology, nutrition services, social work, respiratory therapy, physician and appliances. medical sup~plies, equipment services, or miaction. This Rule is not met as evidenced by:. Based on review of the agency's license, the agency failed to notify the department in writing at least thirty (30) days prior to discontinuing Physical Therapy and Occupational Therapy services. The agency's failure to ensure that the operating license is current, complete and accurate places all patients at risk for not being aware of care services provided by the agency. The finding is: The agency's operating license documents that REPRESENTATIVE'S SIGNATURE LABnRATORY DIRECTOR'S OR PROVIDER/SUPPLIER "02199 H 108 After careful evaluation of the impact to patient risk because of these service listings on its license, the agency has no findings to suggest that presence these service listings hashad any negative impact on its clients, service community or contracted vendors. The agency will continue not to market or advertise Physical and Occupation, Therapy as services it provides as it waits for the amended licenses. The Executive Vice President is responsible for this corrective The time frame to complete the request for ai " TITLE DATE (X6) STATE FORM 9GCZ1 1 Ifcontinuation sheet I of 5 PRINTED: 10111/2007. FORM APPROVED ew York State De artment of Health TATEMENT OF DEFICIENCIES . ND PLAN OF CORRECTION (X1) .PROVIDERJSUPPIERJC LIA IDENTIFICATION NUMBER: . .. . . .. (X2) MULTIPLE. CONSTRUCTION A. BUILDING .- . DATE SURVEY o (X3) COMPLETED . .. B.WING 06121/2007 LC0584A lAME OF PROVIDER OR SUPPLIER . STREET ADDRESS, CITY, STATE, ZIP CODE INC. IREMIER HOME HEALTH CARE SERVICES. X4) ID PREFIX TAG 8002 KEW GARDENS RD STE 402 KEW GARDENS, NY 11415 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CRODSREFERENCED TO THE APPROPRIATE (X5) -COMPLETE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) DATE H 108 Continued From Page 1 H 108 In an effort to identify the potential risk for other patients who may not have been provided with the correct Department of the agency provides" Physical Therapy and Occupatonal Therapy: During the interview on 6/21/07 with the VP of Regional Operations at 3:30 pm, he stated that the agency does not.provide Physical Therapy or Health telephone number to use in the event theclient chooses to express a complaint, the agency Occupational Therapy. Hereviewed provide Home Health Aide and Personal Care Aide from that office. H 222 766.1(a)(8) Patient rights Section 766.1 Patient rights. (a) The governing authority shall establish written policies regarding the rights of the patient and shall ensure the development.of. procedures implementing sucH policies. These rights, policies and procedures shall afford each patient the right to: ,The (8) voice complaints and recommend changes in policies and services to agency staff, the New York State Department of Health or any outside representative of the patient's choice. The or patient expression of such complaints by the free from interference, his/her designee shall be coercion, discrimination or reprisal. This Rule is not met as evidenced by: the Based on record review and interviews, the agency failed to provide the patients with correct telephone number for the Department of Health to lodge a complaint. accurate failure to provide The agency's information placed patients at risk for not being afforded their right to lodge a complaint with the Department of Health. _ E FORM 02119 100% of the remaining branch private pay clinical charts. The audit reveled that in 100% of the remaining charts, the correct Department of Health telephone number was present on each cliehnt's Patient Bill of rights Pl I e and therefore the correct number had been provided.to all other clients. client affected by the deficient practice was proyided with the correctDepartment of Health telephone number ortan rights amended Patient bill of ht t ed and form and instructed that the number is the contact number to express a complaint regarding the home care ser ices he/she receives from the agency. Documentation of the review of the amended numberand its a t purpose is. in the client's clinical chart. H222. 9GCZ1 1 If continuation sheet 2 of 5 New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDERISUPPLIERCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING ______ _____ PRINTED: 10/1112007 FORM APPROVED (X3) DATE SURVEY COMPLETED LC0584A NAME OF PROVIDER OR SUPPLIER 0612112007 STREET ADDRESS, CITY, STATE, ZIP CODE PREMIER HOME.HEALTH CARE SERVICES. INC. (X4) ID PREFIX TAG 8002 KEW GARDENS RD STE 402 KEW GARDENS, NY 11415 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (XS) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H 108 Continued From Page 1 the agency provides " Physical Therapy and Occupational Therapy." the VP of During the interview on 6/21/07 with Regional Operations at 3:30 pm, he stated that the agency does not provide Physical Therapy or Occupational Therapy. He noted that they only provide Home Health Aide and Personal Care Aide from that office. H 222 766.1(a)(8) Patient rights Section 766.1 Patient rights. (a) The governing authority shall establish written policies regarding the rights of the.patient and shall ensure.the development of procedures implementing such policies. These rights, policies and procedures shall afford each patient the right to: (8) voice complaints and recommend changes in policies and services to agency staff, the New York State Department of Health or any outside representative of the patient's choice. The expression of such complaints by the patient or hisfher designee shall be free from interference, coercion, discrimination or reprisal. H 108 a..All of the agency's Patient Bill of Rights forms were reviewed and found to contain the number 21241 7-5888. H 222 Additionally, the agency has modified its Patient Bill of Rights Policy, 15.3, to include the State of New York Department of Health Telephone number and lists NYSDOH as an additional source a client may choose to express a complaint to r regarding the services he/she receives from the agency. (Please see the enclosure) The numbers for the United States Departmhent of Health and JCAHO shall remain in the policy as specified under 766.1(8), clients have a right to voice complaints and recommend changes in policies and services This Rule is not met as evidenced by: Based on record review and interviews, the agency failed to provide the patients with the correct telephone-number for the Department ofp Health to lodge a complaint. The agency's failure to provide accurate information placed patiehts at risk for not being afforded their right to lodge a complaint with the , Department of Health. C FORM ,,,,,g to agency staff, the NYSDOH or any outside representative of the patient's choice. A notice of Policy amendment shall be issued to the agency's branch offices on 11/2//07. 9GCZ1 1Icon nuationlshe I 0f5 PRINTED: 10/11/2007 FORM APPROVED lew York State De artment of Health TATEMENT-OF DEFICIENCIES ND PLAN OF CORRECTION (X) -PROVIDERJSUPPLIERJCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDINGCOMPLETED (X3) DATE SURVEY 'LC584AB. 4AME OF .PROVIDER OR SUPPLIER WING STREET ADDRESS. CITY, STATE, ZIP CODE 06/2112007 INC. 2REMIER HOME HEALTH CARE SERVICES. (X4) IO PREFIX TAG 8002 KEW GARDENS RD STE 402 KEW GARDENS, NY 11415 ID PREFIX TAG PROVIDERS pLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSSDREFERENCED TO THE APPROPRIATE (X) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST-BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H 108 Continued From Page 1 and the agency provides " Physical Therapy H 108 occupational Therapy." During the interview on 6/21/07 with the VP of Regional Operations at 3:30 pm, he stated that the agency does not provide Physical Therapy or An in-service to' review the amended policy will be conducted over the next several weeks during Branch Meetings. Occupational Therapy. He noted that they only provide Home Health Aide and Personal Care ' Aide from that office. H 222 766.1(a)(8) Patient rights Section 766.1 Patient rights. establish written (a) The governing authority shall .monitor ain n h ihs0 policies regarding th rights of the patient and poiisrgrigthe of procedures shall ensure the development implementing such policies. These rights, policies and procedures shall afford each patient the right to: ,charts The completion of the in-service this policy for 12/y3/07. shall be cornpletid by by 12/13/07. H 222 Further, beginning 11/1/07 and over the next 4 months, a 10% sample of private pay clinical and to atidited to will bedetermine on-going compliance with this corrective action plan. At the end of the 4- month period, the agency shall re-evaluate-the need to continue with a sample focus audit. changes in (8) voice complaints and recommend staff, the New policies and services to agency any outside York State Department of-Healthor of the patient's choice. The representative or expression of such complaints by the patient his/her designee shall be free from interference, coercion, discrimination or reprisal. This Rule is not met as evidenced by: Based on record review and interviews, the agency failed to provide the patients with the of correct telephone number for the Department Health to lodge a complaint. The agency's failure to provide accurate information placed patients at risk for not being afforded their right to lodge a complaint with the Department of Health. S EFORM 02119g 9GCZ1 1 If continuation sheet 2 of 5 PRINTED: 10/11/2007 FORM APPROVED New York State De a...e.. f Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION - ( (X2) MULTIPLE CONSTRUCTION .... (Xl) PROVIDER/SUIPLIER/CLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED.. A. BUILDING __________ L584AB. NAME OF PROVIDER OR SUPPLIER WING STREET ADDRESS. CITY, STATE, ZIP CODE 06/21/2007 PREMIER HOME HEALTH CARE SERVICES, INC. (X4) ID PREFIX TAG 8002 KEW GARDENS RD STE 402 KEWGARDENS, NY 11415. ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (x5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H 222 Continued From Page 2 The findings is: The agency's Policy "Patient Bill of Rights 15.3" H 222 The Field Nurse Supervisor is responsible for this corrective action plan completed by 12/14/07.and completion of the documented that patients were being directed to. lodge Complaints to "United States Department of Health Telephone # 1-800-628-5972." The ComplaintlOccurrence Involving Patient Services documents "Joint Commission Hotline 800-994-6610." These are not the correct number to lodge complaints. During interview with the VP of Regional Operations on 6/21/07 at 3:33 pm, the VP of Regional Operations stated that the numbers are incorrect and will be changed. 4-month focus sample audit will be completed on 2/28//08. . The personnel files for employee's # 1,2,3 and 4 were reviewed and fouft notof include documentation to H1306 766.11(c) Personnel . H1306 statement that the employees are 766.11 Personnel.depressants, "free of habituation or addiction Stimulants, narcotics, alcohol'or other drugs o- substances which many alter the individual's behavior. The agency conducts annual random drug screen panel tests on all potential and active employees to screen for The governing authority or operator shall ensure for all health care personnel: (c) that the health status of all new personnel is assessed and documented prior to assuming of patient care duties.The assessment shall be sufficient scope that no person shall1 assume his/her duties unless he/she is free from.a health impairment which is of potential risk to the patient or which might interfere with theperformance of his/her duties, including the habituation or addiction to depressants, stimulants, narcotics, alcohol or other drugs or substances which may alter the individual's behavior. depressants, stimulants, narcotics, and other drug substance usage. This practice has been in effect at the agency lab results of such since 1996 and in each tests are found employee's personnel file in the medical section. 9GCZ1 1 Ifcontinuation sheet 3 of 5 This Rule is not met as evidenced by: The findings are: ST E FORM 021199 PRINTED: 10/11/2007 FORM APPROVED ew York State Department of Health o ATMET rATEMENT OF DEFICIENCIES D PLAN OF CORRECTION MULTIPLE ___________ IA. DETIICTIN UMER (Xl) PROVIDER/SUPPLIERJCLIA...... .(X2) BUILDING CONSTRUCTIONF ""I EFCINCES IDENTIFICATION NUMBER: A. B. WING (X3) DATE SURVEY COMPLETE 062/20 LCO584A AME OF PROVIDER OR SUPPLIER . 0612112007 STREET ADDRESS, CITY, STATE, ZIP CODE INC. 'REMIER HOME HEALTH CARE SERVICES. (X4) ID TAG 8002'KEW GARDENS RD STE 402 KEW GARDENS, NY 11415 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION ACTION (EACH CORRECTIVE AREFIXSHOULD BE DEFICIENCY) CROSS-REFERENCED TO THE APPROPRIATE (X5) oCOMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H 222 Continued From Page 2 The findings is: The agency's Policy "Patient Bill of Rights 15.3" documented that patients were being directed to lodge complaints to "United States Department of Health Telephone # 1-800-628-5972." The Complaint/Occurrence Involving Patient Services documents "Joint Commission Hotline .800-994-6610." These are not the correct number to lodge complaints. numbr tolode coplaits.the During interview-with the VP of Regional Operations on 6/21/07 at 3:33 pm, the VP of Regional Operations stated that the numbers are incorrect and will be changed. H1306 766.11(c) Personnel -766.11 Personnel. The governing authority or operator shall ensure for all health care personnel: is (c) that the health status of all new personnel to assuming assessed and documented prior patient care duties.The assessment shall be of sufficient scope that no person shall assume his/her duties unless he/she is free from a health impairment which is of potential risk to the patient or which might interfere with the performance of-his/her duties, including the habituation or addiction to depressants, or stimulants, narcotics, alcohol or other drugs the individual's. substances which may alter behavior. This Rule is not met as evidenced by: The findings are: . H 222 The agency's health assessment and physical forms were modifed on 5/17/07 and 10/24/07 respectively to include the statement "the person is free of habituation or addiction to depressants, stimulants, d lc oth a ar ts, n other drugs narcotics, alcohol or may alter or substances which individual's behavior". The tAssessment form hais beeh utilized by the agency since June til1/07and thhemodicyedinployeee 1/07 and-.the modified Employee Physical form will be implemented effective 11/1/07. o H1306 i " Ifcontinuation sheet 3 of 5 S' "EFORM 021199 9GCZl 1 PRINTED: 10/11/2007 FORM APPROVED New York State De artmentof Health STATEMENT-OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDERJSUPPLIERJCLIA IDENTIFICATION NUMBER: - (X2) MULTIPLE CONSTRUCT ION A.COMPLETED A. BUILDING WING ~~B. _ ______ _ _ _ _ _ _ _ _____ _ _ (X3) DATE SURVEY LC0584A NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 06/21/2007 PREMIER HOME HEALTH CARE SERVICES, INC. (X4) ID PREFIX TAG 8002 KEW GARDENS RD ,STE 402 KEW GARDENS, NY 11415 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H1306 Continued From Page 3 Based on record reviews and interviews it was. determined that the agency did not obtain health statements for employees. This was evident for 4 of 4 personnel files reviewed for the Freedom of Habituation to Drugs and Alcohol statement. The finding is: The Personnel files for Employees #1, #2, #3 and #4 did not include documentation of H1306 The agency shall perform health assessments on employees 1,2,3 and 4 in advance of their annual schedule by 11/16/07 and for the remaining employees, . statement that the employees are "free of habituation or addiction to depressants, the agency shall capture the the Heiaen to cre Habituation to Drugs and stimulants, narcotics, alcohol or other drugs or substances which may alter the individuals's behavior." Alcohol statement at the time of each individual's next routine health assessment. During the interview with the VP of Regional Operations on 6/21/07 at 4pm, the VP of Regional Operations stated that the statements are "missing". H1337 766.11(f)(ii) Personnel Section 766.11 Personnel The governing authority or operator shall ensure for all health care personnel: o the extent (f)(ii) a criminal history record check to of this Title 400.23 required by section o H1337 The agency's amended Health Assessment and Employment Physical forms are available on the agency's Forms Directory and the version with out the statement has been removed. Each branch Administrator will -review and in-service its staff on the change in the physical form during branch meetings held over. thein e sra l ee ks. e the next several weeks. Time frame for completion of this process is 12/14/07. This Rule is not met as evidenced by: Based on personnel record review and staff interview, it was determined that the agency failed to ensure that a criminal history record check was completed in one (1) of one (1) S- -EFORM 021199 9GCZ1 1 5 Ifcontinuation sheet 4 of PRINTED: 10/11/2007 FORM APPROVED' ew York State Department of Health FATEMENT OF DEFICIENCIES 4D PLAN OF CORRECTION (XI) PROVIDERJSUPPLIER/CLIA IDENTIFICATION.NUMBER: (X2) MULTIPLE CONSTRUCTION ";C"O"P......... A:BUILDING 4,B. IING _ _ _ _ _ __ _ _ _ _ (X3) DATE SURVEY COMPLETED LC584AB. AME OF PROVIDER OR SUPPLIER WING 06/2112007 STREET ADDRESS. CITY, STATE, ZIP CODE REMIER HOME HEALTH CARE SERVICES. INC. (X4) ID REFIX TAG 8002 KEW GARDENS RD STE 402 KEW GARDENS, NY 11415 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (XS) COMPLETE DATE H1306 Continued From Page 3 Based on record reviews and interviews it was determined that the agency did not obtain health statements for employees. This was evident for of 4 personnel files reviewed for the.Freedom of Habituation to Drugs and Alcohol statement. The finding is: The Personnel files for Employees #1, #2, #3 and #4 did not include documentation of statement that the employees are "free of habituation or addiction to depressants, stimulants, narcotics, alcohol or other drugs or substances which may alter the individuals's H1306 The branch shall review 10% of its monthly Health Assessments beginning 12/1/07 for a 4-month period to determine on-going compliance with this corrective action plan. The agency shall reevaluate its need to continue with focus audit at the end of the 4-it mo n t eriod. month period. The time frame for the completion for the sample focus audit is 3/31/08. The Branch Administrator is the person responsible for the correction of this deficiency. H1337 behavior." During the interview with the VP of Regional Operations on 6/21/07 at 4pm, the VP of Regional.Operations stated that the statements are ."missing". H1337 766.11 (f)(ii) Personnel Section 766.11 Personnel The governing authority or operator shall ensure for all health care personnel: (f)(ii) a criminal history record check to the extent required by section 400.23 of this Title This Rule is not met as evidenced by: Based on personnel record review and staff interview, it was determined that the agency failed to ensure that a criminal history record check was completed in one (1) of one (1) FORM 0199 9GCZ1 1 If continuation sheet 4 of 5 .PRINTED: 10/11/2007 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF-CORRECTION (Xl) PROVIDER/SUPPLIERJCLIA . IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED. _____ B. WING ______ 0621/2007 LC0584A NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8 0 0 2 'KEW PREMIER HOME HEALTH CARE SERVICES, INC. (X4) ID PREFIX TAG GARDENS RD STE 402 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE KEW GARDENS,NY 11415 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H1337 Continued From Page 4 personnel record reviewed ( Employee #4). The findings are: Employee #4 personnel record lacked documentation lacked documentation that a Criminal History Record Check was initiated and completed. During the interview with the VP of Regional H1337 The agency was cited for Personnel record #4. The SOD o states that this record was found to lack documentation that a Criminal History Record Check. was initiated and completed on the referenced employee. Operations on 6/21/07 at 3:55pm, the VP of Regional Operations stated the agency does the "Acufact" and the Federal criminal history check on all employees .copeeasvinedbth The aide's Criminal History Record Check was initiated and completed as evidenced by the receipt of confirmation from NYSDOH CHRC division. (Please see the enclosure). The'aide's personnel file did not contain a copy of the DOH CHRC 102 form. Subsequently, the agency requested employee #4 to complete a new 102, which has been provided in this POC as an enclosure. Additionally, a sample focus audit of 26 personnel records was conducted by the agency to determine the presence of the 102 forms in each record. The of the sample files aiidited. S .. TE FORM .01199 9G CZ1 1 If continuation sheet 5 of 5 STATE OF NEW YORK DEPARTMENT OF HEALTH Metropolitan Area Regional Office 90 Church Street, New York, NY 10007 Richard F.Daines Commissioner Wendy E.Saunders Chief of Staff February 25, 2008 Ms. Celestina Tina Cruz, RN VP of Clinical Services Premier Home Health Services, Inc 494 8t Ave New York, NY 10001 Re: Response to Plan of Correction Survey Date: June 28, 2007 License: LC0585A Dear Ms. Cruz: Please be advised that the plan of correction relating to the recent Article 36, survey of your agency have been reviewed by this office. All items were foundto be acceptable and it is expected that you will implement this plan within the time frames that were submitted. A post approval review will be conducted to verity the correction of deficiencies. .If have any questions regarding this matter, please contact (212) 417-5888. you Sincerely, Cheryl Phoenix-Tannis, RN. MSN, CS Program Manager Home Health and Hospices Services Metropolitan Area Regional Offices \ ;i : bome bealtb care services, inc. February 22, 2008 Cheryl Phoenix-Tannis, RN, MSN, CS Program Manager Home Health and Hospice Services Metropolitan Area Regional Office RE: LHCSA License #1086L005 Date of Survey- 6/28/07 Dear Ms. Phoenix-Tannis: First, I would like to thank you for the extension you granted our agency on 2/8/08 for completing the Plan of Correction (POC) for this survey. in Second, there are two sets of attachments with the POC. They contain documentation reference to tags H1008 and H1002. regarding the Please feel free to call me at 914-428-7722 if you have any questions or concerns POC. Sincerely, Celestina (TinaYtruz, RN VP of Clinical Services n *Sent via fax and Federal Express o 02/22/08 . 360 Hamilton Avenue,. Suite 120, White Plains, New York 10601 Phone 914-428-7722 Fax 914-428-2404 l.OQV/I07 PRINTED: 10/151207 FORM APPROVED 4ew York State Department of Health ;TATEMENT OF DEFICIENCIES ,.ID PLAN OF CORRECTION (XI) PROVIDERJSUPPUER/CLIA IDENTIFICATION NUMBER: n(2) MULTIPLE CONSTRUCTION A.BUILDING a. WUIN~ ___________ C(3) DATE SURVEYCOMPLETED LC0585A SCME OIF PRoVDER OR SUPPLIER s WING :STREET ADDRESS, CtTY, STATE, ZIP CODE 0612M12007 -REMIERHOME HEALTH CARE SERVICES. INC. (X4) ID PREFIX TAG 494 8TH AVE NEW YORK, NY 10001 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTrVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (XS) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H 000 Initial Comments H 000 A Full Survey was conducted at Premier Home Health Care Services, Inc.. on June 28, 2007. Eight (8)patient care records were reviewed and are identified as Patients #1 - #8. Five (5) personnel recordswere reviewed and are identified as Employees #1 - #5. H 222 766.1(a)(6) Patient rights H 222 H222 Section 766.1 Patient rights. '(#15.3) (a) The governing authority shall establish b written policies regarding the rights of the patient and shall ensure the development of procedures implementing such policies. These rights; - policies and procedures shall afford each patient the right to: As part of the admission process, it is the policy of Premier Home Health Care Service to review the Patient's Bill of Rights Document and obtain the signature of the patient or patient's representative. A copy of the signed Bill of Rights is filed in the patient's clinical record and in addition, a copy is left the patient. The Bill of for Rights lists the complaint hotline phone (8) voice complaints and recommend changes in policies and services to agency staff, the New York State Department of Health or any outside representative of the patient's choice. The number for the Department of Health. I. Corrective action for those patients found to be affected by the deficient practice: expression of such complaints by the patient or coercion, discrimination or reprisal. oreprisl. his/her designee shall be free from interference, The Statement of Deficiency did not identify which specific patients in the sample were affected by the deficiency. Sample patient This Rule is not met as evidenced by: Based on record review and interviewthe agency failed to provide patients with the correct telephone number for complaint notification, The agency's failure to provide current and accurate information placed patients at risk for #1 was discharged from services. Sample patients #2, #3, #4, #5, #6, #7, and #8 were transferred to another office. Residents #2 and #3 expired and patient #7 was discharged from services. Patients #4, #5, #6, and #8 were readmitted to services when they transferred to the new office. All of the admission paperwork was resigned, including the correct version of the Bill of Rights. Copies of the new, signed Bill of Rights were left in the patients' homes and a copy was placed in their clinical records. not being afforded their right to lodge a complaint with the Department of Health. 9.,OR PR0" ER/SUPPLiNR REPRESENTATIVE'S SIGNATURE Continued next page... TITLE .() DATE AaORATOJKYDIRECT - IPORM ,C W 51 cntinualio' theet 1of 4 U'., ,-,-, ,.vYC ?'VD* 1 ?4,: .,.. ,..A - O03/OO3 '2/17/2008 Now Yory 23:09 12124174938 NE-_YIJRK-DEPARTMENTO PAGE 07/09 tate oi~prrnet i If Health (XI) p1ZCIOER1SUPP IDOiF"IPATION NUMeER (X2) MUILTIPLE CONSTkU TION PRINTED: 1011512007 FORM APPROVED 90) DATE 5GURY ,COLETID " TEENT OF DiEFI IENCES FILA OF _,RRECf"ION LC05B5A NAmE OF PkC'IPER OR -SUPPLIER SRT A BUILDING _=82 _ Ii. .WING _.__ -OB/r207 -Ar)1RES8. CI?'?, STAT19, ZIP CODE~ PREMIER HoME HEALTH CARE SERVICES. INC. (A) ID PRIEFIX TAO 4 4 6TH AVE NEW YORK NY 10001 ID. PREFIX TAG TG PRONADERS PLAN OF CORRECTION (EC* CMOREtr fE ACTION SHOULD BE , CROSS-EF1,ENCED TO THE APPROPRATE DEIChEN~Y SUMMARY STATID ONT OF OPIIENCF (EACH DF-.N REGULATORY C'I'Y=MUST E PRECEDMf B'Y FULL OR IDDNMMNG INFORATION) TAG CoMPLETE DAM H 222 Coninued From Page 1 The finding Is: H 222 1H.Identification of other patients having the potential to be affected by the deficiency and what corrective action will The agency's "PatientBill of Rights instructs patients of the following: *...,to Idge complaints to the State of New York Department of Health at 212-613-4703 ....... The documented number is not the con-ed number to lodge a complaint with the department of health, On 6128/07 at 2:33pm, the Regional Director was be taken: All private pay and case managed patients have the potential to be affected by the deficient practice. All case managed records will be audited by the Office Administrator and Field Nurse Supervisor to determine compliance with the regulation. o For the patients found to be out of compliance, the Field Nurse Supervisor will a home visit to review the correct n rtconduct version of the Bill of Rights with the patient, obtain his/her signature or his/her H1002 representative's signature and leave a copy at the patient's home for their reference. The Interviewed and stated that the number Is incorract 76.1)(a) GoVeMing authority . Secton 766.9 Governing authority, overning authority or operator. as defined Th in Pa 700 of this Titi, of a licensed home care services gency shag: (a) be respb operation of th ible for the management and genCy: D of the home care services FNS will place a copy in the patient's clinical record. Persons responsible: Administrator FNS . Regional DPS Date of Correction: 6/25/08 Ill. Measures that will be put in place to ensure that the deficient practice will not (b) ensure cornplia agency with all appilI le Federal, State and loczl statutes, rules an This Rule is not met as ulations. enrcd by,. Based on record reviews an interviews, the agency failed to hold meating f the governing authority responsible for the ma gement and IRue end Reglation, '--The reoccur: The Field Nurse Supervisors and Per Diem nurses will be directed to immediately remove all unused, incorrect Bill of Rights documents in their possession and in the operation of the agency in complia ce with State The MIlurei to ensure thed the Governin Authority Mneet and porform the required all of the governing functionsat re fo poorhqu body, plac'e y, alty care. ptiets paiens at nrS for Ioor quality ca re. The findings is: ST^'E FORM, office. Administrator, Field Nurse Supervisors and all Per.Diem Nurses will be in-serviced on Policy #15.3 by the Regional DPS. XContinued Persons responsible: Regional DPS Date of Correction: 6/25/08 next page... CKY511 ff ntnulhn rhoci 2 of 02/67/2008 23: 89 12124174938 NEWYORKDEPARTMENTO PAGE '07/89 PRINT;: 1015/2007 FORM APPROVED (W ) DATE SURVEY OOMPLETED NOw Yor k ate Department of ealth (%1) F OVICFEWSUPPIERJUI4A ID;4TM'FI0TICN NUMBER; PM MULTIPLE COIW -TATEENT OF DFIc1IENCIS 0 PLAN OF CORRECTION kUCTION A. W4lLINO_________ LC0S8.SA ?"ME OF PROVIPR OR SUPPLER PREMIER HOME HEALTH CIARE SERCES. INC. (XA) ID PREFIX TAG =812812007 STREET ADRESS. CrIY, TAM, ZP =r;lC 404 8TH AVE NEW YORK NY 10001 ID. PREFIX TAG SUMMARY STATEMMNT OF DFIVE N-- PROYIER*S PLAN OF CORRJTION (SAH cO RCTTVE ACTION SHOULD BE TO THE APPROPRIATE CtRSs[DED DEFCIENCY) COMPLETE DTE (EACH D.RCIENCY MUST M PRP LeD L REGULATORY OR = IOENIFYINC INFORI ATION). H 222 Continued From Page I The finding IS: H 222 FV. How will the corrective action be monitored to ensure the deficient practice will not reoccur? The agernc>s "Patient Bill of Rights" instrcts 25% of the case-managed records will be audited each quarter for a one year period to ensure compliance with the regulation. Parties responsible for the correction and l...,lodge complalnt&; patients of the followh'g: to the State of New Yorlk Department of Health at 212-613-4703 ....... "The documented number is not the correct number to lodge a complaint with the department of health, On 6128/07 at 2:33prn, the FRegional Dit--tor was ongoing compliance are: Office Administrator Field Nurse Supervisors Regional DPS Interviewed and stated that the number Is IncolreOt Vice President of Clinical Services Date of Correction: 6/25/08 H1002 768.9(a) Govemlng authority Section 766.9 Governing authority, The governing authority or operator, as defined in Part 700 of this Title, of a Itcensed home cara. services agency shall:_ H1002 H1002 The agency's Corporate QI committee includes the agency's C.O.O. and V.P. of Human Resources and Administration, both of whom have board designation as members of the agency's executive committee. The executive committee serves at the pleasure of the board The following (a) be respontible fof the management and sections of Premier Home Health Care' , Services Inc.'s Policy and Procedure 5.0, Agency By-Laws, delineate the authority Directors. operation of the agency;, (b) ensure compliance of the home care services agency with all applicable Federal, State and local statutes, rules and regutlations. This Rule is not met as evidenced by. interviews; the Based on record reviews and agency failed to hold meetings of the governing authority responsible for the management and operatilon of the agency in Compliane with State RuleS and Regulations, and delegation powers of the Board of Section 3- Annual and Regular Meetings' Notice: (a) A regular annual meeting of the board of Directors shall be held after the close of the' fiscal year of the Corporation. Continued next page... The failure to ensure that the Governing Authority meet and perform the required functions of the governing body, places all patients at risK for poor quality care. The findings is: STATE FoRM CKY51 I VtlAlan that 2 of .0003/003 62/87/2868 23:. 12124174938 NEWYO,.KDEPARTN-rO PAGE 87/9 PRINTEb: I/I5/72Do7 Now YOM tate Degarmentof Heal, crATYiEn OF OSMFC cIES I PLAN OF CORRECTION " ,ORM (X2)MULTILE CON'TRuCTioN POILIN G APPROVE X) DATE ET OLEM"Z l) PROVOEPtSUppI _P.IA N UIIOIMPM 'A. * LC O85A NAME OF P-OVIpSR ORSUPPUER E w Q _ .. . L in e L~O58SAO~t2DI2DOT ST, ADlDRES T CrlY, STA'E iMp 0:1E PREMIER HOME HEALTH CARE SERVICES, INC. ,._ fXA) ID PREFIX TAG 494 OTH AVE NEW YORK NY 10001 I. SUMMARY ATEAENT OF D1PJIENcls (EACH DEFICIENC ' MUST DE PRtCrO.M BYEUR FULL REGULATORY OR = IDHNTIF C;NC INFORMATION) _ PREFIX TAG . .... PR, D ES PLAN OF CORRECTIDN FAcH cORRECTrE ACTION SHOULD BE CRSt ECFD TO THE APPROPRIATE ) C D EMO N L-Y V XOMPLETE TE H 222 Continued From Page 1 The finding Is: rintwt H222 Section 13- Committees: The Board of Directors, by resolution adopted by a majority of the entire Board, The agencys 'Patient Bil of RI instucts npla a patients of the following . lodgeocomplaints ge to the State of New Yo elpartment of Health at 1d rto 212-613-A703 ........ el::documented number is llai Stthe ,th . ber to lodge a Complain(. Sdept te onec h of h. not may from time to time designate from among its members an executive committee and such other committees, and alternate members thereof, as they deem desirable, each consisting of two or more members, with such powers and authority (to the extent 5ermitted by law) as may be provided H1002 in such resolution. Attached is a copy of. the approval page for the 2006 Policy and Procedure manual. The page points out the Board of Directors involvement with the Corporate Quality Assurance/Performance committee as, they reviewed and accepted themanual. On t I e'i owed and stated that the number Is H1002 Govemlng authority c.o(a) Section 766.9 Govening authority. The goveming authority or op~erator, as defined in Part 700 of this Titln,'of a licensed home carm services agency shagI: (a) be responbible for the operation of the ageny- management and a .sheets (b) ensure corpliance of the home care services agency with allrule,.s and rgulations. local s1ttts, applicable Federal, State and Thialstatuts, rulesot ta regtid ns bfound This Rule is not met as evidenced bT Based on record reviews and interviews, the agency failed to hold meetings of the governing authority responsible for the management and Also attached are copies of the sign-in for the Corporate QI. meetings. Included is the agenda page for one meeting which notes that the meeting was called at the request of the Governing Authority. - 1. Corrective action for those patients . tobe affected by the deficient practice: No specific patients were noted in the citation as being affected by the deficiency. operation of the agenry in compliance with State RuleS afld Regulations, The failure to ensure that the Goveming Authority meet andperfrrm the required . functions of the governing body, places all patients at risK for poor quality care. The findings is: ST&TE FORM iCKY511 II. Identification of other patients having the potential to be affected by the deficiency and what corrective action will be taken: All patients have the potential to be affected by the deficient practice. Continued on next page... " ... -K5 . . 11 EURcatiutmon the 2"" t 2 or o- 8003/003 (2/7/288 23: 9 12124174938 NEWYOPKDEPARTMENTO PAGE 709 PRINTM: 1/15/207 New YceKSate De artment fealth iPLAN OF CORRfEC"ION I " _-ORM ,Ok BULDLING APPROVED MTIPLE ___n-__90)_DATE____UMR L 5eAa wz OtWLETeD ...... ______ LC*585A NAME Of: PRO'lPE~ SUPPUTR OR lx0B2812Q07 STREET ADDRESS. CflY. rTATS, zip =13t 404 NEW TH AVE YOK,Y 10001 11) PREFIX TA' PROVIDEWS PLAN OF cORRETDN (rAC( DORRECTW ACTION SHOULD BE CS,.EN D TO THE APPOPRIATETE PREMIER HOME HEALTH CARE SERVICES. INC. C)n) PREFIX TAG H222 SLIMMAWy STATEMENT 222. Fr. PageCF 1 OF O1PIC3I1NSV-. (EACH FFICENC MUST R PRE .I.M B FULL REGuLATORY OR L&Q lDrNi1FYING INFORMATIO) ______DEFCENCY) CRDnue TH APRPT DAT ContinuedFrmPage1H The finding Is: The agencys "Patient Bill ghts" insTtuctA *... tAo lodge complBint patients of the foll W Department of Health at to the State of Ne 212-613-4703. ,.. The documented number is not the con number to lodge a complaint Pith 222 The Board of Directors will meet biannually with a set agenda reflecting the concerns of the Corporate Quality Improvement Committee. Te Corporate Quality Assurance Committee will continue to meet on a quarterly basis. III. Measures that will be put in place to ensure that the deficient practice will not /2607 tRgioal DrL-torWaereoccur: te 233pn, 0, IZEV07 at 2:33pr, the Regional Director was The Board of Directors will meet biannually "hterviewed and stated that the number Is with set the of the dep ent of health, incorrect .H1002 765.9(a) Governing authority section 766.9 Governing authorilty, The goveming authority or operator as defined in Part 700 of this Title, of a licensed home cam services agency shall: (a) be respont!ile for the management and operation of the agenca, ag n (b) ensure oomplianoe of 6ie home care servids; agency with allrule and regulationst local wtatutes, applicable Federal, State and This Rule is not met as eviden ed by. H1002 the Corporate Quality Improvement Committee. The Board will keep a copy of the meeting agenda and a sign-in sheet to provide evidence of the meeting. The Corporate Quality " Assurance Committee will continue to meet on a qluarterly basis. The Committee will keep a copy of the meeting agenda and sign in sheet to provide evidence of the meeting. IV. How will the corrective action be monitored to ensure the deficient practice will not reoccur? The Vice Presidentsetting the meeting will be responsible for of Clinical Services dates and agendas for both the Board of Directors' meetings and the Corporate Quality Improvement meetings. The first of the Board of Directors meeting dates will be set after the fourth and first quarter Corporate Quality Improvement meetings and the second of the biannual meetings will occur after the second and third quarter Corporate wt e gnarfetn h ocrso Based on record review and interviews, the agency failed to hold meetings of the governing authority responsible for the management and operation of the agency in compliance With State Rules and Regulations," The fallura to erwure that the Governing Authority meet and perform the required f tions of the governing body, places all patients at risK for poor quality c. , are The findings is: T&ArE FORM .CKY51 Quality Improvement meetings. The Vice President of Clinical Services will also keep copies of the sign-in sheets and agendas for the meetings. Date of Correction: 06/25/08 1 ff tunintnr"~ 2 of Uo6/007 PRINTED: 10115f2007 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND) PLAN -OF CORRECTION (X) PRO'1DERJSUPPUERJCUA .. IDENT'IFICATION NUMBER_ Q2) MULTIPLE CONSTRUCTION A. (X3) DATE SURVEYI COMPLETED BUILDING __________ LCO5S5A OF NAWM PROVIDER OR SUPPLIER PREMIER HOME HEALTH CARE SERVICES. INC. I94BTH AVE I NEWYORK NY 10001 (X4) ID TAG SUMMARY STATEMENT OF DEFICIENCIES FULL (ACH DEF"CIENCY MUST BE PRECEDED ESY EPREFIX REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG a. VNG STREET ADDRESS. CITY. STATE, ZIP CODE 061282007 PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (XS) COMPLETE DATE H1D02 Continued From Page 2 There is no.documented evidence of Governing Authority meetings for 2006 and 2007. The Regional Director could not provide H1002 documentation of the Governing Authority meeting minutes o'nducted in 200612007 to ensure that meetings were held. On 6/28/07 at 2:30pm, the Regional Director was interviewed and stated that the Governing Authority "does not meet unless there is an emergency". H1008 766.9(d) Governing authority Section 766.9 Governing authority. The governing authority or operator, as defined in Part 700 of this Title, of a licensed home o care services agency shall: amendments to written (d')adopt and approveman ament and policie regardn th nd en polies reg rdng the manag HI008 H1008 A. *Note: This POC/policy was previously developed for a subsidiary of the organization and was accepted. The agency adopteda HPN policy on - operation of the home care services agency the provision of health care services. This Rule is not met as evidenced by: Based on record review and interview, the agency did. not develop policies for the Health Care Provider Network and Criminal Background Checks for employees. The Governing Authority's failure to maintain current and complete policies and procedures pace the patients at risk for receiving poor pulcet aen 10/22/07 (please see enclosure). c T agency shall insrvc a emloee in-service all employees The who occupy key role positions or have established HPN accounts through the "organization by 03/31/08. The Executive Vice President is responsible for this corrective action plan. Employees authorized to obtain a new HPN account through the agency shall-be inserviced on the agency's HPN policy once the individual's request to'obtain a HPN account is approved by the HPNC. All new HPN account users will be oriented to the agency's policy by the Branch quaty cr. The findings are: The policy and procedure manual did not contain T&TE FORM . Administrator. Continued on next page... CKY51I if coninuation shOt 3 014 New York State Department of Health 5TATEMENT OF DEFICIENCIES' ND PLAN Or CORRECTION (XI) PRO VI(2)MUEI'LSCOSTPCiOUIDENTIICON2) MULTIP CONSTRUCTIONTE PRINTED: 101'1512007 FORM APpROvED BR S. (X3 (N3 DAT SURVD DTESUIA COMPLETED IU LCOS5A ID NTFI ATO 'AME OF PROVIDER OR SUPPLIER A.BUILDING WING __________ STREET ADDRESS, cTy,STATE, ZiP CODE LC0585A 06128/2007 z'REMIER HOME HEALTH CARE SERVICES, INC, PREFIX TAG (X4)ID SUMMARY STATEMENT OF DEFIGIENcIES NEW (EACH DEFICIENCy MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 494 8TH AVE YORK, NY 10001 PREFIX TAG ID (EACH CORRECTIE ACTION SHOULD BE CROSSREFERENC-DEFICIENCY) PRO VIDER* PLAN OF CORRECTION TO THE APPROPRIATE COMPLETE DATE H1008 Continued From Page.3 NT Contind oA H1008 Provider Network and Criminal Background Check.' policies and procedures for the Health Care completed by 3/31/08. The agency's CIO is responsible for this corrective action. B. Te Agency's Policy and Procedure complete review and update of the agency's Communications Directory will be On 6/28/07 at 3:42 pm, the Director was interviewed and stated Regionalpolicies that the will be developed. o I Manual does have a Criminal Background Check policy (9.20 Criminal Background Checks-Fingerprinting). The policy outlines the fingerprinting and criminal background check procedures. The policy will be redistributed to all office managers by 3/31/08. The VP of Clinical Services.will be responsible. E. FORM " l'wCKY-51 " 1 1 -'I---"Ifco ntinuation shmet 4 of - January 11,2006 The Board of directors in conjunction with the Corporate Quality Assurance/Performarce Improvement committee has reviewed the Policy and therein. For the year 2006, all policies and proceduresProcedure Manual and all revisions shall be considered accepted and current unless otherwise indicated or revised. off ice Prsidetof Clinical. Services and uality Management Executive President. V- STATE OF NEW YORK DEPARTMENT OF HEALTH Metropolitan Area Regional Office 90 Church Street, New York, NY 10007 Richard F.Daines iorFissione s Wendy E. Saunders Chief of Staff April 18, 2008 Aaron Bethea President ANR Advance Home Care Services, Inc 2604 Ave U Brooklyn, NY 11229 Re: Response to Plan of Correction Survey Date: February 4, 2008 License: LC0424A Dear Mr. Bethea: Article 36 survey of your Please be advised that the plan of correction relating to the recent agency have been reviewed by this office. implement this plan within All items were found to be acceptable and it is expected that you will to verity the the time frames that were submitted. A post approval review will be conducted correction of deficiencies. 417-'5888. If you have any questions regarding this matter, please contact (212) Sincerely, Cheryl Phoenix-Tannis, RN. MSN, CS Program Manager Home Health and Hospices Services Metropolitan Area Regional Offices PRINTED: 04/07/2008 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIERJCLIA o IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING B.WING ______ _____ LC0424A NAME OF PROVIDER OR SUPPLIER 0210412008 STREET ADDRESS, CITY, STATE, ZIP CODE ANR ADVANCE HOME CARE SERVICES. INC. (X4) ID PREFIX TAG . 2604 AVENUE U NY 11229 BROOKLYN, ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE, CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H 000 Initial Comments H 000 A full Survey was conducted at ANR Advance * Home Care Services, Inc. on 2/4/08. Six (6) Patient Care Records were reviewed and are identified as Patients #1 - #6. Eight (8) Personnel records were reviewed and are identified as Employees #1 - #8. The agency Policy and Procedure Manual, Quality Assurance Committee Meetings and Governing Authority Meeting Minutes were reviewed. 224 766.1(a)(9) Patient rights Section 766.1 Patient rights. (a) The governing authority shall establish written policies regarding the rights of the patient and shall ensure the development of procedures implementing such policies. These rights, policies and procedures shall afford each patient the right to: (9) submit patient complaints about the care and services provided or not provided and complaints concerning lack of respect for property by anyone furnishing service on behalf of the agency, to be informed of the procedure for filing H 224 such complaints, and to have the agency investigate such complaints in accordance with the provisions of subdivision (j) of section 766.9 of this Part. The agency is also responsible for notifying the patient or his/her designee that if the patient is not satisfied by the response the patient may complain to the Department of Health's Office of Health Systems Management. LABORATORY-DI C RS OR PROI tJSU P R REPRESENTATIVE'S SIGNATURETIL . TMHP1 1 j - 6)DATE STATE FORM ) 021199 If continuatio shet 1 of 12 PRINTED: 04/07/2008 FORMoAPPRC ED :w York State Department of Health ATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (Xl) PROV1DER/SUPPLIERJCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED LC0424A ME OF PROVIDER OR SUPPLIER B.WING STREET ADDRESS, CITY, STATE, ZIP CODE 0210412008 NR ADVANCE HOME CARE SERVICES, INC. X4) ID 'REFIX TAG 2604 AVENUE U, BROOKLYN, NY 11229 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE j I SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H 224 Continued From Page I This Rule is not met as evidenced by: Based on record review and staff interview, the agency failed to provide the patients with accurate telephone contact information to lodge a complaint with the Department of Health. Failure to provide current and accurate information places patients at risk for not being I afforded their right to lodge a complaint with the i Department of Health. The finding is: H 224 The agency "Patient's Rights" documents:"......... If the patient is not satisfied with the response by the agency, the patient has the right to call: State of New York Department of Health, OHSM (212) 613-4245..." The documented information is not the correct number to contact the Department of Health. On 2/4/08 at 2:42 pm, the Director of Operations iwas interviewed and did not provide an i explanation. H 502 766.4(a) Medical orders 766.4 Medical orders. (a) The governing authority or operator shall ensure that an order from the patient's authorized practitioner is established and documented for the health care services the. agency provides to those patients who: (1) are being actively treated by an authorized practitioner for a diagnosed health care problem; r ;T 'EFORM H 502 021199 TMHP1 1 If continuation sheet 2 of 12 PRINTED: 04107/2008 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIERJCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION BUILDING AC -BUIWING ________ (X3.) DATE SURVEY COMPLETED NAME OF PROVIDER OR SUPPLIER LC0424AB. WING STREET ADDRESS, CITY, STATE, ZIP CODE 02104/2008 ANR ADVANCE HOME CARE SERVICES. INC. (X4) ID PREFIX TAG 2604 AVENUE U BROOKLYN, NY 11229 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H 502 Continued From Page 2 (2) have a health care need or change in physical status requiring medical intervention; or (3) are home health aide or personal care services patients of a certified home health agency. This Rule is not met as evidenced by: Based on record reviews and staff interview, the agency failed to obtain orders .from an authorized practitioner for health care services. This was evident for five (5) of six (6) patient care records reviewed. ( Patients # 2, 3, 4, 5, and 6) Failure of the agency to maintain documentation of medical orders for home care services places patients at risk for not receiving services authorized by a practitioner. The findings are: 1) Patient #2 was admitted on "1/1/02" with diagnoses of Hypertension, Gastritis and Hypothyroid. The patient care record lacked documentation of medical orders for home care services by an authorized practitioner. 2) Patient #3 was admitted on "9/4/02" with i diagnoses Hypertension, Arthritis and Osteoporosis. The patient care record lacked documentation of medical orders for home care services by an authorized practitioner. H 502 I 3) Patient #4 was admitted on "10/3/05" with diagnoses Hypertension, Osteoporosis. The patient care record lacked documentation of ST'E FORM 021199 TMHP1 1 Ifcontinuation sheet 3 of 12 PRINTED: 04/07/2008 FORM APPROVED w York State Department of Health kTEMENT OF DEFICIENCIES )PLAN OF CORRECTION (X1) PROVIDER/SUPPLIERCLIA IDENTIFICATIONt NUMBER: MULTIP CONSTRUCTION __._COMPLETED DATE SURVEY A. BUILDING B.WING 02/0412008 LC0424A ME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE. ZIP CODE IR ADVANCE HOME CARE SERVICES, INC. (4) ID ZEFIX TAG 2604 AVENUE U BROOKLYN, NY 11229 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H 502 Continued From Page 3 * medical orders for home care services by an authorized practitioner. 4) Patient #5 was admitted on "6/2/06" with diagnoses Parkinson's Disease and Dementia. The patient care record lacked documentation of 'medical orders for home care services by an authorized practitioner. 5) Patient #6 was admitted on"6/1/01" with diagnoses Hyp6rtension, Osteoarthritis, Panic Disorder and Ath-thtis The patient care record lacked documentation of medical .orders for home care services by an authorized practitioner. On 2/4/08 at 11:15 am, the Director of Operations was interviewed and.stated: "Usually with private patients we speak to the MD and get a verbal order for care. It is just not documented." H 622' 766.5(c) Clinical supervision Te Sperisio. 766. Clnicl gveringall 766.5 Clinical supervision. The governing authorityshall ensure for all health care services that: H 502 I H 622 home health and personal to assure who A spreadsheet was developedcare aides that alluhoe heklt adpersona r e euhof weekly supervision prior to the return of their Criminal History Record Check, receive the mandated supervision. The Director of Nursing is responsible to communicate with the field nurses the supervision requirements of the aides, oversee the completeness of the aides' personnel record, and to change the frequency of the supervision when the Criminal History Record Check/ fingerprinting has been received. that:require (c) home health aides or personal care aides are supervised, as appropriate, by a registered professional nurse or licensed practical nurse, or a therapist if the aide carries out simple procedures as an extension of physical therapy, occupational therapy or speech/language pathology, This Rule is not met as evidenced by: Based on record reviews and staff interview, the TATE FORM 021199 TMHP11 Ifcontinuation sheet 4 of 12 PRINTED: 04/07/2008 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION - (Xl) PROVIDERISUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION UCOMPLETEDA- (X3) DATE SURVEY BUILDING __________ LC0424A NAME OF PROVIDER OR SUPPLIER B.WING STREET ADDRESS, CITY, STATE, ZIP CODE 02/04/2008 ANR ADVANCE HOME CARE SERVICES. INC. (X4) ID PREFIX TAG 2604 AVENUE U BROOKLYN, NY 11229 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) D (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL ' REGULATORY OR LSC IDENTIFYING INFORMATION) H 622 Continued From Page 4 agency failed to document supervision of Home IHealth Aides while awaiting the results for the Criminal History Record Check. This was evident 'for two (2) of eight (8) personnel records reviewed. ( Employee # 1 and #2) Failure to document adequate supervision of the paraprofessional staff places all patients at risk for receiving poor quality care from potentially unqualified individuals. The findings are: 1) The personnel record for Employee #1, a Personal Care Aide, has documenteddate of hire as "12/19/07". The record lacks documented evidence of the required supervision while awaiting for the results of the criminal history record check. The personnel record for Employee #2, a i Personal Care Aide, has documented date of hire as "311/07". The record lacks documented evidence of the required supervision while awaiting for the results of the criminal history record check. On 2/4/08 at 2:30pm, the Director of Operations was interviewed and stated: " I will develop a new in-home and phone supervision list." H1036i 766.9(1) Governing authority Section 766.9 Governing authority. The governing authority or operator, as defined in Part 700 of this Title, of a licensed home care i services agency shall: (I) appoint a quality improvement committee to STATE FORM 0211" H 622 Weekly supervision for Employee #1 and #2 has been completed, and is reflected in the nurses' supervisory notes, filed in the personnel records for Employee #1 and #2. To date, neither employee's Criminal History Record Check has been returned to-ANR Advance Services, Inc., therefore, both Home Care are being supervised by the field employees nurses once a week (Employee #1 on Tuesday at 3:00 PM and Employee #2 on Thursday at 2:00 PM). The Director of Nursing conducts periodic audits to assure that all aides are supervised as mandated, that their supervision .visits comply with the developed spreadsheet; the Director of Operations in collaboration with the Director of Nursing conduct periodic record audits to assure that the employees' personnel records contain the documentation necessary to support the adequacy of the supervision. H1036 TMHP1 1 Ifcontinuation sheet 5 of 12 PRINTED: 04/07/2008 FORM APPROVED aw York State Department of Health ATEMENT OF DEFICIENC JD PLAN OF CORRECTION I (Xl) PROV1DER/SUPPLIER/CLLA, IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION ICOMPLETED A. BUILDING "_. (X3) DATE SURVEY LC0424A WE OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 0210412008 2604 AVENUE U BROOKLYN, NY 11229 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE NR ADVANCE HOME CARE SERVICES. INC. (X4) ID 'REFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H1036 Continued From Page 5 establish and oversee standards of care. The quality improvement committee shall consist of a consumer and appropriate health professional persons including a physician if professional health care services are provided.The committee shall meet at least four times a year to: (1) review policies pertaining to the delivery of the health care Services provided by the agency and recommend Changes in such policies to the governing authority for adoption; (2) conduct a clinical record review of the safety, 1adequacy, type and quality of services provided which includes: (i) random selection of records of patients currently receiving services and patients H1036 - discharged from the agency within the past three months; and (ii) all cases with identified patient complaints as of specified in subdivision (j) this section; (3) prepare and submit a written summary of review findings to the governing authority for necessary action; and (4) assist the'agency in maintaining liaison with other health care providers in the community. This Rule is not met as evidenced by: Based on record reviews and staff interview, the agency failed to ensure that the Quality Improvement Committee: discusses complaints, patient care records (current and discharged); review the policy and procedure manual and have a physician present. This was evident for the agency Quality Improvement Committee meetings minutes. 021199 ;TATE FORM TMHP1 1 Ifcontinuation sheet 6 of 12 PRINTED: 04/07/2008 FORM APPROVED Health New York State De artment of STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION - (Xl) PROVIDER/SUPPLIERJCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTIONA_BUILDING (X3) DATE SURVEY COMPLETED * B. WING LC0424A NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 02/0412008 0210412008 ANR ADVANCE HOME CARE SERVICES, INC. (X4) ID PREFIX 'TAG I - 2604 AVENUE U 'BROOKLYN, NY 11229 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H1036 Continued From Page 6 Failure to ensure that the Quality Improvement Committee performs the required functions and contains the required members places patients at risk for poor quality services, unsafe and inadequate care. The findings are: The Quality Improvement Committee Meeting Minutes dated "1/18/07", "4/19/07, "7/30/07", "10129/07" and "1/28/08" lacked documented evidence of discussion of all patient complaints, patient care records (current and discharged) and review of the policy and procedure manual. ." There was no documented evidence of physician attendance. On 2/4/08 at 2:40 pm, the agency Program Consultant was interviewed and stated: "The complaints are discussed. I will schedule another meeting soon to discuss these findings with everyone." H1142 766.9(o) Governing Authority Section 766.9 Governing authority (o) Health Provider Network Access and Reporting Requirements. The governing authority or operator of an agency shall obtain from the Department' s Health Provider Network (HPN), HPN accounts for each agency that it operates and ensure that sufficient, knowledgeable staff will be available to and shall maintain and keep current such accounts. At a minimum, twenty-four hour, seven-day a week contacts for emergency communication and alerts, must be designated by each agency in the HPN Communications Directory. A policy defining the agency' s HPN coverage consistent STATE FORM 021199 H1036 H1142 TMHP1 1 Ifcontinuation sheet 7 of 12 PRINTED: 04/07/2008 FORM APPROI/ED aw York State Department of Health *ATEMENT OF DEFICIENCIES IDPLAN OF CORRECTION (Xl) PROVIDER/SUPPLIERJCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A BUILDING _ __ WING.___ _ __ "1B. (X3) DATE SURVEY PLETED __ _ LC0424A kME OF PROVIDER OR SUPPLIER B STREET ADDRESS, CITY, STATE, ZIP CODE 02/0412008 NR ADVANCE HOME CARE SERVICES. INC. (X4) ID IREFIX TAG 1! 2604 AVENUE U BROOKLYN, NY 11229 ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE (EACH CORRECTIVE ACTION SHOULD BE i SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION DEFICIENCY) (X5) DATE COMPLETE H1142 Continued From Page 7 with the agency' s hours of operation shall be created and reviewed by the agency no less than ;annually. Maintenance of each agency' s HPN accounts shall consist of, but not be limited to, the following: (1) sufficient designation of the agency' s HPN coordinator(s) to allow for HPN individual user application; (2) designation by the governing authority or operator of an agency of sufficient staff users of the HPN accounts to ensure rapid response to requests for information by the State and/or local Department of Health; (3).adherence to the'requirements of the HPN user contract; and (4) current and complete updates of the Communications Directory reflecting changes 1 that include, but are not limited to, general information and personnel role changes as soon as they occur, and at a minimum, on a monthly basis. H1142 This Rule is not met as evidenced by: Based on record review and staff interview, the agency failed to develop policies and procedures for the Health Provider Network (HPN) program. Failure to develop a policy and procedure for the agency HPN account does not direct agency staff in responding to requests for information by the local health department and management in emergency situations. IThe finding is: STATE FORM 021199 TMHP1 1 If continuation sheet 8 of 12 / PRINTED: 04/07/2008 FORM APPROVED New York State De artment of Health . (Xl) PROVIDERJSUPPLIERICLIA STATEMENT OF DEFICIENCIES IDENTIFICATION NUMBER: CORRECTION AND PLAN OF (X2) MULTIPLE CONSTRUCTION A.BUILDCOMPLETED ___________ A. ~~BUILDING (X3) DATE SURVEY. LCO424A NAME OF PROVIDER OR SUPPLIER B.WING STREET ADDRESS, CITY, STATE, ZIP CODE " 02/0412008 ANR ADVANCE HOME CARE SERVICES. INC., (X4) ID PREFIX TAG 2604 AVENUE U BROOKLYN, NY 11229 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H1142 Continued From Page 8 The agency policy and procedure manual lacked documentation of a policy and procedure for the agency HPN account. On 2/4/08 at 2:40 pm, the Director of Operations was interviewed and stated: "We did have them." The Director could not provide the supporting documentation. H 13501 766.11 (k) Personnel 766.11 Personnel. The governing authority or operator shall ensure for all health care personnel:o (k) that an annual assessment of the performance and effectiveness of all personnel is I conducted including at least one in-home visit to observe performance, if applicable. This Rule is not met as evidenced by: Based on record review and staff interview, the agency failed to ensure an administrative performance evaluations were completed for all personnel. This was evident in two (2) of eight #3 (8) personnel records reviewed. (Employees and #4) Failure of the agency to assess the performance and effectiveness of all employees on an annual basis places patients at risk for poor quality and unsafe care. * The findings are: 1) The personnel record for Employee #3, a Personal Care Aide documents a date of hire of "6/1101" The documented performance STA'E FORM 021199 H1142 H1350 TMHP11 If continuation sheet 9 of 12 PRINTED: 04/07/2008 FORM APPROV/ED 1w York State Department of Health ATEMENT OF DEFICIENCIES D PLAN OF CORRECTION (X1) PROVIDERSUPPLIERJCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION AO .(X3) DATE SURVEY MPLETE LC0424AB. ME OF PROVIDER OR SUPPLIER WNG 02/04/2008 STREET ADDRESS, CITY, STATE, ZIP CODE NR ADVANCE HOME CARE SERVICES. INC. X4) ID REFIX TAG 2604 AVENUE U BROOKLYN, NY 11229 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H1350 Continued From Page 9 evaluations in the record are dated: "6/10/03" "6/5/04" and "6/9/05". There are no other documented performance evaluations in the record. 2) The personnel record for Employee #4, a Registered Nurse documents a date of hire of '10/15/01" and a date of rehire as "6/19/06". There are no documented performance evaluations in the employee file. On 2/4/08 at 2:50 pm, the agency Program Consultant was interviewed and stated: ........ it will be done." .3541 766.11(1)(1) Personnel. 766.11 Personnel. The governing authority or operator shall ensure for all health care personnel: H1350 H1354. (I) (1) that a program is implemented and enforced for the prevention of circumstances which could result in an employee or patient/client becoming exposed to significant risk body substances which could put them at significant risk of HIV or other blood-borne pathogen infection during the provision of services, as defined in sections 63.1 and 63.9 of this Title. Such a program shall include: (i) use of scientifically accepted protective barriers during job-related activities which involve, or may involve, exposure to significant risk body substances. Such preventive action shall be taken by the employee with each STATE FORM 021199 TMHP11 If continuation sheet 10 of 12 - PRINTED: 04/07/2008 FORM APPROVED I(X3) DATE SURVEY COMPLETED New York State Department of Health STATEMENT OF, DEFICIENCIES AND PLAN OF.CORRECTION (X1) PROVIDERISUPPLIERICLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A.BUILDING LC0424A NAME OF PROVIDER OR SUPPLIER W0204/2008 B. STREET ADDRESS, CITY, STATE, ZIP CODE ANR ADVANCE HOME CARE SERVICES. INC. (X4) ID PREFIX TAG 2604 AVENUE U BROOKLYN, NY 11229 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) . (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES , (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H1354 Continued FromPage 10 H,1354 patient/client and shall constitute an essential element for the prevention of bi-directional spread of HIV or other blood-borne, pathogen; (ii) use of scientifically accepted preventive ANR. Home Care Services, Inc. Conducted a formal review of all employee records and has scheduled inservice training to assure that allI employees and office staff were practices during job-related activities which involve the use of contaminated instruments or equipment which may cause puncture injuries; (iii) training at the time of employment and yearly staff development programs on the use of protective equipment, preventive practices, .and provided with training for Universal Precautions and HIV Confidentiality. and #5 and evidence Both Employee # 4 2, 2008 attended an in-service on April inppropriateinn ofthey receiving the a ie service training has been filed in their employee record. circumstances which represent a significant risk job-related tasks for all employees whose involve, or may involve, exposure to significant risk body substances; - Whereby an employee did not have evidence of these in-services in their employee record and was not able to attend the scheduled in-service training, the Director of Nursing provided this training by meeting these employees in the field. (iv) provision of personal protective equipment for employees which is appropriate to the tasks being performed; o (v) a system for monitoring preventive programs to assure compliance and safety. This Rule is not met as evidenced by: Based on record review and interview, the agency failed to ensure that all employees receive the required annual training on Universal Precaution and HIV Confidentiality. This was evident for two (2) of eight (8) personnel records reviewed. (Employee #4, and #5) Failure to ensure that employees receive the required annual in-services places patients at risk for poor quality care. The findings are: 1) The personnel record for Employee #4, a Registered Nurse, has a date of hire documented as "10/15/01" and date of re-hire STATE FORM 021199 - TMHP1 1 continuation sheet 11 of 12 If PRINTED: 0407/2008 FORM APPROVED aw York State Department of Health ATEMENT-OF DEFICIENCIES ID PLAN OF CORRECTION (Xl) PROVIDERISUPPLIER/CLA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING ______ _____ (X3) DATE SURVEY COMPLETED LC0424A %ME OF PROVIDER OR SUPPLIER B.WING STREET ADDRESS, CITY, STATE, ZIP CODE 02/0412008 NR ADVANCE HOME CARE SERVICES. INC. X4) ID 'REFIX TAG 2604 AVENUE U BROOKLYN, NY 11229. ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H1354 Continued From Page 11 documented as "6/19/06". The personnel file had no documented evidence of an annual in-service for Universal Precaution and HIV Confidentiality. 2) The personnel record for Employee #5, a Personal Care Aide, has a date of hire documented as "3/1/02". The documented training for Universal Precaution and HIV Confidentiality in the record is dated: "3/1/02." On 2/4/08 at 2:45pm, the Director of Operations was interviewed and confirmed that the training information is not in the file. H1354 ;TATE FORM 021199 TMHP1 1 If continuation sheet 12 of 12 PRINTED: 03/1 2/2008 . .FORM APPROVED (X1) PROVIDERISUPPLIER/CLIA I DENTIFICATION NUMBER (X2) MULTIPLE CONSTRUCTION A k BUILDING B. WING STREET ADDRESS, CITY, STATE, ZIP CODE (X3) DATE SURVEY COMPLETED New York State Department of Health. STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION LC0424A NAME OF PROVIDER-OR SUPPLIER 0210412008 ANR ADVANCE HOME CARE SERVICES, INC. (X4)ID PREFIX TAG 2604 AVENUE U BROOKLYN, NY 11229 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H 000 Initial Comments H 000 A full Survey was conducted at ANR Advance Home Care Services, Inc. on 2/4/08. Six (6) Patient Care Records were reviewed and are identified as Patients #1 - #6. Eight (8) Personnel records were reviewed. and are identified as Employees #1 - #8. The agency Policy and Procedure Manual, Quality Assurance Committee Meetings .and Governing Authority Meeting Minutes were reviewed. 224 766.1(a)(9) Patient rights H 224 ID PREFIX: H224 The Governing Authority shall establish written policies regarding patient's rights...submit complaints about care or services.. the agency is also responsible for notifying the patient or his/her designee that if s/he is not, satisfied patient may complain to the Department of Health's Office of Health Section 766.1 Patient rights. (a) The governing authority shall establish written policies regarding the rights of the patient.and shall ensure the development of procedures implementing such policies. These rights, policies and procedures shall afford each patient the rightto: " ...... Systems Management (9) submit patient complaints about the care and services provided or not provided and complaints concerning lack of respect for property by anyone furnishing service on behalf of the agency, to be informed of the procedure for filing to v tservice agcyn such complaints, and to have the agency investigate such complaints in accordance with the provisions of subdivision ()of section 766.9 of this Part.. The agency is also responsible for notifying the patient or his/her designee that if the patient is not.satisfied by the response the patient may complain to the Department of Health's Office of Health Systems Management. . 'senior PLAN OF CORRECTION: All documents representing the client's/designee's right to access the Departments of Health's Office of Health Systems Management were reviewed and where required, in the Client's Admission Packet, the telephone number was corrected. An in-service was presented to all staff on 02/25/08 concerning the client's/designee's right to be able to access this information and the agency's 'open-door' policy concerning any complaint/feedback generated by the clients and/or clients' representatives. The revised Client's Grievance Form was distributed to all active clients, providers representing ANR Advance Home Care Services and replaced the erroneous document in eh Client's Admission Packet. In addition, during two scheduled inAides and Personal Care Aides in attendance; the remainder of the staff is scheduled to attend an in-service on 03/25/08, at which time, it will be assure that all current staff is aware of the NYSDOH, OHSM. Attachment A represents the information provided to the clients, their designees and all persons representing training programs, the document was presented to the Home Health the agency. LABORAT RY DIRECTOR'S OR P5OVIDE _A SUPPLIER REPRESENTATIVE'S SIGNATURE TT E S,, E FORM 0211" TMHP1 1 a on s eet I of12 PRINTED: 03/12/2008 FDRM APPROVED Jew York State Department of Health ;TATEMENT OF DEFICIENCIES ,ND PLAN OF CORRECTION (XI) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A BUILDINGCOMPLETED B~ WING ___________ (X3) DATE SURVEY LC0424A JAME OF PROVIDER OR SUPPLIER 02/04/2008 STREET ADDRESS. CITY. STATE, ZIP CODE \NR ADVANCE HOME CARE SERVICES. INC. (X4) ID PREFIX TAG 2604 AVENUE U BROOKLYN, NY 11229 ID PREFIX TAG PROVIDE (EACH COR CROSS-REFE1 -AN OF CORRECTION FIVE ACTION SHOULD BE AICED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H 224 Continued From Page 1 This Rule is not met as evidenced by: Based on record review and staff interview, the agency failed to provide the patients with accurate telephone contact information to lodge a complaint with the Department of Health. Failure to provide current and accurate information places patients at risk for not being afforded their right to lodge a complaint with the Department of Health. The finding is: The agency "Patient's Rights" documents: .......... If the patient is not satisfied with the response by the agency, the patient has the right to call: State of New York Department of Health, OHSM --(212) 613-4245..." The documented information is not the correct number to contact the Department of Health. On 2/4/08 at 2:42 pm, the Director of Operations was interviewed and did not provide an explanation. H 224 H 502 7664(a) Medical orders 766.4 Medical orders. (a) The governing authority or operator sha ensure that an orderfrom the patient's authorized practitioner is established and documented for the health care services th( information on the 485/physician order form, a self-addressed stamped envelop, and assure the accuracy of the provider's contact information when a client is agency provides to those patients who: admitted to the agency. The completed folder is forwarded to the Director of PLAN OF CORRECTION: To assure that all services are provided under the direction of the client's authorized practioner and that the authorized practioner is informed when there are changes in the client's medical condition, several operational changes have been made as interim procedures. A focus QPI survey was conducted on 02/07/08; the findings of this survey reflected the findings of the NYSDOH Full Survey on 02/04/08. The Director of Nursing was assigned the responsibility for ensuring that all services are authorized and this authorization is represented by a completion of one of three document, (1) the 485, (2) a MlQ or (3) Authorized Practioner's Order Form (Attachment B). A support staff person was hired, and has the responsibility of completing all biographical (1) are being actively treated by an authoriz, Nursing who, through her direct efforts or referral to another field supervisor, practitioner for a diagnosed health care prol completes the 485/Authorized Practioner's Order Form, sends by facsimile when the the Practioner approves this method, and sends to the Authorized Practioner 3TATE FORM 021199 TMHP1 1 Ifcontinuation sheet 2 of 12 , ,FORM - APPROVED (X3) DATE SURVEY . New York State De artment of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1i) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: LC0424A NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A BUILDING B. WING 02/0412008 STREET ADDRESS, CITY, STATE, ZIP CODE ANR ADVANCE HOME CARE SERVICES. INC. (X4) ID PREFIX TAG H 502 2604 AVENUE U BROOKLYN, NY 11229 ID PREFIX TAG PR (EAC CROSS 1IDER'S PLAN OF CORRECTION 'ORRECTIVE ACTION SHOULD BE ZFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH,DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From Page 2 (2) have a health care need or change in physical status requiring medical intervention; or (3) are home health aide or personal care acertd services3patiensofhome health agency. This Rule is not met as evidenced by: Based on record reviews and staff interview, the practitioner for health care services. This was ' services patients of a certified home healthDirector o T D H 502 The Director of Nursing assures written (original) document for his/her signature. that all orders are current'and accurately reflect the condition of the client. To has assure continued compliance, ANR Advance Home Care Services, Inc. clinical record from August Systems received a demonstration of an automated order is (Attachment C) which will assure that an accurate 485/Practioner's completion of the 485/Practioner's order, the automated generated. After the of Nursing and/or his/her designee and will be forwarded to the client's Authorized Practioner. Additionally, a clerical staff employee has been hired to serve.as a messenger, bringing the necessary from the documents to the client's authorized practioner's location or procuring of documents from the Authorized Provider. Two weeks after the procurement Home agency failed to obtain orders from an authorized expected outcome at this interval was 65% compliance. ANR Advance report Improvement Committee orders procedures were changed, a follow-up focus review was conducted. The Care Services, Inc: Quality and Performance agency revealed that the compliance threshold was 83% at that time. The evident for five (5) of six (6) patient care records reviewed. ( Patients # 2, 3, 4 , 5, and 6) to maintain documentation Failure of the agency home care services places of medical orders for patients at risk for not receiving services authorized by a practitioner. The findings are: 1) Patient #2 was admitted on "1/1/02" with diagnoses of Hypertension, Gastritis and Hypothyroid. The patient care record lacked documentation of medical orders for home care services by an authorized practitioner. 2) Patient #3 was admitted on "9/4/02" with diagnoses Hypertension, Arthritis and Osteoporosis. The patient care record lacked documentation of medical orders for home care services by an authorized practitioner. 3) Patient #4 was admitted on "10/3/05" .with diagnoses Hypertension, Osteoporosis. The patient care record lacked documentation of STATE FORM 021199 additional focus survey was continues to increase its compliance to this area. An Correction. The conducted on the day of the completion of this Plan of by the next compliance threshold was found to be 89%. The targeted threshold Quality and Performance Improvement Committee meeting on 03/24/08 is 90%. TMHP 1 1 If continuation sheet 3 of 12 ork State Department. of Health ENT OF DEFICIENCIES OF CORRECTION (Xl) PROVIDER/SUPPLIER/CLIA ,N IDENTIFICATION NUMBER: .(X2) MULTIPLE CONSTRUCTION PRINTED: 03112(2008 FORM APPROVED ( I(X3) o A. BUILDING B WING . DATESURVEY COMPLETED LC0424A F PROVIDER OR SUPPLIER 02/04/2008. STREET ADDRESS, CITY, STATE. ZIP CODE DVANCE HOME CARE SERVICES. INC. SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 2604 AVENUE U BROOKLYN, NY 11229 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE '2 Continued From Page 3 medical orders for home care services by an authorized practitioner. 4) Patient #5 was admitted on "6/2/06" with diagnoses Parkinson's Disease and Dementia. The patient care record lacked documentation of medical orders-for home care services by an authorized practitioner. 5) Patient #6 was admitted on "6/1/01" with diagnoses Hypertension, Osteoarthritis, Panic Disorder and Arthritis. The patient care record lacked documentation of medical orders for home care services by an 3uthorized practitioner. On 2/4/08 at 11:15 am, the Director of Operations was'interviewed and stated: "Usually, with private patients we speak to the MD and get a verbal order for care. It is just not documented." 766.5(c) Clinical supervision 766-5 Clinical supervision. The governing authority shall ensure for all health care service that: H502 (c) home health aides or pe~rsonal care aides are supervised, as appropriate, by a registered professional nurse or licensed practical nurse, or a therapist if the aide carries out simple procedures as an extension of physical therapy, occupational therapy or speech/language pathology. This Rule is not met as evidenced by: Based on record reviews and staff interview, the ?M PLAN OF CORRECTION: The agency's policies and procedures were reviewed. The findings were that, although the appropriate level of supervision was beirg conducted by field nursing staff, and coordinated by The Director of Nursingr Director of Operations, the documentation did not accurately reflect this process. To assure that those home health aides/personal care aides whose Criminal Background History has not been received by the agency are properly supervised, the Coordinator of Human Resources has created a process by which all coordinators, and The Director Of Nursing are informed when the Criminal Background History Record Check is completed, agency's staff to supervise the home health aide/personal thus allowing the care every two weeks or when necessitated by changes in the duties they needaideconduct, to and/or changes in policies, procedures and/or regulations. A focus surveywas conducted on 02/21/08 to assess the degree of compliance to the change in te documentation strategies used for communicating the supervision of home health aides/personal care aides. 021199 T T1 H - - - -... .... If continuation sheel 4 of 12 .............. PRINTED: 03/12/2008 FORM APPROVED New York,State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIERCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A (X3) DATE SURVEY COMPLETED LC0424A NAME OF PROVIDER OR SUPPLIER WNG B. STREET ADDRESS, CITY, STATE, ZIP CODE 0210412008 ANR ADVANCE HOME CARE SERVICES, INC. (X4) ID PREFIX TAG 2604 AVENUE U BROOKLYN, NY 11229 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H 622 Continued From Page 4 1H 622 agency failed to document supervision of Home Health Aides while awaiting the results for the Criminal History Record Check. This was evident for two (2) of eight (8) personnel records reviewed. ( Employee # .1 and,#2) Failure to document adequate supervision of the paraprofessional staff places all patients at risk for receiving poor quality care from potentially unqualified individuals. The findings are:. 1) The personnel record for Employee #1, a Personal Care Aide, has documented date of hire as "12/19/07". The record lacks documented evidence of the required supervision while awaiting for the results of the criminal history record check. The personnel record for Employee #2, a Personal Care Aide, has documented date of hire as "3/1/07". The record lacks documented evidence of the required supervision while awaiting for the results of thte criminal history record check. On 2/4/08 at 2:30pm, the Director of Operations was interviewed and stated: " I will develop a new in-home and phone supervision list." PLAN OF CORRECTION: To assure the optimal contribution of the Quality and H1036 766.9(l) Governing authority Section 766.9 Governing authority. Performance Improvement Committee, Dr Yevgeniya Karamzena (GP) has been appointed to the QPI Committee and PAC. Dr Karamezena brings a unique set of experiences to these committees as her parents have been clients of ANR Advance Home Care Services, and she is the physician caring for several of the agency's clients. The additional members-of the QPI Committee can be found on Attachment D. In order that patient complaints were effectively documented, and The governing authority or operator, as defined the necessary actions, contingent upon these complaints were taken, the policies concerning patient's complaints was staff who will collect in Part 700 of this Title, of a licensed home care agency's QPIThe Director of QI was identified as the senior reviewed by the QPI .Committee. services agency shall: ...... (1) appoint a quality improvement committee to STATE FORM .021199 the data concerning patient complaints, and interview the appropriate staff and/or provider associated to the agency, to ensure all information is reliable, that the employee about whom the complaint was made has the opportunity to provide a statement regarding his/her perceptions of the situation when it is required, and If continuation sheet 5 of 12 TMHP1 1 PRINTED: 03/12/2008 F@RM ,P PROVED lew York State Department of Health TATEMENT OF DEFICIENCIES ND PLAN OF CORRECTION (X1) PROVIDERISUPPLIERJCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3)DATE SURVEY COMPLETED A. BUILDING B. WING LC0424A LAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE 02/04/2008 ItNR ADVANCE HOME CARE SERVICES. INC. (X4).ID PREFIX TAG 2604 AVENUE U BROOKLYN, NY 11229 ID PREFIX TAG . SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE H 1036 Continued From Page 5 establish and oversee standards of care. The quality improvement committee shall consist of a consumer and appropriate health professional persons including aphysician if professional to that all complaints are effectively resolved. The mandatory survey process analyze the nature of this information was conducted on data collected from were few 02/07/08 to 03/20/08. The findings of this survey were that there complaints by either clients (2; both of which concerned the tardiness of the, home health aide/personal care aide) or their representatives (0). The work of these coordinators who are responsible for the oversight of the was not characteristic of their conduct, but did employees reported that tardiness health care services are provided.The committee shall meet at least four times a year to: (1) review policies pertaining to the delivery of the health care services provided by the agency the and recommend changes in such policies to governing authority for adoption: .of adequacy,.type and quality of services provided discuss with these aides the need to be timely, and the clinical/professional have importance of maintaining their schedules. To further assure that all clients greater access to agency staff, an additional employee has been hired to way, augment the work of the coordinators to conduct attendance checks. In this to the has been able to extend the affability with which it relates the agency to discuss their clients, and provides the clients an informal opportunity both current staff. To ensure that patient care records, experiences with agency to the QPI regulations, and the agency's policies/procedures will be presented policy and procedure manual is a function and discharged, and the review of the the committee as identified in the NYSDOH the QPI Committee, the function of meeting on 03/24/08. Two new procedures will be (2) conduct a clinical record review of the safety, Committee during its next which includes: (i) random selection of recdrds of patients currently receiving services and patients discharged from the agency within the past three months; and (ii) all cases with identified patient complaints as .specified in subdivision (j) of this section; (3) prepare and submit a written summary of review findings to the governing authority for necessary action; and presented to the committee: (1) the procurement of authorized practioner's orders and (2) the tracking of supervision for home health or personal care aides a prior to receipt of.the Criminal Background History information.a Additionally,tool Utilization Review was conducted on 20 client records to pilot new review and to provide focus survey data, as aforementioned. The findings of the review will be a part of the QPI Committee meeting; input from the committee will serve necessary for greater compliance to to direct the quality improvement initiatives QPI Committee meeting, a the targeted areas. During the 2 nd Quarter number active and discharged client's records and representative sample of the the clinical (Disease) categories serviced by the agency will be reviewed. The findings of this Utilization Review will reported to the committee members by The Director of QI and will be a part of the agenda of the meeting for the 3 Idquarter. At this time, the QPI Committee will analyze the data and the appropriate quality and performance improvement activities will be determined.- (4) assist the agency in maintaining liaison with other health care Providers in the community. This Rule is not metas evidenced by: Based on record reviews and staff interview, the agency failed to ensure that the Quality Improvement Committee: discusses complaints, patient care records (current and discharged); review the policy and procedure manual and have a physician present. This was evident for the agency Quality Improvement Committee meetings minutes. 3TATE FORM 021199 TMHP1 1 if continuation sheet 6 of 12 PRINTED: 0312/2008 - ' . FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED LC0424A NAME OF PROVIDER OR SUPPLIER B.WING _ 02/0412008 STREET ADDRESS, CITY, STATE, ZIP CODE ANR ADVANCE HOME CARE SERVICES. INC. (X4) ID PREFIX TAG 2604 AVENUE U BROOKLYN, NY 11229 ID. PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSSREFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC.IDENTIFYING INFORMATION) H1354 Continued From Page 11 documented as "13/19/06". The personnel file had no documented and HIV Confidentiality. the ID PREFIX H1354: ... personnel file had no documented evidence of an annual in-service for Universal Precautions and HIV Confidentiality PLAN OF CORRECTION: To assure that all employees and agency representatives are knowledgeable of the policies on Universal Precautions and all evidenceHV Confidentiality, the agency's policies and procedures were reviewed ith of an annual in-service for Universal Precaution field nurses and nursing supervisors. The registered nurses will be responsible for providing the home health and personal care aides with these policies and the necessary tutorials to make certain that the annual presentation of this 2) The personnel record for Employee #5, a Personal Care Aide, has a date of hire documented as "301/02'. .in-services information is presented. Upon completion of each in-service, the home health attestation form (Attachment E) which will and personal care aides will sign an record. Additionally, during the mandatory be employee a part of their permanent scheduled in May 2008, these policies and procedures will be reviewed. The documented training for Universal Precaution and HIV Confidentiality in the record is dated: "3/1/02." On 2/4/08 at 2:45pm, the Director of Operations was interviewed and confirmed that the training information is not in the file. STATE FORM ---- TMHP1 1 Ifcontinuation sheet 12 o 12 3 .. Richard F.Daines STATE OF NEW YORK. DEPARTMENT OF HEALTH ....... Metropolitan Area Regional Office 90 Church Street, New York, NY 10007 ommissioner January 9, 2008 Ms. Dawn Brill, RN Vice President or Regional Operations-NE Premier. Home Health Care Services 360 Hamilton Ave, Suite 120 White Plains, NY 10601 Re: Response to Plan of Correction Survey Date: November 1 6 th 2007 License: 1086L003 Dear Ms. Brill: 36 Please be advised that the plan of correction relating to the attempt to perform an Article survey of your agency have been reviewed by this office. within All items were found to be acceptable and it is expected that you will implement this plan the the time frames that were submitted. A post approval review will be conducted to verity correction: of deficiencies. If you have. any questions regarding this. matter, please contact (212) 417-5888. Cheryl Phoenix-Tannis, RN. MSN, CS Program Manager Home Health and Hospices Services Metropolitan Area Regional Offices home health care services,inc January 3, 2008 New York State Department of Health Metropolitan Area Regional Office 90 Church Street New York, NY 10007 Attn: Cheryl Phoenix- Tannis, RN, MSN, CS Program Manager- Home Health and Hospice Services Dear Ms. Phoenix- Tannis, RN, MSN, CS of Deficiency, for Enclosed is the Plan of Correction in response to the Statement Home Health Care the full survey conducted on November 1672007 at Premier Services, 1800 White Plains Road, Bronx, NY 10462. If you have any questions, please contact me at 845-489-2395. Sincerely, Dawn Brill, RN Vice President of Regional Operations- North East cc: File Enclosure 360 Hamilton Avenue, Suite 120, White Plains, New York 10601 Phone 914-428-7722 Fax 914-428-2404 PRINTED: 12/17/2007 FORM APPROVED v York State, Department of Health TEMENTOF DEFICIENCIES PLAN OF CORRECTION (X1) PROVIDER/SUPPLIERICLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING __COMPLETED_ _. (X3) DATE SURVEY S86L03ING OF PROVIDER OR SUPPLIER 1111612007 1 STREET ADD RESS, CITY, STATE, ZIP CODE EMIER HOME HEALTH CARE SERVICES. INC. 4) ID EFIX 'AG 1800 WHITE PLAINS ROAD BRONX, ny 10462 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE TO THE APPROPRIATE DCROSSREFERENCED (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H 000, Initial Comments H 000 A Full Survey was conducted at Premier Home Health Care Services, Inc. on November 16, 2007. Five (5) Patient Records were reviewed and are identified as Patients #1 to #5. Personnel Records were reviewed and Seven (7) are identified as Employees #1 to #7. The agency Policy and Procedure Manual, Federal Tax ID, Quality improvement/Quality Assurance Committee Meeting Minutes, and Admission Packet were reviewed. 704 766.1(a)(1) Patient rights Section 766.1 Patient rights. (a) The governing authority shall establish written policies regarding the rights of the patient and shall ensure the development of procedures implementing such policies. These rights, policies and procedures shall .afford each patient the right to: right to of these rights, and (1) be informedrights,,in writing prior thethe to exercise such by written initiation of care, as evidenced clinical record; documentation in the ' (2) be given a statement of the services available by the agency and related charges; (3) be advised before care is initiated of the extent to which payment for agency services may be expected from any third party payors and the extent to which payment may be required from the patient. BORTORY DIRECT H 204 H204 As part of the admission process, it is the Policy of Premier Home Health Care Service (#15.3) for the Field Nurse Supervisor to review the Patient Bill Of Rights Document, and obtain the patient's or patient's representative's signature. A copy of the signed Patient Bill Of Rights is filed in the patient's clinical file and a copy is provided to the patient. I. Corrective actions that will be found accomplished for those patients to have been affected by the deficient practice. The Field Nurse Supervisor will perform a home visit to patients #1, #2, #3, #4, #5 who were noted to have the deficiency upon DOH survey. The Field Nurse Supervisor will review the Patient Bill Of Rights, and obtain the (X6) DATE SIGNATURE S ORPROVIDERkSUPPLIER REPRESENTATIVE'S TIT E T. FORM .:. 021199 . Z9 41 If continuat n sheel of 20 PRINTED: 12/14/2007 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLANOF CORRECTION (Xl) PROVIDERISUPPLIERICLIA IDENTIFICATION NUMBER: " X2) MULTIPLE CONSTRUCTION A. BUILDING . WIN.G (X3) DATE SURVEY COMPLETED 1086003 NAME OF PROVIDER OR SUPPLIER 11/16/2007 STREET ADDRESS. CITY, STATE. ZIP CODE PREMIER HOME HEALTH CARE SERVICES. INC. (X4) ID PREFIX TAG 1800 WHITE PLAINS ROAD BRONX, ny 10462 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL ~DEFICIENCY) REGULATORY OR LSC IDENTIFYING INFORMATION) H 204 Continued From Page 1 (i) The agency shall advise the patient of any changes in information pDovided under this paragraph or paragraph (2) of this subdivision as soon as possible,,but no later than 30 calendar days from the date the agency becomes aware of the change.. ih-Heather H 204 patient's or patient'.s representative's signature. A copy of the signed Patient Bill Of Rights will be filed in the patient's clinical file and a copy will be provided to the patient. parties responsible for the correction and ensuring continued compliance: Simon- Office Administrator, Director of Patient Services, and Field Nurse Supervisor Date of Completion: 4/4/08 [H. How to identify other client's having the potential to be affected by the same deficient practice and what corrective action will be taken. All active private pay files will be audited to assess if the Patient Bill Of Rights is present and signed in the patient's clinical file: Parties responsible for the correction and ensuring.continued compliance: Heather Simon- Office Administrator, Director of Patient Services, and Field Nurse Supervisor Date of Completion: 4/4/08 . (ii) All information required by this paragraph shall be provided to the patient both orally and in writing; (4) be informed of all services the agency is to . provide, when and how services will be provided, and the name and functions of any person and affiliated agency providing care and services. This Rule is not met as evidenced by: Based on record review and staff interview, the agency failed to provide the patients (at the initiation of care) with written information regarding the specific services to be provided and the financial liability. This was evident for five (5) out of five (5) records reviewed. ( Patient records # 1,2,3,4 and 5). Failure to inform the patient of the services to be . provided and the financial liability places the patients at risk for not being fully informed of all their rights, The findings are: 1)Patient #1 was admitted on 5/4/03 with diagnoses of Non Insulin Dependent Diabetes Mellitus, Retinopathy and Pneumonia. The patient care record lacked documented evidence that the patient was informed of the services to be provided. STATE FORM 02199 o I. Measures that will be put in place to ensure that the deficient practice will not recur All Field Nurse Supervisors and the Administrator will be re in-serviced on Policy (#15.3) Patient Bill Of Rights, as well as the Patient Bill Of Rights Document that requires a patient or patient's representative's signature, and filing in patient's clinical file. Z97411 Ifcontinuation sheet 2 0120 PRINTED: 12/14/2007 FORM APPROVED -w York State Department of Health - OF DEFICIENCIES ATEMENT ID PLAN OF CORRECTION (X2) MULTIPLE CONSTRUCTION (XlI) PROVIDER/SUPPLIERICIA . .. O pR~IDEISUPLIERCUACOMPLETEDA BUILDIN'G " ATEMNT o A: BUILDING IDENTIFICATION NUMBER: . B. WING ___________1111 (X3) DATE SURVEY . 1086L003 WE OF PROVIDER OR SUPPLIER - 612007 STREET S0 ADDRESS, CITY, STATE, ZIP CODE REMIER HOME HEALTH CARE SERVICES, INC. :X4) ID ;REFIX TAG 1800 WHITE PLAINS ROAD BRONX, ny10462 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION ACTION SHOULD 8E (EACH CORRECTIVE TO THE APPROPRIATE CROSS-REFERENCED DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H 204 Continued From Page 2 H 204 .2) Patient #2 was admitted on 4/22/04 with dia'gnoses of Cerebrovascular Accident with left Hemiparesis and Hypertension. The patient care record lacked documented evidence that the patient was informed of the services to be provided and financial liability. 3) Patient #3 was admitted on 4/1/06 with diagnoses of Muscular Dystrophy and Seizures. atient care record-lacked documented evidence that the patient was informed of the services to be provided and financial liability. 4) Patient #4 was admitted on 3/1/07 with diagnoses of Chronic Obstructive Pulmonary and Disease, Lung Cancer, Hypertension Parties responsible for the correction and ensuring continued compliance: Director of Patient Services, and Cruz, RN- Vice President of .Celestina iClinical Services. Date of Completion: 4/4/08 IV. How the corrective action will be monitored to ensure the deficient practice will not recur 25% of the active private pay client's files will be audited each month to assess if the Patient Bill Of Rights is present and signed in the patient's clinical file. Parties responsible for the correction and ensuring continued compliance: Heather Simon - Office Administrator, Field Nurse Supervisor, and Director of Patient Services, and Celestina Cruz, RN Vice President of Clinical Service. Date of Completion: 4/4/08 -Dawn Brill,-RN -' Vice President of Regional . Hyperlipidemia. The patient care record documents that the patient was informed of their rights, the services to be provided and financial liability on 4/17/07. with 5) Patient #5 was admitted on 9/27/05 Insulin Depen dent Diabetes diagnoses of Mellitus, Hypertension and Blindness. The patient care record lacked documented evidence that the patient was informed of the services to be provided and financial liability. On November 16, 2007 at 3:40pm, the Operations Manager was interviewed and stated: "the corporate office is interviewing a nurse today for the field nurse position. Because of the lack of field nurses we have had to do the best we can." ;TATE FORM 021199 Z97411 If continuation sheet 3 of 20 PRINTED: 12/14/2007 FORM APPROVED New York State Department of Health SI'ATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDERSUPPLIERJCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION " A. BUILDING" (X3) DATE SURVEY COMPLETED B.WING .11/16_2007 1086L003 PREMIER HOME HEALTH CARE SERVICES. INC. ID (X4) PREFIX TAG NME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11/16/2007 1800 WHITE PLAINS ROAD BRONX, ny 10462 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE -CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES ' (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H 224 Continued From Page 3 H 224 766.1(a)(9) Patient rights S.As Section 766.1 Patient rights. (a) The governing authority shall establish written policies regarding the rights of the patient and shall ensure the development of procedures implementing such policies. These rights, policies and procedures shall afford each patient the right to: ...... (9) submit patient complaints about the care and services provided or not provided and complaints concerning lack of respect for property by. anyone furnishing service on behalf of the filing agency, to be informed of the procedure for such complaints, and to have the agency investigate such complaints in accordance with the provisions of subdivision (j) of section 766.9 of this Part. The agency is also responsible for notifying the patient or his/her designee thatif the by the response the patient is not satisfied to the Department of patient may complain Management. Health's Office of Health Systems H 224 H 224 I H224 part of the admission process, it is e L Ior f#7.4 the ieid Nurse C mC ,t Supervisor to inform the patient in writing of their right to voice concerns or complaints about the care or services provided by Premier, and the procedures for filing suchlconcerns or complaints. The Field Nurse Supervisor provides the patient or patient's representative with a Patients Bill Of Rights as well as Premier s g Complaint/Occurrence Involving Patient Services Form; they provide the process for filing a complaint, and the numbers to the patient's Premier Branch, the Department of Health, and the Joint Commission Hotine. I. Corrective actions that will be aCcive for thatie accomplished for those patients round practice. The Field Nurse Supervisor will s Re is nperform a home visit'to patients #1, #2, #3, #5, who were noted to have the deficiency upon DOH survey. The Field Nurse Supervisor will review the Patient Bill Of Rights with the correct Department of Health's phone number, and obtain the patient's or patient's representative's signature. A copy of signed Patient Bill Of Rights will be filed in the patient's clinical file and a the patient. fopy i . This Rule is not met as evidenced by: Based on record review and staff interview, it was determined that the agency failed to provide accurate telephone contact information to lodge a complaint with the Department of.Health . This was evident for 4 of 4 patients reviewed. ( Patients # 1,2,3 and 4) tthe u Failure to provide current and accurate information places patients at risk for not being afforded their right to lodge a complaint with the Department of Health. The findings are: STATE FORM 021199 Z97411 If continuation sheet 4 of 20 PRINTED: 12/14/2007 FORM APPROVED Iw York State Department of Health (X) PROVIDERISUPPLIERCLIA DTEMENTOFEFICIENCIES D PLAN OF CORRECTION NUMBER: "..."..IDENTIFICATION ()2) MULTIPLE CONSTRUCTION _:__. A. (X3) DATE SURVEY COMPLETEDILG 10861003 .ME OF PROVIDER OR SUPPLIER B.WWNG STREET ADDRESS. CITY, STATE, ZIP CODE 11116/2007 ZEMIER HOME HEALTH CARE SERVICES. INC. 14) ID REFIX TAG t , 1800 WHITE PLAINS ROAD BRONX, ny 10462 ID PREFIX TAG . SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE (XS) COMPLETE DATE H 224 Continued From Page 4 patient #1 was admitted on 5/4/03 with ienntEUR of Non nSUlin Dependent Diabetes . -_ Ius, R .... Mellitus, Retinopathy and Pneumonia. The patient care record included documented evidence of the patient's receipt of the agency phone Patient Bill of Rights on 5/2/03 with the documented number for the Department "212-788-9648" and on 5/21/07 with the phone as number for the Department documented documented number is not "212-588-4771". The York the correct information to contact the New Department of. Health. State 2) Patient #2 was admitted on 4/22/04 with left diagnoses of Cerebrovascular Accident with Hypertension Hemiparesis and The patient care record has documented evidence of the patient's receipt of the agency "Patient Bill of Rights" on 11/13/04. In the the documents, the space to write the phone number of the Department of Health is blank. 3) Patient #3 wasadmitted on 4/1/06 with diagnoses of Muscular Dystrophy and Seizures. The patient care record has documented evidence of the patient's receipt of the PatientBill of Rights on 4/3/06 with the phone number for as the Department of Health documented '212-268-6689." 4) Patient #5 was admitted on 9/27/05 with diagnoses of Insulin Dependent Diabetes Mellitus, Hypertension and Blindness. The patient care record has documented evidence of the patient's receipt of the Patient Bill of Rights on,10/7/05 with the phone number for ;TATE FORM o2119 H 224 oThe Field Nurse Supervisor will review Premier's Complaint/Occurrence Involving Patient Services Form that provides Premier's branch phone number and the phone number to the joint Commission Hotline. Parties responsible for the correction and ensuring continued compliance: Director of Patient Services and Field aF srv nt Nirs S e r /4/0 Nurse Supervisor io/4 Date o I. How to identify other-client's having the potential to be affected by the same deficient practice and what corrective action will be taken. o All active private pay files will be audited to assess if the Patient Bill Of Rights is present, signed, and has the correct phone number to the Department of Health, and that the patient received Premier's Complaint/Occurrence Involving Patient Services Form. Parties responsible for the correction and ensuring continued compliance: Heather Simon- Office Administrator, Director of Patient Services, and Field ""*r Nurse Supervisor . Date of Completio . M. Measures that will be put in place to ensure that the deficient practice will not recur o All Field Nurse Superyisors and the Administrator will be re in-serviced on Z97411 Ifcontinuation sheet 5 of 20 iw York State Department of Health .TEMENT OF DEFICIENCIES PLAN OF CORRECTION (XI) PROVIDERISUPPLIER/CLLA DE 0 T FC T mB. IDENTIFICATION NUMBER:1086L003 (X2) MULTIPLE CONSTRUCTION DLIG .. A. WING (X3) DATE SURVEY .. .... . 1 1 6 2 0 1111612607 ,ME OF PROVIDER ORSUPPLIER , STREET ADDRESS, CITY. STATE, ZIP CODE OMEHELTHCAR ~EMER S REFiX TAG SRVICES. INC. 1800 WHITE PLAINS ROAD BRONX, ny 10462 IO TAG I SUMMARY STATEMENT OF DEFICIENCIES .PREFIX . (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (X5) COMPLETE TO HOULD BE (AECORRECE CROSS-REFERENCED TO THE APPROPRIATE H 224 Continued From Page 4 1) Patient #1 was admitted on 5/4/03 with diagnoses.of Non Insulin Dependent Diabetes Mellitus; Retinopathy and Pneumonia. The patient care record included documented evidence of the patient'sreceipt of the agency Patient Bill of Rights on 5/2/03 with the phone . number for the Department documented on 5/21/07 with the phone "212-788-9648" and number for the Department documented as "212-588-4771" . The documented number is not the correct information to contact the New York State Department of Health. 2) Patient #2 was admitted on 4/22/04 with diagnoses of Cerebrovascular Accident with left . Hemiparesis and Hypertension The patient care record has documented evidence of the patient's receipt of the agency the "Patient Bill of Rights" on 11/13/04. In thenumber the space to write the phone documents, of the Department of Health is blank. i 3 fThe , 3) Patient #3 was admitted on 4/1/06 with Muscular Dystrophy and Seizures. diagnoses of H 224 . . - I Policy (#7.4). The in-service will include the Patient Bill Of Rights and -ensure that the correct Department of Health's phone number is provided, as well as Premier's Complaint/Occurrence Involving Patient Services Form with Premier's branch telephone number, and the Joint Commissions Hotline number. Parties responsible for the correction and ensuring continued compliance: Director of Patient Services, and Celestina Cruz, RN- Vice President of Clical Services. Date of Completion: 4/4/08 IV. How the corrective action will be monitored to ensure the deficient practice will not recur .25% of the active private pay client's files will be audited each month to assess if the Patient Bill Of Rights is is present, has the correct phone number to the department of health, and signed in the patient's clinical file. Field Nurse Supervisor must also note that she has presented Premier's Complaint/Occurrence Involving Patient Services Form with Premier's branch telephone number, and the Joint Commissions'Hotline number. I evidence of the patient's receipt of the Patient Bill ! of Rights on 4/3/06 with the phone number for the Department of Health documented as , 1 "212-268-6689." The patient care record has documented Parties responsible for the correction 4) Patient #5 was admitted on 9/27/05 with diagnoses of Insulin Dependent Diabetes Mellitus, Hypertension and Blindness. and ensuring continued compliance: Heather Simon - Office Administrator,. Field Nurse Supervisor, and Director of Cruz, Patient Services, and Celestina Service. PaieN Vice President of Clinical 4/4/08 Date of Completion: Dawn Brill, RN Vice President of Regional Operations-North East for i of Rights on 10/7/05 with the phone number 0,s . ...T FORM . ATE FORM0119Z71 1 The patient care record has documented evidence of the patient's receipt of the Patient Bill Z9741 1 If continuation sheet 5 of 20 PRINTED: 12/14/2007 FORM APPROVED w York State De artment of Health .TEMENT OF DEFICIENCIES )PLAN OF CORRECTION (XI) PROVIDERISUPPLIERICLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A.BUIDN6__________ (X3) DATE SURVEY COMPLETED 11086_003 ME OF PROVIDER OR SUPPLIER B. 'NG STREET ADDRESS, CITY, STATE, ZIP CODE 11/16/2007 tEMIER HOME HEALTH CARE SERVICES. INC. (4) ID REFIX TAG 1800 WHITE PLAINS ROAD BRONX, ny 10462 ID PREFIX TAG PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE AcTIoN SHOULD BE CROSSDREFERENCED TO THE APPROPRIATE (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H 224 Continued From Page 5 the Department of Health documented as H 224 "212-268-6689." .The documented numbers is not the correct information to contact the Newi York State Department of Health. On November 16, 2007 at 3:45pm, the Operations Director was interviewed and stated: I did not know." H 408 766.3(d) Plan of care 766.3 Plan of care. The governing authority or operator shall ensure that: o...(d) the plan of care is reviewed and revised as frequently as necessary to reflect the changing care needs of the patient, but no less frequently H 408 H 408 It is-the Policy of Premier 'Home Health Care Service (#14.3) that the Field Nurse Supervisor develops a Plan of Care for each patient upon admission. The Field Nurse Supervisor must also review/revise the Plan of Care as necessary and at least every six months. I. Corrective action will be accomplished for those patients found to have been affected by the deficient practice. The Field Nurse Supervisor is to:. -Arrange and perform a home visit to patients #1, #2, #3, #4, #5 that were to bedeficient upon theDOH survey. Review and revise the care plan to meet the client's present needs. o Complete the physician telephone orders and obtain a physician signature. . Document visit and findings in client's . file. Parties responsible for the 'correction oand ensuring continued compliance: , than every six months;acopihdfrtseainsfud (1) each review shall be documented inthe clinical record; and (2) agency professional personnel shall promptly alert the patient's authorized Practitioner and other affected care providers to any significant a changes in the patient's condition that indicate need to alter the plan of care. This Rule is not met as evidenced by: . Based on record review and staff interview, the agency failed to review the plan of care for patients. This was noted for five (5) of five (5) records reviewed. (Patients # 1, #2, #3, #4, and #) .found #5) Failure of the agency to ensure that patient care FORM TATE 021159. Z97411 If continuation sheet 6 of 20 PRINTED: 12/14/2007 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLANIOF CORRECTION (X1) PROVIDER/SUPPLIERJCLIA IDENTIFICATION NUMBER: ..... (X2) MULTIPLE CONSTRUCTION .. A. BUILDING B. WING (X3) DATE SURVEY .COMPLE'TEOD...... 10861003. NAME OF PROVIDER OR SUPPLIER 1111612007 STREET ADDRESS, CITY, STATE, ZIP CODE PREMIER HOME HEALTH CARE SERVICES, INC. 0 (X4) ID PREFIX TAG 1800 WHITE PLAINS ROAD BRONX, ny 10462 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION ACTION SHOULD BE (EACH CORRECTIVE TO THE APPROPRIATE CROSS-REFERENCED DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGUI1ATORY OR LSC IDENTIFYING INFORMATION) H 408I Continued From Page 6 .H H 408 plans are updated to reflect the changing needs of the patient,ri plih rre. patients at risk of rnrr places all unsafe r.......o vI . I 1 'The findings are: k Heather Simon- Office Administrator, Field Nurse Supervisor, Director of Patient Services, and Celestina Cruz, RN- Vice President of Clinical Services Date of Completion: 4/4/08 1) Patient #1 was admitted on 5/4/03 with . diagnoses of Non Insulin Dependent Diabetes Mellitus, Retinopathy and Pneumonia. The "Home Health Certification and Plan of Treatment" dated for the certification period of period datedCare 5/4/03 to 11/4/03 and certification period dated . 11/4/03 to 4/4/04, which was signed by the MD no documented evidence ofDedfrevsoadocmnti. 1/26/04 have . dParties e nc04he I. How to identify other patients having the potential to be affected by the same deficient practice and What corrective action will be taken pay plans on all active private charts will be reviewed for content, need for revision, and documentation. responsible for the correction Simon- Office compliance: and ensuring continued Administrator, Heaer Suo-vOfic Dirator, Patient Services, and Celestina Cruz, Vice President of Clinical I 1Services: Date of Completi n 4/4/08 Measures that will be put inplace I. ensure that thedeficient practice will not recur Per Policy 14.3 Plan of Care -When the patient's condition changes, the RN modifies the care plan and notifies the physician of any needed new or revised orders. *on i ~~Heather 2) Patient #2 was admitted on 4/22/04 with diagnoses of Cerebrovascular Accident with left oRNHemiparesis and Hypertension. and Plan of The "Home Health Certification Treatment" for the certification period dated 6/21/07 to 12/22/07 has no documented evidence of review priorto this certification period in the patient's care record. 3) Patient #3 was-admitted on.4/1/06 with diagnoses of Muscular Dystrophy and Seizures. The patient care record has no documented evidence of Home Health Certifications and Plan of Treatments. 4) Patient #4 was admitted on 3/1/07 with a diagnoses of Chronic Obstructive Pulmonary Disease, Lung Cancer, Hypertension and Hyperlipidemia. The "Home Health Certification and Plan of Treatment" for the certification period dated STATE FORM 021199 1 -to Z97411 Ifcontinuation sheet 7 of 20 (ork State Department of Health IENT OF DEFICIENCIES AN OF CORRECTION (XI) PROVIOERISUPPLIERICLIA IDENTIFICATION NUMBER: . (X2) MULTIPLE CONSTRUCTION 1A. BUILDING' B.WING _ _ _ _ _ _ _ _ o . (X3) DATE SURVEY COMPLETED _ _ 1086L003 OF PROVIDER OR SUPPLIER . N 11116/2007 STREET ADDRESS. CITY. STATE. ZIP CODE IIIER HOME HEALTH CARE SERVICES. INC. D 1800 WHITE PLAINS ROAD BRONX, ny 10462 PROVIDER'S pLAN OF CORRECTION ID (EACH CORRECTIVE ACTION SHOULD BE PREFIX , "R O LOTAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY). (XE) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) - Continued 408 From Page 6 plans are updated to refleCt the changing needs of the patient, places all patients at risk of H 408 - Procedure: The Staffing Coordinator will inform the Field Nurse Supervisor of schedule changes due to: Client/Family requesting change in The findings are 1) Patient #1 was admitted on 5/4/03 with diagnoses of Non Insulin Dependent Diabetes Mellitus, Retinopathy and Pneumonia. The HoDocument The "Home Health Certification and Plan of Treatment" dated for the certification period of 5/4/03 to 11/4/03 and certification period dated :11/4/03 to 4/4/04, which was signed by the MD on 1/26/04 have no documented evidence of reviw sice 004.. review since 2004. 2) Patient #2 was admitted on 4/22/04 with - hours.. I . Io The Field NurseSupervisor is to adhere to the following when there is a change in client status: in the nursing narrative that she has received a notice of change in client status. and rm ahe visnt. Re *Reviews and revises care plan to meet client's present needs. Instruct aide on revised plan of care. Complete the physician telephone * .the with left diagnoses of Cerebrovasculaf AccidentHyertnsio. Hemiaress ad Hemlparesis and Hypertension.* The "Home Health Certification and Plan of Treatment" for the certification period dated no documented 6/21/07 to 12/22/07 has ' evidence of review prior to this certification period in the patient's care record, 3) Patient #3 was admitted on 4/1/06 with diagnoses of Muscular Dystrophy and Seizures. The patient care record has no documented evidence of Home Health Certifications and Plan of Treatments. of Teatmnts.clienit's 4) Patient #4 was admitted on 3/1/07 with a diagnoses of Chronic Obstructive Pulmonary Disease, Lung Cancer, Hypertension and . Hyperlipidemia. The "Home Health Certification and Plan of Treatment" for the certification period dated SE FORM -021 in I orders and obtain physician signature. file. Document visit and findings in client's The T RN is to adhere to the following w change in hours: Document in the nursing narrative that she has received a notice of change in hours. - Contact the client/family to assess reason for change in hours. Arranges and performs home visit if required. present nleeds Instruct to on Reviews and revises care planaidemeet revised plan of care. ?Completes physician telephone orders and obtains physician signature. Document visit and findings in client's file. Z97411 continuation sheet 7 of20 If w York State Department of Health \TEMENT OF DEFICIENCIES D PLAN OF CORRECTION (Xi) PROVIDERJSUPPLIER/CLIA IDENTIFICATION NUMBER:'(X2) MULTIPLE CONSTRUCTION A. BUILDING __________ - (X3) DATE SURVEY COMPLETED 1086L003 ME OF PROVIDER OR SUPPLIER B.WING STREET ADDRESS. CITY, STATE, ZIP CODE 11/16/2007 IEMIER HOME HEALTH CARE SERVICES. INC. () ID REFIX TAG 1800 WHITE PLAINS ROAD BRONX, ny 10462 ID PREFIX TAG PROVIDERs PLAN OF CORRECNCTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETE DATE SUMMARY STATEMENT' OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL R TAG REGULATORY OR LSC IDENTIFYING INFORMATION) REUL H 408 Continued From Page 6 H 408 -Staffing Coordinators, Office plans are updated to reflect the changing needs of the patient, places all patients at risk of Administrator, and Field Nurse Supervisors will be in-serviced on the Parties responsible for the correction and ensuring continued compliance Heather Simon- Office Administrator, FieldNurse Supervisor, Director of Patient Services, and Celestina Cruz, RN-Vice President of Clinical Services of Completion: 4/4/08 D f e 4 The findings are: 1) Patient #1 was admitted on 5/4/03 with diagnoses of Non Insulin Dependent Diabetes Mellitus, Retinopathy and pneumonia ,Date The "Home Health Certification and Plan of , Treatment" dated for the certification period of 5/4/03 to 1114/03 and certification period dated which was signed by the MD 11/4/03 to 4/4/04,no documented evidence of on 1/26/04 have review since 2004. , dcinw torrete ote monitored to ensure the deficient practice will not recur 4 25% of the active private pay client's p content, revision, and care be audited each month for plan of d documentation. and ensuring continued compliance: Parties responsible for the correction aderingmontie comince: Oerv dminsrator, Heater S Supervisor, Director of Field Nurse Patient Services, and Celestina Cruz, tRN-Vice President of Clinical Services Date of Completion: 4/4/08 .. 2) Patient #2 was admitted on 42204will left With i diagnoses of Cerebrovascular Accident Hemiparesis and Hypertension. i The "Home Health Certification and Plan of Treatment" for the certification period dated 6/21/07 to 12/22/07 has no documented V-evidence of review prior to this certification period in the patient's care record. 3) Patient #3 was admitted on 4/1/06 with diagnoses of Muscular Dystrophy and Seizures. The patient care record has no documented and Plan I evidence of Home Health Certifications of Treatments. 4) Patient #4 was admitted on 3/1/07 with a diagnoses of Chronic Obstructive Pulmonary Disease, Lung Cancer, Hypertension and Hyperlipidemia. The "Home Health Certification and Plan of Dawn Brill, RN Vice President of Regional Operations- North East Treatment" for the certification period dated FORM %TE 021199 Z97411 . 20 continuation sheet 7 of If PRINTED: 12/14/2007 FORM APPROVED -wYork State Department of Health ATEMENT OF DEFICIENCIES - D PLANOF CORRECTION (X1) PROVIDER/SUPPLIERJCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION ~COMPLETED A. BUILDING' (X3) DATE SURVEY C........ o ME OF PROVIDEROR SUPPLIER I 1086L003 108- -3B.WING STREET ADDRESS, CITY, STATE, ZIP CODE 11/16/2007 REMIER HOME HEALTH CARE SERVICES, INC. X4) ID 'REFIX TAG 1800 WHITE PLAINS ROAD BRONX, ny 10462 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H 408 Continued From Page 7 6/13/07 to 12/13/07 has no documented evidence of review prior to this certification period. 5) Patient #5 was admitted on 9/27/05 with a diagnoses of Insulin Dependent Diabetes Mellitus, Hypertension and Blindness. The "Home Health Certification and Plan of Treatment" for the certification period dated 1/31/07 to 7/31/07 was not signed or dated by .the physician. There were no documented evidence of review prior or after this certification period. On November 16, 2007 at 3:25pm, the Operations Manager was interviewed and stated: "The DPS recently resigned and two other field nurses were terminated we have had to start new books for the patients because we could not find previous paperwork." . H 408 H 622 766.5(c) Clinical supervision -766.5 Clinical supervision. The governing I authority shall ensure for all health care services that: ... (c) home health aides or personal care aides are supervised, as appropriate, by a registered a therapist if the aide carries out simple procedures as an extension of physical therapy, H 622 H622 It is the Policy of Premier Home Health Care Service (#9.20) that all paraprofessional staff receives su.pervision while awaiting the results of their Criminal History Record Check, per the Department of Health Regulations. Employees will be professional nurse or licensed practical nurse, or telephone supervised and field supervised on alternate weeks, until the occupational therapy or speech/language pathology. This Rule is not met as evidenced by: Based on record reviews and staff interview, the agency failed to document complete supervision of the paraprofessional staff while awaiting the ,TATE FORM 02110 employees criminal background check results are obtained by Premier. Z97411 Ifcontinuation sheet 8 of 20 w York State De artment of Health TEMENT OF DEFICIENCIES OF PLAN CORRECTION . -- (XI) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A ______ A. BUILDING B. WING (X3) DATE SURVEY. COMPLETED _____ 11116/2007______ 1086L003 ME OF PROVIDER ORSUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11116/2007 'EMIER HOME HEALTH CARE SERVICES. INC. .4) ID ifEFIX rAG rA - 1800 WHITE PLAINS ROAD BRONX, ny 10462 i ID PREFIX TAGo . . I SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYNG INFORMATION) I I - PROVIDER'S PLAN OF CORRECTION SHOULD BE (EACH CORRECTIVE ACTION APPROPRIATE CROSS-REFERENCED TO THE . DEFICIENCY) (Xf) COMPLETE DATE . H 622 Continued From Page 8 results for the Criminal History Record Check. This was-evident for one (1) out of four (4) H622 I. Corrective actions that will be accomplished for those patients found to have been affected by the deficient records reviewed. ( Employee # 4) paraprofessional staff places all patients at risk receiving poor quality care from potentially for unqualified individuals. o i Failure to document adequate supervision of the :will " frreturned. .. practice. FThe personnel file of employee #4 be reviewed to ensure that the Criminal Background Check has If the Criminal Background Check has not returned, Premier's i I Home The personnel record for Employee record #4,( Health Aide) documents a hire date of "2/9/07. The record lacks documented evidence (f the of supervision while awaiting for the results criminal history record check. .Date Policy #9.20 should be adhered to. Parties responsible for the correction and ensuring continued c0ippliance: HaderSgmontied dmincer Heather Simon- Office Administrator, Field Nurse Super-visor, an Director of F Patient Services. of Completion: 4/4/08 I II. How to identify other client's having the potential to be affected by the same deficient practice and what. corrective action will be taken. The personnel files of all-provisional .* employees will be audited to ensure that Documentation of supervision for the weeks-of 2/19/07 and 3/26/07; the whole month of April; the weeks of 515/07-5/16/07, the last two weeks 7 the of July,2007; the month of August,200 and week of 10/15/07 were missing from the recod. o I On November 16, 2007 at 3:33pm, the Operations Manager was interviewed and stated: "the nurses were supposed to be doing this and when they left we found a lot of paperwork missing.' H 708 766.6(a)(3) Patient care record 766.6 Patient care record. .- o they are being supervised in accordance with the Department of Health egulations. H 708 (a) The agency shall maintain a confidential record for each patient admitted to care to include: (3) nursing assessments conducted to provide services. 021199 TEFORM Z97411 If continuation sheet 9 of 20 PRINTED: 12/14/2007 FORM APPROVED N York State Department of Health (XI) PROVIDERJSUPPLIERCLIA TEMENT OF DEFICIENCIES PLAN OF CORRECTION . IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED. C . 1086L003 AE OF PROVIDER OR SUPPLIER B.WING STREET ADDRESS, CITY, STATE, ZIP CODE, 11/16/2007 EMIER HOME HEALTH CARE SERVICES. INC. .4)ID [ .EFIX FAG FAG.. 1800 WHITE PLAINS ROAD BRONX, ny 10462 ",R ID PREFIX " PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE ENC Y) EF CROSS-REFERENCED TO THE APPROPRIATE (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) 2 L 622 CotneCFo ~ ae ~ ~~ H Criminal History of four Check. results forevident for one (1) outRecord' (4) .his was the records reviewed (Employee # 4) of the Failure to document adequate supervision places all patients at risk paraprofessional staff for receiving poor quality care from potentially unqualified individuals. The Findings are: aParties responsible for the correction and ensuring continued compliance: office Administrator, eather SimondR coordinators, and Celstina Cruz, RN- Vice President of Clinical Services. Date of Completion: 4/4/08 Th esonlrcodfrEmployee record #4,( of Home Health Aide) documents a hire date record lacks documented evidence "2/9/07". The of supervision while awaiting for the results of the criminal history record check. weeks'of Documentation of supervision for the Measures that will be put in place deficient practice to ensure that the recur will not Field Nurse Supervisors, Office *All Administrator, HR Coordinators will be i re in-serviced on Policy (# 9.20). Parties responsible for the correction and ensuring continued compliance: R Hl.Coordinators, Field Nurse Heather Simon- Office Administrator, 2/19/07 and 3/26/07; the whole month of April; the weeks of 5/5/07-5/16/07, the last two weeks of July,2007; the month of August,2007 and the week of 10/15/07 were missing from the record. the 2007 at 3:33pm, On November 16, stated: Operations Manager was interviewed and supposed to be doing this and "the nurses were when they left we found a lot of paperwork missing." H 708 766.6(a)(3) Patient care record 766.6 Patient care record. (a) The agency shall maintain a confidential to care to record for each patient admitted include: Supervisor, and Celestina Cruz, RNVice President of Clinical services. Date of Completion: 4/4/08 H 708 (3) nursing assessments conducted to provide services. . FORM ATE 021199 Z97411 continuation sheet. 9 of 20 If w York State Department of Health TEMENT OF DEFICIENCIES PLAN OF CORRECTION (X1) PROVIDERJSUPPLIER/CLIA IDENTIFICATION NUMBER' (X2) MULTIPLE CONSTRUCTION A. B1UILDING _____ _____ (X3) DATE SURVEY COMPLETED 10861-003 ME OF PROVIDER OR SUPPLIER B WING 1111612007 STREET ADDRESS, CITY, STATE, ZIP CODE INC. 1EMIER HOME HEALTH CARE SERVICES. (4) ID EFIX LAG 1800 WHITE PLAINS ROAD BRONX, ny 10462 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSSREFERENCED TO THE APPROPRIATE DEFICIENCY) (5 ()DSUMRSTTMNOFDEFICIENCIES SUMARYSTAEMETEO (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) COMPLETE DATE H 622 Continued From Page 8 results for the Criminal History Record Check. This was evident for one (1) out of four (4) H 622 . - records reviewed ( Employee # 4) Failure to document adequate supervision of the IV. How the corrective action will be monitored to ensure the deficient practice will not recur * 25% of the personnel files of all provisional employees will be audited monthly.to ensure that they are being paraprofessional staff places all patients at risk for receiving poor quality care from potentially unqualified individuals. The Findings are: supervised in accordance with the Department of Health Regulations. o.HR The personnel record for Employee record #4,(, Home Health Aide) documents a hire date of Parties responsible for the correction and ensuring continued compliance: Heather Simon- Office Administrator, Coordinators Field Nurse Supervisor, and Celestina Cruz, RNVice President of Clinical Services. "2/9/0T'. The record lacks documented evidence I . of supervision while awaiting for the results of the criminal history record check. Documentation of supervision for the weeks-of 2/19/07 and 3/26/07; the whole month of April; the weeks of 5/5/07-5/16/07, the last two weeks 7 of July,2007 the month of August,200 and the week of 10/15/07 were missing from the record. I Date of Completion: 4/4/08 . Dawn Brill, RN Vice President of Regional Operations- North East - ! On November 16, 2007 at 3:33pm, the Operations Manager was interviewed and stated; "the nurses were supposed to bedoing this and when they left we found a lot of paperwork missing." H 708 766.6(a)(3) Patient care record 766.6 Patient care record. (a) The agency shall maintain a confidential record for each patient admitted to care to I H 708 ' H708 It is the Policy of Premier Home Health Care Services (# 11.6) that the Field Nurse Supervisor completes an Initial Nursing Assessment at the time of admission. Sinclude: (3) nursing assessments Conducted to provide services. 02119 " . Z97411 Itcontinuation sheet 9 of20 TE FORM PRINTED: 12/1412007 FORM APPROVED -w York State Department of Health ATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION .... (Xl) PROV1DER/SUPPLIERCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY 1086L003 ME OF PROVIDER OR SUPPLIER NG B W I . 1111612007 STREET ADDRESS, CITY, STATE, ZIP CODE REMIER HOME HEALTH CARE SERVICES. INC. X4) ID ,REFIX TAG SUMMARY STATEMENT OF DEFICIENCIES . (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) o 1800 WHITE PLAINS ROAD BRONX, ny 10462 ID PREFIX TAG !I PROVIDER'S PLAN OF CORRECTION .(EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE H.7081 Continued From Page 9 H 708 This Rule is not met as evidenced by: Based on record review and staff interview, the ensur e' ',to e that a nursing ,g, conducted on.all patients. This assessment is 1. Corrective actions that wil'be accomplished for those patients found hv the deficient -. ,ffPeted .. practice. was evident for three (3) of five (5) records reviewed. (Patient Care Records 1,2 and 5) . Failure of the agency to ensure complete documentation of nursing assessments places, all patients at risk for poor quality care. The findings are: 1) Patient #1 was admitted on 5/4/03 with diagnoses of Non Insulin Dependent Diabetes Mellitus, Retinopathy and Pneumonia. . - The Field Nurse Supervisor will perform a home visit and complete an Initial Nursing Assessment on patients on paient #ta Nri aese fournd deficient #1, #2, #5 that were during the DOH survey. The Initial Nursing Assessment will be placed in the patient's clinical file., Parties responsible for the correction compliance: and ensuring continued Administrator, Heather Simon- Office Field Nurse Supervisor, Director of Patient Services, and Celestina Cruz, RN- Vice President of Clinical aServices.Completion: 4/4/08 of II. How to identify other client's having the potential to be affected by the same deficient practice and what corrective action will be taken. oThe clinical files of all active clients will be audited for the presence and completion of the Initial Nursing Assessment. Parties responsible for the correction and ensuring continued compliance: Heather Simon- Office Administrator, Field Nurse Supervisor, Director of Patient Services, and Celestina Cruz, RN- Vice President of Clinical Services. Date of Completion: 4/4/08 The patient care.record does not contain documented evidence of a complete initial nursng asessent.Date nursing assessment. 2) Patient #2 was admitted on 4/22/04 with diagnoses of Cerebrovascular Accident with left Hemiparesis and Hypertension, The patient care record does not contain documented evidence. of a complete initial nursing assessment. 3) Patient #5 was admitted on 9/27/05 with diagnoses of Insulin Dependent Diabetes Mellitus, Hypertension and Blindness. The care record does not contain documented evidence of a nuirsing assessment for 2007. On November 16, 2007 at 3:55pm, the . Operations Manager was interviewed and stated: ......have not had a field nurse in a while and we the ones we had were terminated." TATE FORM 021199 Z97411 continuation sheet 10 of 20 If ew York State Department of Health "ATEMENT OF DEFICIENCIES IDPLAN OF CORRECTION (X1) PROVIDEPJSUPPLIER/CLIA IDENTIFICATION.NUMBER:A : iX2) MULTIPLE CONSTRUCTION A BUILDINGETED BIWING __AT___m__A._BUILDING (X3) DATE SURVEY . PLE OFPR ORSU VDE SUPPLIER kME~~~~~ %ME OF PROVIDER OR 108 L003 STREET ADDRESS, CITY, STATE, ZIP CODE. 11f16/2007 1800 WHITE PLAINS ROAD BRONX, ny 10462 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE DEFICIENCY) CROSS-REFERENCED TO THE APPROPRIATE (Xf) COMPLETE I DATE REMIER HOME HEALTH CARE SERVICES. INC. X4) ID 'REFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) o H 708i Continued From Page 9 H 708 Tto I. Measures that will be put in place ensure that the deficient practice not met asevidenced by: This Rule is Based on record review and staff interview the - ,,,d e;;su~e '' ........ will not recur The Field Nurse Supervisors and assessment is conducted on all patients. This was evident for three (3) of five (5) records reviewed. (Patient Care Records 1,2 and 5) ~and Failure of the agency to ensure complete Office Administrator will be re inserviceson.Policy#11.6. Parties responsible for the correction ensuring continued compliancecopianc Densr otied Director of Patient Services, and placesCestaCrzR-ViePsdnto documentation of nursing assessments all patients at risk for poor quality care. Clinical Services.. Date-of Completion: 4/4/08 are* The IV. How the corrective action will be monitored to ensure the deficient Monitice to eur Patient #1 wasadmitted on 5/4/03 with 1) of Non Insulin Dependent Diabetes diagnoses will not recur nd neuroni.,.practice . Melltus Retn~pthy -25% of the clinical files of all active Mellitus, Retinopathy and Pneumonia.,. audited private pay clients will beand monthly for the presence not contain The patient care record does the.itial Nursng documented evidence of a complete initialo I ' nursing assessmentoAssessment 2) Patient #2 was admitted on 4/22/04 with left diagnoses of Cerebrovascular Accident with not contain The patient care recordof a complete initial documented evidence does assessmet. 3)Patient #5 was admitted on 9/27/05 with an Hyertnsio Melltus Blndnss.Dawn diagnoses of Insulin Dependent Diabetes ,Hypertension and Blindness. The care record does not contain documented evidence of a nursing assessment for 2007. On November 16, 2007 at 3:55pm, the Operations Manager was interviewed and stated: have not had a field nurse in a while and o..we ones we. had were terminated." the ATE FORM o1199 and ensuring continued coplin Heather Simon- Office Administrator, Field Nurse Supervisor, Director of Patient Services, and Celestina Cruz, RN- Vice President of Clinical Services. Date of Completion: 4/4/08 trill, RN Vice President of Regional Operations- North East -i , , Z97411 continuation sheet 10o120 If PRINTED: 12/14/2007 FORM APPROVED w York State Department f Health TEMENT OF DEFICIENCIES PLAN OF CORRECTION o (XI) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING .WING__1/1612007___ TE 1086L003 OF A1E PROVIDER OR SUPPLIER . 11/16/2007 STREET ADDRESS, CITY, STATE, ZIP CODE EMIER HOME HEALTH CARE SERVICES, INC. :4) ID. IEFIX TAG - 1800 WHITE PLAINS ROAD BRONX, ny 10462. . SUMMARY STATEMENT OF DEFICIENCIES MUST BE PRECEDED BY (EACH DEFICIENCY~DEFICIENCY) FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE (X5) COMPLETE DATE H 708 Continued From Page 10 H 708 H 712 766.6(a)(5) Patient care record 766.6 Patient care record. H 712 .H712 yshall maintain a confidential (aThe ag carento rer fagency ha atintain record for each patient admitted to care to include: .the progress notes following s ddated (5) signedateaching, all each patient visit or phone contact by professional personnel providing care which include a summary of patient status and contacts response to the plan of care and any and other with family, informal supports the community resourcesthat are relevant to It is the Policy of Premier Home Health Care Services (# 11..6) that the Field Nurse Supervisor performs home visits after the initial nursing assessment to patient as ordered by the physician, for patient reassessment, patient ide supervision. The supervisio The d and aide Fi all home visits and telephone calls in nd isits tele. ahe the patient's clinical file. I. Corrective actions that will be accomplished for those patients found to have been affected by the deficient practice. The Field Nurse Supervisor will perform a home visit and complete documentation on patients #1, #2, #3, #4, #5 that were found deficient during the DOH survey. The home visit documentation will be placed in the patient's clinical file. Parties responsible for the correction and ensuring continued compliance: Field Nurse Supervisor, Director of Patient Services, Office Administrator, and Celestina Cruz, RN- Vice President of Clinical Services. Date of Completion: 4/4/08 patient's condition and treatment. This Rule is not met.as evidenced by: the Based on record review and staff interview, documentation of agency failed to maintain patient progress in the patient care records. This was evident for five (5) of five (5) retords reviewed. (Patient Care Records #1, # 2, #3,. #4,and #5) Failure of the agency to document patient care places all patients at risk of unsafe, poor quality care. . The findings are 1) Patient #1 was admitted on 5/4/03 with diagnoses of Non Insulin Dependent Diabetes Mellitus, Retinopathy and Pneumonia. The patient care record does not include progress notes to document patient contact and progress. 021199 Z97411 If continuation sheet 11 of 20 TATE FORM York State DeDartment of Health ,'w ATEMENT OF DEFICIENCIES 0 PLAN OF CORRECTION (xi) PROVIDERtSUPPLIERICLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION " (X3) DATE SURVEY " . B.WIING . ______ . COMPLETED 1086L003 %MEOF PROVIDER ORSUPPLIER . 11/1612007 STREET ADDRESS , CITY. STATE, ZIP CODE REMIER HOME HEALTH CARE SERVICES, INC. XA) ID REFIX TAG 1800 WHITE PLAINS ROAD BRONX, ny 10462 . SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY oR LSC IDENTIFYING INFORMATION) ID PREFIX TAG I PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (XE) COMPLETE DATE .71)Continued H 712 1 cn From Page 1l1 '. H 712 . How to identify other client's having the potential to be affected by the same deficient practice and what corrective action will be taken. The clinical files of all active private pay clients will be audited for the presence and completion ofpatient o i home visits, telephone calls, and all associated progress notes.. Parties responsible for the correction ! and ensuring continued compliance: a e Field Nurse Supervisor, Director of Patient Services, Office Administrator, and Celestina Cruz, RN- Vice President of Clinical Services. Date of Completion: 4/4/08 l]].Measures that will be put in place to ensure that the deficient practice not recur 2) Patient #2 was admitted on 4/22/04 with diagnoses of Cerebrovascular Accident with left Hemiparesis and Hypertension. The patient care record does not include progress notes to document patient contact and progress. . 3) Patienlt #3 was admitted on"4/1/06 with diagnoses of Muscular Dystrophy and Seizures. The patient care record does not include progress notes to document patient contact and progress. 4) Patient #4 was admitted on 3/1/07 with diagnoses of Chronic Obstructive Pulmonary Disease, Lung Cancer, Hypertension and Hyperlipidemia. *will The patient care record does not include progress notes to document patient contact and progrss. . 5Patient #5wsam.don92/5wt 5) Patit#5 was admitted on 9/27/05 with diagnoses of Insulin Dependent Diabetes Mellitus, Hypertension and Blindness. The patient care record does not include ..-. The Field Nurse Supervisors and I Office'Administrator will be re inp eserviced on Policy #11.6. and ensuring continued compliance: Parties responsible for the correction a ector o tie Serv i and DietroPaenSrvcsan, of Celestina Cruz, RN- Vice President o Clinical Services. progress notes to document patient contact and progress. On November 16, 2007 at 3:28pm, the .D IV. How the corrective action will be monitored to ensure the deficient will not recur opractice o25% of the clinical files of a active Operations Manager was interviewedand stated: contact and they were terminated mainly because of this." . , The nurses were to be documenting all private pay clients will be audited , monthly for the presence and completion of home visits, telephone communication, and all associated progress notes. . TE FORM 02119 Z97411 continuation sheet 12 of 20 If PRINTED: 12/14(2007 FORM APPROVED Jew York State Department of Health TATEMENT OF DEFICIENCIES ND PLAN.OF CORRECTION . (Xl) PROVIDER/SUPPLIER/CLIA IDENTIFCATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING ______ _____ (X3).DATE SURVEY COMPLETED 1086L003 tME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY. STATE, ZIP CODE 11/16/2007 1800 WHITE PLAINS ROAD BRONX, ny 10462 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) IREMIER HOME HEALTH CARE SERVICES, INC. (X4) ID PREFIX TAG H 712 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X5) COMPLETE DATE Continued From Page 11 -and 2) Patient #2 was admitted on 4/22/04 with diagnoses of Cerebrovascular Accident with left SHemiparesis and Hypertension. H 712 The patient care record does not include progress notes to document patient contact and progress. 3) Patient #3 was admitted on 4/1/06 with diagnoses of Muscular Dystrophy and Seizures. The patient care record does not include progress notes to document patient contact and progress. 4) Patient #4 was admitted on 3/1/07 with diagnoses of Chronic Obstructive Pulmonary Disease, Lung Cancer, Hypertension and Hyperlipidemia. The patient care record does not include progress notes to document patient cointact and progress. 5) Patient #5 was admitted on 9/27/05 with diagnoses of Insulin Dependent Diabetes Mellitus, Hypertension and Blindness. The patient care record does not include progress notes to document patient contact and progress. On November 16, 2007 at 3:28pm, the Operations Manager was interviewed and stated: .........The nurses were to be documenting all contact and they were terminated mainly because of this." Parties responsible for the correction ensuring continued compliance: Field Nurse Supervisor, Director of Patient Services, Office Administrator, and Celestina Cruz, RN- Vice President of Clinical Servides. ,Date of Completion: 4/4/08 Dawn Brill, RN Vice President of Regional Operations- North East . - - -ATE FORM o21199 Z97411 Ifcontinuation sheet 12 of 20 PRINTED: 12114/2007 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES . AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIERJCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION B. WING (X3) DATE SURVEY ETED C O.MPLEBUILDING _ _ _ _ _ _ _ _ _ 1086L003 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11/16/2007 PREMIER HOME HEALTH CARE SERVICES. INC. (X4) ID PREFIX TAG 1800 WHITE PLAINS ROAD BRONX, ny 10462 ID PREFIX TAG -DEFICIENCY) I I SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE (X5) COMPLETE DATE H 714 Continued From Page.12 H 714 766.6(a)(6) Patient care record 766.6 Patient care record. (a) The agency shall maintain a confidential record for each patient admitted to care to include: (6) supervisory reports of the registered professional nurse, licensed practical nurse or the therapist, if applicable, of the home health i H 714 H 714 I I H714 It is the Policy of Premier Home Health Care Services (# 12.2) that the Field Nurse Supervisor is responsible for the supervision of services and care provided by the home health aide. Uponeach home visit to the patient, the Field Nurse Supervisor completes a Paraprofessional Supervisory Evaluation Form that documents her findings and supervision of the home health aide during that visit. I. Corrective actions that will be accomplished for those patients found i aide or personal care aide. This Rule is not met as evidenced by: Based on record reviews and staff interview, the agency failed to document supervisory reports in five (5) out of five (5)patient care records . reviewed. Failure to document adequate supervision of the services and care provided by their staff places all patients at risk for receiving poor patient care. The findings are: to have been affected by the deficient practice. oThe Field Nurse Supervisor will perform a supervisory home visit and complete the Paraprofessional Supervisory Evaluation Form for home health aides that are assigned to patients #1, #2, #3, #4, #5 that were found deficient during the DOH survey. Parties responsible for the correction and ensuring continued compliance: Nurse Supervisor, Director of Patient Services, Office Administrator, and Celestina Cruz, RN- Vice President of Clinical Services. Date of Completion: 4/4/08 1. How to identify other client's having the potential to be affected by the same deficient practice and what corrective action will be taken. * The clinical files of all active private pay clients will be audited for the presence and completion of home 1) Patient#1 was admitted on 5/4/03 With diagnoses of Non Insulin Dependent Diabetes Mellitus, Retinopathy and Pneumonia. -The order document that the patient is to receive "3 days 4 hours a day of Home Health Aide services." There is no documented evidence of supervision for the Home Health Aide after 12/25/06. 2) Patient #2 was admitted on 4/22/04 withdiagnoses of Cerebrovascular Accident with left Hemiparesis and Hypertension. The orders STATE FORM 021199 .Field Z97411 - If continuation sheet 13 of 20 PRINTED: 12/14/2007 FORM APPROVED !w.York State Department of Health %TEMENT OF DEFICIENCIES PLAN OF CORRECTION D (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED 1086g003 ME OF PROVIDER OR SUPPLIER B.WING STREET ADDRESS, CITY, STATE, ZIP CODE 11/16/2007 tEMIER HOME HEALTH CARE SERVICES, INC. <4) tD REFIX TAG 1800 WHITE PLAINS ROAD BRONX, ny 10462 _____(X5 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) - (X5) COMPLETE DATE H 714 Continued From Page 13 document that the patient is to receive "6 days 6. hours a day of Home Health Aide services." There is no documented evidence of supervision of Home Health Aide supervision for 2006 or 2007. 3) Patient #3 was admitted on 4/1/06 with diagnoses of Muscular Dystrophy and Seizures. The patient care record has an authorization form which documents for the patient to receive: "6 hours 7 days of Personal Care Aide services." The patient record did not contain documented evidence Personal Car Aide supervision. 4) Patient #4 was admitted on 3/1/07 wit diagnoses of Chronic Obstructive Pulmonary Disease, Lung Cancer, Hypertension. and Hyperlipidemia. The orders documents that the patient is to receive: "5 days 4 hours of Personal Care Aide services." The patient care record does not contain Aide documented evidence of Personal Care s io25% supervision. H 714 health aide supervisory visits, and the completion of the Paraprofessional supervisory Evaluation Form. parties responsible for the correction and ensuring continued compliance: Field Nurse Supervisor, Director of Patient Services, Office Administrator, and Celestina Cruz, RN- Vice President of Clinical Services. Date of Completion: 4/4/08 iM. Measures that will be put in place to ensure that the deficient practice will not recur * The Field Nurse Supervisors and Office Administrator will be re inserviced on Policy #1 1.6. -Parties responsible for the correction and ensuring continued compliance: Director of Patient Services, and Celestina Cruz, RN- Vice President of Clinical Services. D IV. How the corrective action will be ensure the monitored to not recur deficient practice will of the clinical files of all active audited private pay clients will be and monthly for the presence e orthpen and mon f 5) Patient #5 was admitted on 9/27/05 with diagnoses of Insulin Dependent Diabetes Mellitus, Hypertension and Blindness. fr te ptien The rdes dcumet toreciveSupervisory The orders document for the patient to receive: .and "5days 6 hours of Home Health Aide services". The patient care record does not contain documented evidence of Home Health Aide supervision for 2007. rATE FORM 021199 completion of supervisory home visits of the home health aides, and completion of the Paraprofessional Evaluation Form... Parties responsible for the correction ensuring continued Compliance: Field Nurse Supervisor, Director of tror ic PieN Servis, Services, Office Administrator, Patient Z97411 Itcontinuation sheet 14 of 20 PRINTED: 12/14/2007 FORM APPROVED New York State DeDartment of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A BUILDING _ . (X3) DATE SURVEY COMPLETED ' 1086L003 NAmE OF PROVIDER OR SUPPLIER [B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 11/16!2007 PREMIER HOME HEALTH CARE SERVICES, INC. (X4) ID PREFIX TAG '1800 WHITE PLAINS ROAD BRONX, ny 10462 . ID PREFIX TAG - PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X5) COMPLETE DATE H 714 Continued From Page 14 On November 16, 2007 at 3:50pm the Operations Manager was interviewed and stated: "th6 two nurses that were terminated were supposed to provide the supervision." H 714 and Celestina Cruz, RN- Vice President 'ofClinical Services. Date of Completion: 4/4ce8. Dawn Brill, RN VP of Regional operations- North East H1020 7669(j) Governing authority. H10 7As Section 766.9 Governing authority, The governing authority or operator, as defined 'in Part 700 of this Title, of a licensed home care shall I services agency shaprovided ( ensure the development and implementation of a patient complaint procedure to include: (1 ) documentation of receipt, investigation and resolution of any complaint, including the maintenance of a complaint log indicating the dates of receipt and resolution of all complaints received by the agency; ri b e (2) review of each.complaint with a written, response to all written complaints and to oral complaints, if requested by the individuals making the oral complaint: .. H1020 H1020 part of the admission process, it is the Policy of Premier Home Health Care Service (#7.4) for the Field Nurse Supervisor to inform the patient in. writing oftheir right to voice concerns or complaints about the care or services by Premier, and the procedures for filing such concerns or complaints. Policy (#7.4) also outlines the procedure for processing all reported complaints including: Staff completion of the Complaint/Occurrence Report (FormC 110) which includes all relevant information, the investigation, outcome, resolution, and follow-up actions. The Office Administrator is responsible for ensuring that this form is completed and forward to the Vice President of Clinical Services. The Vice President prepares a written response to all written and oral complaints if rquested, and the decision of the agency within 15 days of receiving the.complaint. The person making the complaint has the right to appeal the Agency's decision by having ihe Agency's Chief Operating Officer review the appeal. If the patient is not satisfied with the Agency's response that patient may forward their complaint to the Department of Health. All Complaints are to be tracked on the " Complaint Log (Form- C 103) and filed in the Complaint Log Binder. 9 Z97411 If conlinuation sheet 15 of 20 explaining the complaint investigation findings (i) and the decisions rendered to date by the agency within 15 days of receipt-of such complaint; and (ii) advising the complainant of the right to appeal i the outcome of the agency's complaint investigation and the appeal procedure to be followed; (3) an appeals process with review by a member or committee of the governing authority within 30 days of receipt of the appeal; and STATE FORM O R2119 ' PRINTED: 12/14/2007 FORM APPROVED w York State Department of Health k TEMENT OF DEFICIENCIES ) PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING ______ ____ (X3) DATE SURVEY COMPLETED 1086L003 *ME OF PROVIDER OR SUPPLIER B.WIG STREET ADDRESS, CITY, STATE. ZIP CODE . 11/16/2007 'EMIER HOME HEALTH CARE SERVICES, INC. (4) ID REFIX TAG 1800 WHITE PLAINS ROAD BRONX, ny 10462 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE . SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H10201 Continued From Page 15 " (4) notification to the patient or his or her designee that if the patient is not satisfied by the agency's response, the patient may complain to the Department of Health's Office of Health Systems Management. H1020 This Rule is not met as evidenced by:. Based on record review and staff interview, the agency failed to maintain a complaint log to document the receipt and resolution of complaints received by the agency. "eceived Failure to ensure that an accurate and complete complaint log is maintained places all patients at risk for poor quality patient care. . The finding is: The agency presented an "Occurrence Log" book when the complaint log was requested. There was no documented evidence of an agency complaint log to document complaint investigations and resolutions. On November 16,2007 at 3:10pm, the Operations Manager wasinterviewed and was unable to. provide an explanation. . , H1036 766.9(1) Governing authority Section 766.9 Governing authority. The governing authority or operator, as defined in Part 700 of this Title, of a licensed home care services agency shall: (I) appoint a quality irprovement committee to establish and oversee standards of care. The quality improvement committee shall. consist of a consumer and appropriate health professional ATE FORM 021199 H1036 1. Corrective actions that will be accomplished for those patients found to have been affected by the deficient practice. II. How to identify other client's having the potential to be affected by the same deficient practice and what corrective action will be taken. Measures that will be put in place WIL. to ensure-that the deficient practice will not recur * Re In-Service all Office Staff on Policy # 7.4: This will include the completion of the Complaint/Occurrence Report (Form Cl10), verbally notifying and faxing the Vice President of Clinical Services per the Complaint Level, placing all complaints on the Complaint Log (Form-C103) and filing in the complaint binder by quarter, and reporting complaints at each quarterly QI Meeting. Parties responsible for the correction and ensuring continued compliance: Field Nurse Supervisor, Director of Patient Services, Heather Simon- Office Administrator, Director of Patient Services, and Celestina Cruz, RN Vice President of Clinical Services. Date of Completion: 4/4/08 . . Z9741 1 If continuation sheet 16 of 20 w York State De arment ofHealth JTEMENT OF.DEFICIENCIES PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIERCLIA IDENTIFICATION. NUMBER: (X2) MULTIPLE CONSTRUCTION A. UILDICOMPLETED (X3) DATE SURVEY 1086L003 ME OF PROVIDER OR SUPPLIER B.WING STREET ADDRESS, CITY. STATE. ZIP CODE 11/1612007 tEMIER HOME HEALTH CARE SERVICES. INC. ID :4) EFIX fAG 1800 WHITE PLAINS ROAD BRONX, ny 10462 " ID PREFIX TAG . PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE " DEFICIENCY) : CROSS-REFERENCED TO THE APPROPRIATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X5) COMPLETE DATE H00Continued From Page 15 (4) notification to the patient or his or her the designee that if the patient is not satisfied by H1020 IV. How the corrective action will be monitored to ensure the deficient . practice will not recur Administrator to ensure that the agency's response, the patient may complain to theDepartment of Health's Office of.Health Systems Management. 'evof This Rule is not met as eviand Based on record review and staff interiew, the agency failed to maintain a complaint log to document the receipt and resolution of complaints received by the agency. complaint received has been documented, communicated to the VP commnictedmoetetV documntedServices, filed accordingly, Clinical presented and the Quarterly QI Meetings per Policy # 7.4. Celestina Cruz, RN, Vice President of Clinical Services will review the complaint Policy with the Office Administrator Failure to ensure that an accurate and complete complaint log is maintained places all patients at risk for poor quality patient care. The finding is: and monitor the complaints monthly and quarterly. Parties responsible for the correction and ensuring continued compliance: Field Nurse Supervisor, Director of Services, Heather Simon- Office 'Patient Administratoi, Director of Patient The agency presented an "Occurrence Log" book when the complaint log was requested. There was no documented evidence of an agency complaint.log to documehit complaint investigations and resolutions. On November 16, 2007 at 3:10pm, the Services, and Celestina Cruz, RN Vice President of Clinical Services. Date of Completion: 4/4/08 DawnBrill, RN Vice President of Regional Operations- North East Operations Manager was interviewed and was unable to provide an explanation. H1036. 766.9(1) Governing authority I H1036 Section 766.9 Governing authority. te n ' I The as defined H1036 766.9 It is Premier's Policy (#7.1) to provide a Quality Improvement Program and Committee that establishes ad oversees the standards of care. The Corporate Quality Improvement Committee consists of a Consumer, Physician, Directors of Patient Services. 1 in Part 700 of this Title, of a licensed home care : services agency shall: appoint a quality improvement committee to i (I) consumer and appropriate health professional TE FfORM 02119 Regional Vice Presidents, and Regional establish and oversee standards of care. The f quality improvement committee shall consist of a Z97411 ifconlinualin sheet 16 of 20 PRINTED: 12/1412007 FORM APPROVED tw York State Deoartment of Health \TEMENT OF DEFICIENCIES -D PLAN OF CORRECTION (X2) MULTIPLE CONSTRUCTION (XI)PROV1DERISUPPLIE CLIA IDENTIFICATION NUMBERBUILDING (X3) DATE SURVEY COMPLETED 1086L003 ME OF PROVIDER OR SUPPLIER B WING 11/16/2007 STREET ADDRESS, CITY, STATE, ZIP CODE tEMIER HOME HEALTH CARE SERVICES. INC. (4) ID ,EFIX TAG 1800 WHITE PLAINS ROAD BRONX, ny 10462 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H1036 Continued From Page 16 I H1036 persons including a physician if professional health care services are provided.The committee shall meet at least four times a year to: -- of (1) review policies pertaining to the delivery services provided by the agency the health care and recommend changes in such policies to the governing authority for adoption; (2) conduct a clinical record review of the safety, adequacy, type and quaity of services provided asubmits adeqach inde: The Committee meets quarterly to review: policies, initiatives, clinical record audits, complaints, and submits a written summary of review fmdings to the governing authority. The Regional Quality Improvement Committee of of the lconsists Regiomal Diector Patient Services, Regional Vice President, Field Nurse Supervisors, and Coordinators. The Committee meets quarterly to review: policies, initiatives, clinical record audits, complaints, and a written summary to the I (X5). COMPLETE DATE which includes: fptet f eod eeto (i) random selection of records of patients months; and .~no Corporate Committee. Attached are the Corporate as both the for 2007. Dr. Banc served QI Minutes ser. anc for Physician and the Consumer. currently receiving services and patients discharged from the agency within the past three (i) all ,cases with identified patient complaints a's specified in subdivision () of this section; (3) prepare and submit a written summary of review findings to the governing authority for .and necessary action; and I. Measures that will be put in place to ensure that the deficient practice will not recur The Staff will be re in-serviced on Policy #7.1 Parties responsible for the correction ensuring continued compliance: Office Administrator, Director of Patient Services, and Celestina Cruz, (4) assist the agency in maintaining liaison with other health care providers in the community. RN - Vice President of Clinical Services. This Rule is not met as evidenced by: Based on record review and staff interview, the agency failed to ensure that the QA/QI Committee met four times a year; the meetings include a physician and a consumer and the committee performs the random record review of patients that are currently receiving services and. patients discharged from the agency within the past three (3) months as well as all cases with identified patient complaints, Failure to ensure that the Quality Improvement Committee performs the required functions 'ATE FORM 021,99 Date of Completion: 2/4/08 H.How the corrective action will be monitored to ensure the deficient practice will not recur The Vice President of Clinical Services will attend the First Quarter QI Meeting for the Bronx Office, and will monitor all QI Meeting documentation for 2008. Parties responsible for the correction and ensuring continued compliance: Z97411 Ifcontinuation sheet 17 of 20 PRINTED: 12/14/2007 FORM APPROVED New York State Department of Healih STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY . COMPLETED A. BUILDING 1086L003 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11/1612007 1800 WHITE PLAINS ROAD BRONX, ny 10462 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE' CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE PREMIER HOME HEALTH CARE SERVICES, INC. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDEDBY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H10361 Continued From Page 17 places patients at risk for poor quality services, unsafe and inadequate care. The findings are: The Quality Improvement ( QI) meeting minutes for First Quarter 2007, dated May 17, 2007 and Quality Improvement meeting minutes for Second Quarter 2007. dated September 27, 2007 lacked documented evidence of the attendance of a physician and a consumer. The (QI) meeting minUtes lacked documentation of therandom review of patient records currently receiving services, patients that were discharged , within the past three months and cases with identified patient complaints. - H1036 Office Administrator, Director of Patient Services, and Celestina Cruz, RN -Vice President of Clinical Services. Date of Completion: 2/4/08 Dawn Brill, RN Vice President of Regional Operations- North East As per the agency staff, the Quality Improvement Committee Meeting Minutes for the Year 2006 were "not available" for review as it was "in the Corporate office" and "unable to be faxed". On November 16, 2007 at 3:06pm, the Operations Manager was interviewed and stated: ".... the corporate office has the QI meeting m inutes ......... H1306 766.11(c) Personnel 766.11 Personnel. The governing authority or operator shall ensure fopersonnel: for all health care (c) that the health status of all new personnel is assessed and documented prior to assuming patient care duties.The assessment shall be of sufficient scope that no person shall assume his/her duties unless he/she is free from a health STATE FORM 021199 H1306 oH1306 766.11 It is the Policy of Premier- Home Health Care Services (# 9.7 Drug Free Work Place, #9.8 Field Caregiver Physical) that the potential employee undergo Pre-employment Physical (El 11) that includes a forensic drug screen. The forensic drug screen isalso completed yearly thereafter at the time of the required Annual Health Assessment (E125). This practice has 6 een in effect Z97411 If continuation sheet 18 of 20 aw York State DeDartment ATEMENT OF DEFICIENCIES IDPLAN OF CORRECTION f Health (Xl) PROVIDER2SUPPLIERCLA IDENTIFICATION NUMBER: (X) MULTIPLE CONSTRUCTION AB B. WING PRINTED: 12/14/2007 oFORM APPROVED " (X3) DATE SURVEY COMPLETED 1086L003 ME OF PROVIDER OR SUPPLIER 11/16/2007 STREET ADDRESS, CITY. STATE, ZIP CODE ZEMIER HOME HEALTH CARE SERVICES, INC. X4) ID REFIX TAG 1800 WHITE PLAINS ROAD BRONX, ny 10462 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE . CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H1306 Continued From Page 18 H1306 since 1996 and lab results pertaining to the forensic drug screen can be found in temdclrcrsscino h of the medical records section Thethe agency's personnel file. Assessment Form (E125) and and sment " HEl ploment Form (E1l) ter.e substanrem nhih4!/7mysialer 1,dthetat on 4/5/07, to include that the potential employee and existing employee are free from habituation or addiction to depressants, stimulants, narcotics,. alcohol, or other drugs or substances which may alter the individual's behavior. I. Corrective actions that will be accomplished for those patients found to have been affected by the deficient practice. Personnel #1, #2, #3 will complete the updated Annual Health Assessment Form (E125), that includes the statement free from habituation or addiction to depressants, stimulants, narcotics, alcohol, or other drugs or substances which may alter the individual's behavior. All remaining employees will complete the updated Annual Health Assessment Form (E 125) during the 2008 calendar year at their scheduled yearly due date. Parties responsible for the correction and ensuring continued compliance: Employment Coordinators, Field Nurse Supervisor, Director of Patient Services, Office Administrator, and Celestina Cruz, RN- Vice President of Clinical Services. of Completion: 2/4/08 impairment which is of potential risk to the patient or which might interfere with the performance of his/her duties, including the habituation or addiction to depressants, .employee's habiuatin o addctin todepessatsHealth stimulants, narcotics, alcohol or other drugs or " substances which may alter the individual's behaior.modified b is not met as evidenced by: by: ince a This o n ot et Based on record reviews and interviews, the .agency failed to obtain " Freedom of Habituation I to Drugs and Alcohol " statements and annual health assessment from employees. This was evident for 3 of 4 personnel files reviewed. ( Emnployees # 1, 2 and 3) Failure of the agency to ensure that all employees are free from the habituation or addiction to depressants, stimulants, narcotics, alcohol or other drugs or substances which may alter the individual's behavior places all patients at risk for unsafe care. The findings are: The Personnel files for Employees #1 ,2 and #3 did not include documentation of statements that the employees are "free of habituation or addiction to depressants, stimulants, narcotics, alcohol or other drugs or substances which may alter the individuals's behavior." The personnel files for Employee # 1 ( Home Health Aide) and Employee # 3 ( Registered Nurse) do not include health assessments health status assessment on file for Emplojee # 1 Is "5/31/06". datedOn ./16.7Date Manager On 11/16/07 at 3:00pm, the Operations was interviewed and was unable to provide an explanation. kTE FORM 021199 Z97411 Ifcontinuation sheet 19 of 20 FKIN IL: FORM APPROVED 1Z/14/ UU/ New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED 1086L003 "N_ OF PROVIDER OR SUPPLIER B.WING STREET ADDRESS, CITY, STATEiZIP CODE 11116/2007 PREMIER HOME HEALTH CARE SERVICES. INC. (X4) ID PREFIX TAG 1800 WHITE PLAINS ROAD BRONX, ny 10462 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATEDEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H'1306 Continued From Page 18 H1306 impairment which is of potential risk to the patient or which might interfere with the peFormance of his/her duties, including the habituation or addiction to depressants, stimulants, narcotics, alcohol or other drugs or substances which may alter the individual's . behavior. This Rule is not met as evidenced by. Based on record reviews and interviews, the agency failed to obtain " Freedom of Habituation to Drugs and Alcohol " statements and annual health assessment from employees. This was evident for 3 of 4 personnel files reviewed. ( Employees # 1,.2 and 3) Failure of the agency to ensure that all employees are free from the habituation or addiction to depressants, stimulants, narcotics, alcohol or other drugs or substances which may alter the individual's behavior places all patients II. How to identify other client's " having the potential to be affected by the same deficient practice and what corrective action will be taken. All remaining employees will complete the updated Annual Health Assessment Form (E125) during the 2008 calendar o year at their scheduled yearly due date. All potential employees will complete an updated Pre-employment Physical (El 11) Parties responsible for the correction and ensuring continued compliance: Employment Coordinators, Field Nurse Supervisor, Director of Patient Services, Office Administrator, and Celestina Cruz, RN- Vice President of Clinical Services. Date of Completion: 2/4/08 . at risk for unsafe care. The findings'are: The eAll The Personnel files for Employees #1 ,2 ard #3 did not include documentation of statements that the employees are "free of habituation or addiction to depressants, stimulants, narcotics, alcohol or other drugs or substances which may alter the individuals's behavior." The personnel files for Employee # 1( Home " Health Aide) and Employee # 3 ( Registered Nurse) do not include health assessments health status assessment on file for Employee # 1 is . dated "5/31/06'". On 11/16/07 at 3:00pm, the Operations Manager was interviewed and was unable to provide an explanation. STATE FORM o2i1" f1. Measures that will be put in place to ensure eu the deficient practice wl o that will not recur Office staff will be re in-serviced on Policy #9.7, #9.8, and the updated PreEmployment Physical (El 11) and the upate Annual ealth assssen p(E125), thatare located in the forms ' 1 directory. Parties responsible for the correction and ensuring continued compliance: Employment Coordinators Field Nurse Supervisor, Director of Patient Services, Office Administrator, and Celestina Cruz, RN- Vice President of Clinical Services. Date of Completion: 2/4/08 Z9741 1 Ifcontinuation sheet 19 of 20 rmiiuI' FORM APPROVED L. 14j iQI4UI ew York State.Department of Health rATEMENT OF DEFICIENCIES 4D PLAN OF CORRECTION (Xl) PROVIDERISUPPLIERJCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING . __________ (X3) DATE SURVEY COMPLETED 1086L003 -OF 1111612007 STREET ADDRESS, CITY. STATE, ZIP CODE PROVIDER OR SUPPLIER , REMIER HOME HEALTH CARE SERVICES, INC. X4) ID 'REFIX TAG 1800 WHITE PLAINS ROAD BRONX, ny 10462 A" ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF. DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTfFYING INFORMATION) .H=1306 Continued From Page 18 H1306 IV. How the corrective action will be monitored to ensure the deficient practice will not recur 25% of the employee personnel files will be audited monthly for the presence and completion of the updated PreEmployment Physical (El 11) and the updated Annual Health Assessment ( E125) that refer to the statement free from habituation or addiction to depressants, stimulants, narcotics, alcohol, or other drugs or substances t r bhio behavior. Parties respOnsible for the correction and ensuring continued compliance: Emrployment Coordinators, Field Nurse Supervisor, Director of Patient Services, Office Administrator, and Celestina Cruz, RN- Vice President of Clinical Services. Date of Completion: 4/4/08 impairment which is of potential risk to the patient or which might interfere with the perormance of his/her duties, including the habituation or addiction to depressants, stimulants, narcotics, alcohol or other drugs or substances which may alter the individual's behavior. This Rule is not met as evidenced by: Based on record reviews and interviews, the agency failed to obtain " Freedom of Habituation to Drugs and Alcohol " statements and annual . health assessment from employees. This was evident for 3 of 4 personnel files reviewed. Employees # 1, 2 and 3)Paterepnilfothcreto' Failure of the agency to ensure that all employees are free from the habituation or addiction to depressants, stimulants, narcotics, . alcohol or other drugs or substances which may alter the individual's behavior places all patients at risk for unsafe care.. The findings are: - The Personnel files for Employees #1 .2 and #3 did not include documentation of statements. Dawn Brill, RN that the employees are "free of habituation or addiction to depressants, stimulants, narcotics, Vice President of Regional Operations- North East alcohol or other drugs or substances which may alter the individuals's behavior." The personnel files for Employee# 1( Home Health Aide) and Employee # 3 ( Registered Nurse) do not include health assessments health status assessment on file for Employee # 1 is dated "5/31/06". On 11/16/07 at 3:00pm, the Operations Manager was interviewed and was unable to provide an explanation. ,TE FORM 21I9 IZ97411 _ Ifcontinuation sheet 19of20. New York State DeDartment of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION 4 PRINTED: 12/14/2007 FORM APPROVED (X2) MULTIPLE CONSTRUCTION .A. (Xl) PROVIDERJSUPPLIERJCLIA IDENTIFICATION NUMBER: BUILDING -_. (X3) DATE SURVEY COMPLETED 1086L003 N, ...- OF PROVIDER OR SUPPLIER B. WING. 11/16/2007 STREET ADDRESS, CITY, STATE, ZIP CODE PREMIER HOME HEALTH CARE SERVICES. INC. (X4) ID PREFIX TAG BRONX, ny 10462 1800 WHITE PLAINS ROAD ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ( (X5) COMPLETE DATE H1306 Continued From Page 19 H1306 ;TATE FORM 0219 Z9741 1 Ifcontinuation sheet 20 of 20 STATE OF NEW YORK DEPARTMENT OF HEALTH S,,Metropolitan Area Regional Office 90 Church Street, New York, NY 10007 Richard F. Daines M. D. Commissioner January 17, 2008 Ms. Robert Silbering, Trustee/Chairman of the Board Brooklyn CHHA Grantor Trust President & Chief Executive Officer Forensic Investigative Association, Inc.. 230 Park Avenue, Suite 422 New York, NY 10169 Re: Family Care Certified Services Provider # 337-7264 Survey Date: 1115, 11/6, 11/7, 11/8, 11/9, 11/13107 Dear Mr. Silbering: Please be advised that the Plan of Correction relating to the recent Article 36, Medicaid/Medicare survey of your certified home health agency has been reviewed by this office. All items were found to be acceptable and it is expected that you will implement this plan within the time fram'es that were submitted. A post approval review will be conducted to verify the correction of deficiencies cited. If you have any questions regarding this matter please do not hesitate to contact this office at (212) 417-5888. Sincerely Cheryl Phoenix-Tannis RN, MSN, CS Program Manager Home Health and Hospice Services .Metropolitan Area Regional Office cc: Deborah Walsh, Administrator Galina Sirota; Director of Patient Services I- DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIERCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING PRINTED: 12/05/2007 FORM APPROVED 0MB NO. 0938-0391 CX3 P SURVEY DAT 337264 NAME OF PROVIDER OR SUPPLIER B.WING STREET ADDRESS, CITY, STATE, ZIP CODE 405 91ST STREET 11/13/2007 FAMiLY CARE CERT SERVICES OF BROOKLYN QUEENS (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID ,PREFIX TAG BROOKLYN, NY 11209 PROVIDER'S PLAN OF CORRECTION ACTION SHOULD BE (EACH CORRECTIVE TO THE APPROPRIATE CROSSREFERENCED DEFICIENCY) (X51 COMPLETION DATE G 000 INITIAL COMMENTS '. G 000 A standard recertification survey was conducted on 11/5/07, 11/6/07, 11/7/07, 11/8/07, 11/9/07, and 11/13/07 at Family Care Certified Services. Twenty five (#1-25) clinical records were reviewed. Ten (10) home visits were conducted for ten (10) patients #2, #3, #4, #6, #7, #8, #9, #10, #11, and. #12. Ten (10) personnel files #1-10 were reviewed. G 118 484.12(a) COMPLIANCE WITH FED, STATE, LOCAL LAWS The HHA and its staff must operate and furnish services in compliance with all applicable Federal, State, and local laws and regulations. If State or applicable local law provides for the licensure of HHAs, an agency not subject to licensure is approved by the licensing authority as meeting the standards established for licensure. This STANDARD is not met as evidenced by: Based on clinical record review, and agency personnel interview, the agency failed to ensure that home health aides employed by the agency possessed valid Certification, references and physical assessments.This was evident for (1) one of (4) personnel records reviewed. (Employee #6) Failure to ensure home health aide certification requirements, employee references, and employee health assessments has the potential to place agency patients at risk for care to be provided by unqualified personnel: SIGNATURE LABORATORY DFEC9,-R'S 0 PROVIDER/SUPPLIER REPRESENTATIVE'S TITLE G 118 (X6) DATE itis determinedthat which the institution may be excused from correcting providing ficiency statement ending with an asterisk (*) denotes a deficiency above are disclosable 90 days (See instructions.) Except for nursing homes, the findings stated .afeguards provide sufficient protection to the patients. o, of correction are disclosable 14 is provided, For nursing homes, the above findings and plans following the date of survey whether or not a plan of correction an approved plan of correction is requisite to continued to the facility. If deficiencies are cited, days following the date these documents are made available program participation. I FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q1X1 11 Facility ID: 4096 If continuation sheet Page 1 of 9 )EPARTMIENT OF HEALTH AND HUMAN SERVICES ;ENTERS FOR MEDICARE & MEDICAID SERVICES TATEMENT OF DEFICIENCIES AND 'LAN OF CORRECTION PROVIDER/SUPPLIERCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING 337264 'AME OF PROVIDER OR SUPPLIER FAMILY CARE CERTIFIED SERVICES OF BROOKLYN/QUEENS (X4),ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B. WING 11/1312007 (X3) DATE SURVEY COMPLETED PRINTED: 12/5/2007 FORM APPROVED OMB NO. 0938-0391 STREET ADDRESS, CITY, STATE, ZIP CODE 405 91 5T STREET BROOKLYN, NY 11209 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY). (X5) COMPLETION DATE s G 118 o 11/1312007 Employee #6 was removed from the case and a replacement Home Health Aide " I . was assigned. 1/31/2008 o Two additional Home Health will be hired Aide Coordinators (one is currently in training) by January 31, 2008, in order to more closely monitor Home Health Aide profiles and certificates. A new profile request form was developed (attachment #1) and will be faxed to the licensed agency providing the Home Health Aide. No Home Health Aide will be permitted to work on a case until the profile is received, reviewed and approved by Family Care Certified Services. * A new policy was written 1/15/2008 (attachment #2).and sent to all licensed vendor agencies (attachment #3). The policy will be initiated by January 15, - 2008. * Ten Home Health Aide vendor agencies per quarter will receive on-site surveys by the Clinical Care Manager of the department to review ten - 12/31/2007 complete personnel files. Tool * to be developed by December 31, 2007. Results will be submitted to the Performance Improvement department and results analyzed. First Performance Improvement quarter report due May 15, 2008. Ongoing 5/15/2008 .. surveillance planned quarterly. FORM CMS-2567 (02-99) Previous Versions Obsolete Event ID: QX11i Facility ID: 4096 Page I PRINTED: 12/5/2007 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PROVIDER/SUPPLIERCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. 'BUILDING (X3) DATE SURVEY* COMPLETED FORM APPROVED OMB NO. 0938-0391 337264 NAME OF PROVIDER OR SUPPLIER FAMILY CARE CERTIFIED SERVICES OF BROOKLYNIQUEENS (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B. WING 11113/2007 STREET ADDRESS, CITY, STATE, ZIP CODE 405 9 1 ST STREET BROOKLYN, NY 11209 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE G 143 o Patient #7 - On November 8, 2007 a PRN visit was made. An 02 safety precaution poster was placed in the home. Instruction was given to the patient and caregivers and documented in the patient's record. The Home Health Aide Plan of Care was corrected to include 02 safety and 11/8/2007 precautions. On November 15, 2007, the Performance Improvement monthly presentation on 02 -safety and precautions was conducted as already scheduled. A copy of the education material (attachment #4) was sent to all patients and clinicians. -During the November 29, 2007 11/15/200' 11/15/200 * 11/29/200 case management meeting #5) the case (attachment managers were in-serviced regarding monitoring documentation of 02 safety and precautions by the field staff. During the December 20, 2007 12/20/20C case management meeting (attachment #6) planned monitoring of the Home Health Aide Plan of Care will be reinforced. A compiled list 11/20/20( (done on November 20, 2007) of all patients receiving home '02 therapy was given to the Performance Improvement department. A tool was. 12/12/20( developed (attachment #7) and will be used to monitor 50% of patients on 02 therapy quarterly for one year. The first report is - 5/15/200 due on May 15, 2008. 4 FORM CMS-2567 (02-99) Previous Versions Obsolete Event ID: Q1Xl 11 Facility ID: 4096 Page 2 PRINTED: 12/5/2007 DEPARTMENT OF HEALTH AND*HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PROVIDEP/SUPPLIERCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CQUSTRUCTION A. BUILDING 337264 B!, WING 1111312007 (X3) DATE SURVEY COMPLETED FORM APPROVED 0MB NO. 0938-0391 NAME OF PROVIDER OR SUPPLIER FAMILY CARE CERTIFIED SERVICES OF BROOKLYN/QUEENS (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) STREET ADDRESS, CITY, STATE, ZIP CODE 40591 STREET BROOKLYN, NY 11209 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE G 143 o Patient #8 - On November 7, 11/7/2007 2007 a PRN visit was made at the change of shift to supervise the care provided by the Home Health Aide. Documents were reviewed after the visit and the RN gave in-service to the aide in T + P and leg elevation. The November 20, 2007 and December 7, 2007 mandatory in-service of the field staff reinforced the agency policy 11/20/2007 12/7/2007 regarding Home Health Aide supervision when dealing with 2 hours shifts and supervision of night time Home Health Aides (attachment #8). A memo was sent to all field staff on December 17, 2007 12/17/2007 o reinforcing the policy (attachment #9). The December 20, 2007 case . manager meeting will reinforce the policy (attachment #6). A chart review tool was developed (attachment #10) and will be utilized by the Performance Improvement department to monitor 25% of patients with night time Home Health Aides. The first report will be due May 15, 2008 for the first quarter project and will continue with information for the second quarter of 2008 and - 12/20/2007 12/12/2007 5/15/2008 reassessed. . FORM CMS-2567 (02-99) Previous Versions Obsolete Event ID: Q1Xl 11 Facility ID: 4096 Page 3 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PROVIDER/SUPPLIERJCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING - PRINTED: 12/5/2007 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED 337264 B. WING 1111312007 NAME OF PROVIDER OR SUPPLIER FAMILY CARE CERTIFIED SERVICES OF BROOKLYN/QUEENS (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) STREET ADDRESS, CITY, STATE, ZIP CODE 405 91S1 STREET BROOKLYN, NY 11209 PROVIDER'S PLAN OF CORRECTION ID , PREFIX TAG (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) DATE . COMPLETION G 143 o 11/6/2007 Patient #8 - On November 6, 2007 case manager called Dr. Asbel to clarify medication changes as observed during the visit. The medication sheet was - updated and physician's verbal sent and signed orders were (attachment#11). The Community Health Nurse was counseled on (attachment #12) 11/6/2007 November 6, 2007 and a supervisory visit was made to follow up on medication assessment with management. Field Community Health Nurses 11/20/200" were in-serviced on November 12/7/2007 20, 2007 and December 7; 2007 #8) regarding (attachment medication management and assessment and the importance of reporting changes to the case manager and/or the MD and' * documentation of same. A memo was also sent.(attachment #9) 12/17/200 dated December 17, 2007 Certified reinforcing Family Care -Services policies on medication management (attachment #13); a medication management tool was sent with the memo. The case management staff will' be in-serviced at the December 12/20/200 20, 2007 meeting regarding the of asking the importance Community Health Nurses if there were any medication changes during the client case conference. A tool will be 12/31/20C created by December 31, 2007 to monitor compliance via home visits by supervision; ten patients per quarter will be monitored. Data will be submitted to the Performance Improvement Department for analysis. The 51 2 first quarter data report is due 5/15/200 , -May 15, 2008. - FORM CMS-2567 (02-99) Previous Versions Obsolete Event ID: Q1X111 Facility ID: 4096 Page 4 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PROVIDERISUPPLIER/CLIA, IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING 337264 NAME OF PROVIDER OR SUPPLIER FAMILY CARE CERTIFIED SERVICES OF BROOKLYNIQUEENS (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B. WING o PRINTED: 12/5/2007 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED 11/13/2007 STREET ADDRESS, CITY, STATE, ZIP CODE S STREET BROOKLYN, NY 11209 4 0 5 91 T ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) * (X5) COMPLETION DATE G 143 * * 11/12/2007 Patient #17 - Case manager was counseled on November 12, 2007 regarding proper documentation of discharge planning and conversion follow up (attachment #14). As of 12/14/2007 December 14, 2007 patient's M11Q was sent to MD. The M27R is completed. The December 20, 2007 case 12/20/2007 management meeting will reinforce proper discharge planning protocol and documentation requirements (attachment #6). A tool was developed to monitor compliance (attachment #15). ThePerformance Improvement department will perform chart reviews. Reviews will consist of twenty-five discharge charts per,quarter. The first report is due, \5/15/2008 May 15, 2008. FORM CMS-2567 (02-99) Previous Versions Obsolete Event ID: QIX1 11 Facility ID: 4'096 Page 5 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PROVIDER/SUPPLIERJCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A., BUILDING 337264 NAME OF PROVIDER OR SUPPLIER FAMILY CARE CERTIFIED SERVICES OF BROOKLYN/QUEENS (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B. WING 11/13/2007 (X3) DATE SURVEY COMPLETED PRINTED: 12/5/2007 FORM APPROVED OMB NO. 0938-0391 STREET ADDRESS, CITY, STATE, ZIP CODE 405 9 1 ST STREET BROOKLYN, NY 11209 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) * (X5) COMPLETIOI DATE G 143 o o * Patient #14 -The Physical Therapist was counseled regarding proper documentation of discharge (attachment #16). A summary note was done on the patient and added to the patient's medical record (attachment #17). An in-service is scheduled for the end of January 2008 for all therapy staff. Agenda to include proper discharge planning. Documentation and use of discharge summary note to reflect summary of care and goals met. A memo was also sent on December 12, 2007 reinforcing documentation requirements stated above (attachment #18). At the December case management meeting (attachment #6) proper discharge planning in conjunction with all service Will be reinforced. A tool will be developed by the Rehabilitation department supervisor to monitor compliance with discharge planning and use of discharge summary note. The Performance Improvement department will monitor twelve discharge charts per quarter times two quarters. First Performance Improvement report is due May 15, 2008. 1/31/200 12/12/20C 1/15/200. 15o2- FORM CMS-2567 (02-99) Previous Versions Obsolete Event ID: Q1 X111 Facility ID: 4096 page 6 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PROVIDER/SUPPLIERJCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTIONA. BUILDING 337264 NAME OF PROVIDER OR SUPPLIER FAMILY CARE CERTIFIED SERVICES OF BROOKLYNIQUEENS SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B.. WING 11/1312007 (X3) DATE SURVEY COMPLETED PRINTED: 12/5/2007 FORM APPROVED OMB NO. 0938-0391 - STREET ADDRESS, CITY, STATE, ZIP CODE 405 9 1 S T STREET BROOKLYN, NY 11209 ID PREFIX' TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE (X4) ID PREFIX TAG G 143 o o Patient #20 - Physician's MD order dated June 18, 2007 was signed (attachment #19). Case manager was counseled regarding the importance of obtaining signed MD orders in a timely manner (attachment #20). Home Care Case Manager meeting is planned for December 20, 2007. All case managers to reinforce the importance of obtaining MD Verbal orders in a timely manner (attachment #6). 6/18/2007 12/20/2007 Tool was developed to monitor submission of signed MD verbal orders (attachment #21). Performance Improvement will A review fifty charts per month every quarter. First report due May-15, 2008. G 158 o Patient #8 - The Community Health Nurse was counseled o November 6, 2007 (attachment #12). Clinical supervisor conducted a supervisory visit on November 9, 2007 to reinforce wound procedure with Community Health Nurse and check on patient's clinical status no wound infection observed. Community Health Nurse will receive an additional supervisory visit by clinical supervisor before December 31, 2007. A memo was sent to all field Community Health Nurses on December 12, 2007 (attachment #9) reinforcing wound care policy and proper wound technique. A mandatory in-service was conducted on November 20, >/15/2008 11/6/2007 1119/2007 12/31/2007 * 12/12/2007 o 2007 and December 7, 2007 (attachment #8) to reinforce wound procedure. 11/20/2007 12/7/2007 FORM CMS-2567 (02-99) Previous Versions Obsolete Event ID: QXl11- Facility ID: 4096 Page 7 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PROVIDERISUPPLIER/CLIA IDENTIFICATION NUMBER: PRINTED: 12/5/2 FORM APPROVE OMB NO.: 0938-0 (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY ( COMPLETED '-_'_'___ 11/13/2007 337264 NAME OF PROVIDER OR SUPPLIER FAMILY CARE CERTIFIED SERVICES OF BROOKLYN/QUEENS (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 405 91ST STREET BROOKLYN, NY 11209 ID PROVIDER'S PLAN OF CORRECTION . PREFIX (EACH CORRECTIVE ACTION SHOULD BE TAG CROSS-REFERENCED TO THE APPROPRIATE (X5) COMPLET DATE G 158 o Patient #8 (continued) - A tool DEFICIENCY) to monitor compliance with wound care will be developed by December 31, 2007. Ten 12/31/2C home visits will be made quarterly by the clinical supervisorusing the tool to monitor wound procedure compliance. The data will be submitted to the Performance Improvement department. Data will be collected for two quarters. First report de M A 5/20( 15, 2008. FORM CMS-2567 (02-99) Previous Versions Obsolete Event ID: QlX1 11 Facility ID: 4096 Page 8 STATE OF NEW YORK DEPARTMENT OF HEALTH Metropolitan Area Regional Office 90 Church Street, New York, NY 10007 ,ichard F.Daines ;ommissioner Wendy E.Saunders , Chief of Staff .February 12, 2008 Mr. Kenneth P. Kilroy VP/Administrator Progressive Home Health Services, Inc 132 West 31 Street, 7 th Floor NewYork, NY 10001 Re: Response to Plan of Correction Survey Date: February 16, 2007 License: 1348L001 Dear Mr. Kilroy: Please be advised that the plan of correction relating to the recent Article 36, survey of your agency have been reviewed by this office. All items were found to be acceptable and it is expected that you will implement this plan within the time frames that were submitted. A post approval review will be conducted to verity the correction of deficiencies. If you have any questions regarding this matter, please contact (212) 417-5888. Sincerely, Cheryl Phoenix-Tannis, RN. MSN, CS Program Manager Home Health and HospicesServices Metropolitan Area Regional Offices. PRINTED: 09/27(2007 FORM APPRO\vED New York-State Department of Health 0-.TEMENT OF DEFICIENCIES PLAN OF CORRECTION (XI) PROV1DERJSUPPLIERJCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING __ _ _ _ _ _ _ _ (X3) DATE SURVEY COMPLETED 1348L001 NAME OF PROVIDER OR SUPPLIER B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 02/1612007 PROGRESSIVE HOME HEALTH SERVICES. INC. (X4) ID PREFIX TAG 132 WEST 31STSTREET. 7TH FL. NEW YORK,.NY 10001 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H 000 Initial Comments H 000 A full survey and complaint investigation 766.5(b)(4) Clinical Supervision (#07-01-50071) was conducted on 02/15/07 and 02/16/07. In addition, off-site telephone interviews were conducted on 2121/07 due to the complaint investigation. During the survey five (5) patient care records (identified #1 - #5) and eleven (11) personnel records were reviewed (identified #1 - #11 ). H 620 766.5(b)(4) Clinical supervision 766.5 Clinical supervision. The governing authority shall ensure for all health care services that (b) all staff delivering care in patient homes are (dq l sShould The department shall adequately supervised. consider the following factors as evidence of adequate supervision: ...... (4) plans of care are revised as needed and (b) all staff delivering care in patient homes are adequately supervised. Kind Care has instituted the following to better address the adequacy of Clinical supervision regulation: Home attendants will continue to be oriented to the Plan of Care by Kind Care Nursing Staff. A replacement home attendant is considered any home attendant that has not serviced the'patient within six (6) months. A schedule of Kind Care Nursing Staff on duty has been developed to ensure that there is a nurse available at all times in the-office and during off hours. the Kind Care Nursing Staff assigned. be absent or out of the office, arrangements are made in advance to ensure coverage. H 620 06/25/07 Coordination staff is responsible for informing the Kind Care Nursing Staff of the replacement via a Replacement Orientation changes are reported to the patients authorized practitioner, other staff providing care to the patient, and other agencies which authorize payment for services, as appropriate and necessary. This Rule is not met as evidenced b Based on clinical record review and interviews, the agency failed to supervise and ensure that the aide plan of care (developed by the skilled nurse to direct the paraprofessional staff in the care and services to provide to the patient) is complete, accurate and reviewed/revised as necessary, to address changes in the patient' s - Form (Attachment A). The coordination staff will submit a Daily Replacement List (Attachment B) to the Data Entry Liaison for the replacements that the Kind Care NursingStaff received. Once the Kind Care Nursing Staff completes the orientation, the Replacement Orientation Forms are given to the Data Entry Liaison. The Data Entry Liaison will then verify that a Replacement Orientation Form has been received for every patient on the Daily Replacement List. Ifthere is a discrepancy, the Data Entry Liaison will inform the Kind Care Executive Director or the Assistant Director of Field Operation who will then condition. This was evident for (1) of five (5) Clinical records reviewed, Failure to ensure complete and accurate aide. ensure'that a replacement orientation is conducted for the patient inquestion. ,"/ ZGT011 ' If colnuation tet1Of 7 PRINTED: 09/272007 FORM APPROVED New York State Department of Health -TATEMENT OF DEFICIENCIES 'D PLAN OF CORRECTION (Xl) PROVIDERISUPPUERJCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION . BUILDING __________ B. WING (X3) DATE SURVEY. COMPLETED 1348L001 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE 02/16/2007 PROGRESSIVE HOME HEALTH SERVICES, INC. (X4) ID PREFIX TAG 132 WEST 31STSTREET. 7TH FL NEW YORK, NY 10001 IO PREFIX TAG PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H 620 Continued From Page 1 Plan of Care that directs the paraprofessionals in caring for patient, has the potential for the patient to receive inadequate /inappropriate care and poor patient outcomes. The finding is: Patient#5 was admitted to the agency on 04/06/05 with diagnoses of Hypertensiar_....... Glaucoma, Dementia, Coronary Artery Disease, and Depression. The clinical record documents that the patient was discharged from the agency on 11/7106. The Medical Request for Home Care (Form M-11 q) dated 11/30/05 documents that the patient required assistance with personal care and housekeeping services. The clinical record documents that the patient received home attendant services seven days/week twenty-four hours/day. The agency provides home attendant services under contract with the New York City Department of Social Services of the Human Resources Administration. The Nurse 's Assessment Visit Report dated 9/20G6 documentsthat patient was "confused";. duesmtatient edd "patient's had0" had "impaired judgement, needed prompting/.ueing with all activities", was "incontinent of bladder/bowel", and required "total assistance" with personal care. The record documents that the patient could "not be alone in the home." The aide Plan of Care (POC) dated 9/20/06 documents that the patient required total assistance with personal care needs and that the patient was on'a "low salt puree diet. The aide POC also directs the home attendant to report changes." - H 620 The Replacement Orientation Form is filed in the patient's chart by the Data Entry Liaison. All home attendants are being advised through initial orientation and at inservices that if they are working as a replacement aide and if they do not hear from the Kind Care Nursing Staff within an hour of their start time, they should contact the office immediately and request to speak with the Kind Care Nursing Staff. The Kind Care Executive Director will be responsible for implementing this Plan of Correction. 11/05/07 11/05/07 (4) Plans of Care are revised as needed and changes are reported to other agencies which authorized payment for services. All Kind Care Nursing Staff have received additional training from the Assistant Director of Nursing, in a clinical meeting and during ongoing individualized sessions. Emphasis has been place on the review of medication and body systems during patient assessments. When there is a change in the condition or medication, the Plan of Care must be revised to reflect this change. The Plan of Care is reviewed during every quarterly patient visit. Each Kind Care Nursing Staff must sign off that the Plan of Care has been reviewed. Where there is no change, the Kind Care Nursing Staff will write 'no change" and sign the Plan of Care. The visit paperwork is then submitted to the Assistant Director of Nursing or designee for a clinical review. 06/25/07 06/25/07 S *'FEFeRMl PRINTED: 09/27/2007 FORM APPROVED New York State Department of Health ':;TATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (X1) PROVIDER/SUPPLIERICLIA IDENTIFICATION NUMBER: (X2) MULTIRLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED 1348L001 NAME OF PROVIDER OR SUPPUER B. WING 02/1612007 STREET ADDRESS, CITY, STATE, ZIP CODE PROGRESSIVE HOME HEALTH SERVICES, INC. (X4) ID PREFIX TAG 132 WEST 31STSTREET, 7TH FL. NEW YORK, NY 10001 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (x5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H 620 Continued From Page 2 H 620 The Client Notes dated 11/07/06 documents that the home attendant reported on 11/06/06 that the The Assistant Director of Nursing or designee will review the paperwork to ensure that the patient "died ir the bed." In a complaint received by the Department of Health (DOH), the complainant alleges that the "Home Attendant (HAl) was trained by the ifamil t y e prevo us Aided (HA ) a t previous aide (HA) and the family to add Plan of Care matches the Kind CareNursing Staff assessment, and that the Plan of Care reflects the Scope of Tasks for a home attendant. If there is a discrepancy, the Assistant Director of Nursing or designee will contact theKind Care Nursing Staff. Should changes be necessary, the Kind Care chair dead. " . HAI was present and stated that .the patient "had been cool for a while." The complainant stated that it was the family member that called 911. Thick-it to Ensure when feeding the patient. HA1 did not add the Thick-it which resulted in the patient' s dead due to aspiration of Ensure." The complaint also alleges that a family member "came home to find" the patient "sitting in a Nursing Staff will be responsible for updating the Plan of Care and ensuring that the patient and home attendant are aware of the. changes. A revised Plan of Care is left in the patient's home for home attendant use. The Assistant Director of Nursing or designee will continue to reinforce with the Kind Care Nursing Staff the importance of reporting and recording changes in patient's status. This 10/01/07 On 01/25/07, the Medical Examiner from the was aspiration of Ensure." will occur at the next quarterly clinician meeting. In addition, during the Annual Regulatory Compliance Inservice held in April 2007 June 2007, special emphasis was placed on New York City Medical Examiner' s Office notified DOH that the patient' s "cause of death 07/10/07 On 02/16/07 at 2PM, the skilled nurse (SN), who supervised the aide and prepared the aide plan of care was interviewed and stated that the patient was "on puree diet including Ensure". However, the SN was unable to state whether the patient was on aspiration precaution or if the aide added Thick-It to the patient' s juice and Ensure. The Clinical review record including the the home attendants calling in and reporting changes. The home attendants are being encouraged to report any requests from family members, patients, other nurses or doctors involved with their patient that would involve a task that is not part of the Plan of Care. This is being reinforced at every inservice session held throughout the year and with every clinical contact. The Assistant Director of Nursing will be responsible for this corrective action and aide plan of care did not document that the patient's diet included Ensure. A telephone interview was conducted on ensuring continued compliance. 02/21/07at 1PM with the Assistant Director of Nursing, Incident Supervisor, and the Horne Attendant (HA1) who was present in the home at the time of the patient' s death. The HAI stated that she was the "replacement aide" who 6Sl*IE-Fe~i - New York State Department of Health S;TATEMENT OF DEFICIENCIES JD PLAN OF CORRECTION (Xl) PROVIDER/SUPPUERJCLIA IDENTIFICATION NUMBER: " (X2) MULTIPLE CONSTRUCTION A BUILDING __________ PRINTEb: 09127/2007 FORM APPROVED " (X3) DATE SURVEY COMPLETED 1348L001 NAME OF PROVIDER OR SUPPLIER B.WING STREET ADDRESS, CITY, STATE, ZIP CODE 02/1612007 PROGRESSIVE HOME HEALTH SERVICES, INC. (X4) ID PREFIX TAG 132 WEST 31STSTREET. 7TH FL NEW YORK, NY 10001 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H 620 Continued From Page 3 provided service on 10129/06, 11/04/06, 11/05/06, and 11/06/06 and the patient required total care which included turning and reposition and feeding the patient ( who was on a liquid/puree diet including Ensure.) HA1 stated that she "did not receive any instructions from the agency regarding the aide Plan of Care" nor did she receive "instructions regarding adding Thick-it to liquids including Ensure." In the Employee Statement dated 2/21/07, HAI reported that "on 11/06/06 she "gave the client a bed bath in the morning and turned the client every two hours. The client was fed a liquid puree diet that was prepared by the client' s daughter. The client may have used a sippy cup to dnnk her meals. The cfient did not choke or spit up the meal." HA1 reported that she "raised the bed" when she fed the client "About an hour after turning the client, the daughter came to. check on her mother. When the daughter touched her, she stated that her mother felt cold. 911 was called." On 2121/07 at 3PM with the Administrator,. Director, Assistant Director of Nursing, and the regularly assigned Home Attendant (HA2) were interviewed. HA2 stated that she provided care to the patient from April2005 to November 03, 2006 andthe patient "required total care including feeding". She further stated that the patient was on a "liquid puree diet including Ensure" and she "started adding Thick-it to the patient' s juice andEnsure after the patient' s was hospitalized in October 2006." HA2 stated that "after the hospitalization, the patient' s daughter said that the doctor recommended a Gastric Tube (G-Tube) insertion for the patient and that the family had refused." HA2 added that since the family refused to insert the G-Tube, the doctor ordered that the patient be H 620 Page intentionally left blank. skg C,. 2O 5 PRINTED: 09/27/2007 FORM APPROVED New York State Department of Health qTATEMENT OF DEFICIENCIES \ID PLAN OF CORRECTION (X1) PROVIDERSUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A.BUILDING _____ ____ (X3) DATE SURVEY COMPLETED 1348L001 NAME OF PROVIDER OR SUPPLIER B.WING STREET ADDRESS, CITY. STATE, ZIP CODE 0211612007 PROGRESSIVE HOME HEALTH SERVICES, INC. (X4) I0 PREFIX TAG 132 WEST 31STSTREET. 7TH FL. NEW YORK, NY 10001 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (x5) COMPLETE 'DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H620 Continued From Page 4 placed on Thick-it due to the "patient' s swallowing problem" which included choking 'and coughing while eating. HA2 added that the daughter was given a packet of Thick-It at the hospital and later purchased additional packets. HA2 said that the patient' s daughter gave instructions on how to use the Thick-it and she complied by adding Thick-it to the patient' s juice and Ensure. HA2 stated that she also instructed to HA1 on how to use Thick-it. In the Employee Statement dated 02/21/07 (received by DOH on 02/26/07), HA2 reported that " most of the time she fed the client and it. was an all day process. The client was fed spoonfuls while sittingup in bed. " HA2 also reported that she advised the replacement aide (HAI) on the patient' s needs. The clinical record documents that the patient was hospitalized on 10/10/06. The clinical record titled Client Notes dated 10/12/06 documents: client ready for hospital discharge 10113/06 at 11AM ...P/U (pick-up)." The record failed to document any communication with the hospital regarding any changes in the patient' s plan of care. The clinical record also lacked documentation that HA2 reported any changes to the agency after the patient was discharged from the hospital. Additionally, a review of the Replacement Flow Sheet which documents supervision of replacement HA failed to document that the agency provided any supervision to HAl. On interview of 02/20/07, the Assistant Director of Nursing(DON) stated that it was the responsibility of the hospital to inform the agency of any changes in the patient care that required a revision in the plan of care. . The Assistant DON added that hospital did not inform theagency of H620 Page intentionally left blank. . . ',, .. .. Mal , PRINTED: 09/27/2007. FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES NO PLAN OF CORRECTION (XI) PROVIDERJSUPPLER/CLIA IDENTIFICATIONNUMBER-(X2) MULTIPLE CONSTRUCTION A. BUILDING __ (X3) DATE SURVEY COMPLETED 1348L001 NAME OF PROVIDER OR SUPPUER B, WING STREET ADDRESS, CITY, STATE, ZIP CODE NEW YORK, NY' 10001 02/1612007 PROGRESSIVE HOME HEALTH SERVICES. INC. (X4) ID PREFIX TAG 132 WEST 31STSTREET._7TH FL ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DERCIENCY) (XS) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H 620 Continued From Page 5. any changes. H 718 766.6(a)(8) Patient care record 766.6 Patient care record. (a) The agency shall maintain a confidential record for each patient admitted to care to include: (8) documentation of accidents and incidents. This Rule is not metas evidenced by. Based on review of clinical records, agency policy and procedure, and interviews with agency staff, the agency failed to ensure that an incident was investigated with a completed report. This was evident for one (1) of five (5) clinical records reviewed (Patient #5). Failure of the agency to ensure the. documentation of accidentsincidents places the patients at risk for receiving unsafe and poor quality of care. The finding is: Patient#5 was admitted to the agency on' 04/06/05 with diagnoses of Hypertension, Glaucoma, Dementia, Coronary Artery Disease, and Depression. The Client Notes dated 11/07/06 documents: " 11/6106 @ 6PM - aide called to report that the client passed away half hour ago. She said the police and the family are there. Aide said the client passed in her bed." The clinical record documents that the patient received home attendant services seven days/week twenty-four hours/day. . H 620 H 718 7666a)(8) Patient care record 766.6 Patient care record (a) the agency shall maintain a confidential record of each patient admitted to care to include: (8) documentation of accidents and incidents. All staff are responsible for, and encouraged to, report incidents. Kind Care will be using the same incident policy followed by Progressive Home Health Services, Inc. All Kind Care Staff, including off hours staff, were retrained on the incident policy to ensure appropriate reporting and documentation of all incidents, including deaths. The Kind Care Executive Director and the Incident Supervisor will be responsible for this corrective action and ensuring continued implementation. 06/25/07 The Senior Vice PresidentChairman will provide the information identified inthis Plan of Correction to Kind Care's Quality 11/01/07 Improvement Committee and to the Governing Board for review and approval. 7 PRINTED: 09/2712007 - FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES tD PLAN OF CORRECTION (Xl) PROVIDERISUPPUER/CUA IDENTIFICATION NUMBER: ) (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED 1348L001 NAME OF PROVIDER OR SUPPLIER B.WING STREET ADDRESS, CITY. STATE, ZIP CODE 02/1612007 PROGRESSIVE HOME HEALTH SERVICES, INC. (X4) ID PREFIX TAG 132 WEST 31STSTREET. 7TH FL NEW YORK, NY 10001 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (XS) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H 718 Continued From Page 6 The agency policy/procedure for Incidents documents: "Documentation of the situation will be entered onto the Attendance System and an Incident Report will be completed, as necessary. All home health employees will provide interview and/or statement as requested." The" Incident Log" lacked any documentation that an incident report was completed or that agency employees were interviewed. On interview of 2/16107 2PM, the Director stated that the agency did not complete an incident report because it was determined that "one was not necessary in this case." H 718 Pagd intentionally left blank. e,.J ~/ . /? DEPARIMENT OF HEALTH1 AND HUMAN SERVICES CLNTERS FOR MEDICARE AND MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 337301 AMERICARE CERTIFIED SPECIAL. SERVICES SUB-UNIT PRINTED: 02/28/2008 FORM APPROVED OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A.BUILDING .13, WING STREET ADDRESS, CITY, STATE, ZIP CODE 900 MERCIIANTS CONCOURSE SUITE Ll-l5 WESTBURY, NY 11590 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO TI I APPROPRIATE DEFIENCY) (X) . COMPLETION (X3) DATE SURVEY COMPLETED R 02/13/2008 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFIENCIES (EACH DEFIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) DATE (G 000} INITIAL COMMENTS A Follow-up and Complaint Survey was conducted at Arnericare Certified Special Services on 02/11/08-02/13/08. Twelve (12) clinical records were reviewed and identified as Patients fl I - # 12. Five (5) home visits were made to Patients #1, #2, #5, #6 and #7. 484.30(a) DUTIES OF TI1. REGISTERED NURSE {G 000) {G176} G1761 The registered nurse prepares clinical and progress notes, coordinates services, informs the physician and other personnel of changes in the patient's condition and needs, This STANDARD is not met as evidenced by: Based on clinical record review, home visit and stafr interview, the nurse failed to ensure coordination of services regarding the administration of prescribed medications between the Adult Care Facility (ACF) staff and the agency staff in one (1) of five (5) home visits (Patient #1). The agency's failure to ensure effective Theaen'seiure oensuredeffetie patiatient's/facilities coordination.of service resulted in the patient not receiving the required medication ad places all patients at rsk for pour quality care. 'Findings are: Patient #1 was admitted to the agency on 04/28/05 with diagnoses of Chronic Airway Obstruction, Schizophrenia, Hypertension and Esophageal Reflux. The nurse in question was previously disciplined for failure to perform her expected duties appropriately assess patient's medical and needs. She was placed on an action plan in December and informed if there is not a "noticeable" improvement she would be discharged at the end of February. Her last date of employment is Feb. 29, 2008. (See attachment # I- IIR policies regarding progressive discipline and termination). All reside~nts in Adult Care facilities have rights guaranteed to them under federal and state law. These rights include the resident's right to selfadministration of medication, if the resident requests to self-administer drugs, 'and the physician certifies it is safe (in writing). The Americare nurse will assess, spervise, direct and instinct the patient under the physician's plan of care (485), The Americare nurse will review (based on the frequency of nursing visitsl the medication administrative record (MAR) with the facilities Med-Tech or other designated individual for medication dosage too ish/low, medication interactions, side effects. allergies. therapeutic benefits, admiistration issues including schedule and route, compliance with selfadministration and adeqatesupply. (See attachment # 2 Mecdication Review Form) accordance to Federal regulations independent self-administration occurs when a patient/resident is independently able to directly apply a legend drug or controlled substance by ingestion, inhalation, injection or othermeans. In licensed Adult ITomes, self-administration may include situations in which an individual cannot physically self-administer medications (i.e., patient with arthritic hands, may require assistance to open a cap on a medication bottle) but can aceurately direct others. Americare Nurses, aspractiiners. will determine if selfadministration of medications with assistance is a propriat, This willbe achieved by direct observation and quesioning. Feb. 29, 2008 Westbury February 21,2008 & Suffern by March 27, 2008 -In '._ ORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients, (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above tindings arid plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation . FORM CMS-2567 (02-99) Previous Versions Obsolete Event ID: 1RIJ 12 Facility ID: 4706A If continuation sheet Page I of 4 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND. MEDICAID SERVICES F IAfLMLNF OF DEFICIENCIES MtPLAN OF CORRECTION - PRINTED: 02/28/2008 FORM APPROVED OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (XI) PROVIDERISUPPLIER/CL[A IDENTIFICATION NUMBER: A.BUILDING 337301 B. WING R 02113/2008 AMERICARE CERTIFIED SPECIAL SERVICES SUB-UNIT STREET ADI)RF.SS, CITY, STATE, ZIP CODE 900 MERCHANTS CONCOURSE SUITE LL-15 __WESTBURY,NY 11590 " 11) PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACIH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFIENCY) Certified Home Health Aides in a community setting, and non-practitioners (Med Techs) in the Adult Home may assist the "self-directing" patient/resident in the self-administration of their medications as follows: o Remitiding or coaching the individual to (X4) ID, PREFIX TAG SUMMARY STA'I'MIENT OF DEFIENCIES (EACH DEFIENCY MUST BE PRECEEDED BY FULL REGULATORY OR I.SC IDENTIFYING INFORMATION) (X5) "COMPLETION DATE {G 176} Continued From page 1 I The Plan of Care (POC) for 12/14/07-02/11/08 ordered Skilled Nurse (SN) twice daily for sixty {G 176} (60) days for nebulizer treatment. 'lste POC also ordered Combivent two (2) puffs inhalation two (2) times daily self administered and pm (as needed). take their medication, - handing the medication container to the patient, record contained a "Supplemental The clinical r Physician Order" dated 01/04/07 ordering . opening the medication container, using enablcr, or placing the medication in the hand of the Combivent inhaler two (2) puffs TID (three times daily), a fourth dose can be given PRN (as needed). The record contained a subsequent patient/resident. The patient/resident must be able to put the medication into his or her mouth or apply or instill the medicalion. The patient/resident does not necessarily need to state the name of the medication, intended effects, side effects, or other details, but be aware that he/she is receiving medications & why (i.e., this blue pill is fbr my blood pressure and I take I tablet inthe morning). Assistance inay be provided with pre-filled insulin syringes. Assistance islimited to handing the ire-filled insulin syringe to a patient/resident. The patient/resident retains the right to refuse medication. Inthe event a patient refuses medication the paticnts hysician will be notified .. e order dated 01/14/08 ordering Combivent two (2) puffs two (2) times a day - self administer. A Hmust A Home Visit (-IV) was conducted on 02/12/08 to the patient's residence at the AC. During the visit, the surveyor interviewed the patient regarding the usage of the Combivent Inhaler The patient stated he "does not use the inhalers". Review of the ACF.'s Medication Administration Records (MAR) for Janu.ary 2008 listed the Combivent and documented "Pls (please) see at the back". Review of the back of the MAR failed to dcuntent-infoi-maiation regpardingthe Combivent. The February 2008 MAR lists the Combivent with no indication of whether the patient received the medication. During the HV on 02/12/08 at 11: 10 AM, the nurse was observed performing a clinical Americare Nurse. Sell-administration of medication occurs when the resident assumes the res-p nsibility for taking the right medication at the right dose, via the right route. at the right time. and for the right reason. Americare assessment of the patient. The nurse failed to evaluate the patient on the usage ofthe Combivent inhaler. The nurse was observed administrinha lier theurea n oe en. administering a nebulizer treatment to the patient. CSS nursing staff function as educators and suoerviSO. The responsibility for storage, documentation of the administration of the medication on the MAR, and re-ordering is between the resident and ACI: staff. The nurse will notify the facility Administrator and MD if there is a delay in orderi ng medications and/or other medication issues. If an patient/resident cannot safely self-administer medication or self-administer with assistance and/or cannot indicate an awareness that he or she is taking a medication, then the medication must be administered to the patient/resident by a person legally authorized to do so (Med Tech) or by the Anericare Nurse. Event ID: IRUI2 Facility ID: 4706A, If continuation sheet Page 2 of 4 Review of the nursing visit reports for visits of 0 1/0 1/08 -02/06/08, the nurse consistently FORM CMS-2567 (02-99) Previous VersionsObsolete f "ITERS DEPARTMENT OF HEALTH AND HUMAN SERVICES FOR MEDICARE AND MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xt) PROVIDERISUPPLIER/CLIA. IDENTIFICATION NUMBER: 337301 B_ WING (X2) MULTIPLE CONSTRUCTION PRINTED: 02/28/2008 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED R ABUILDING 02/13/2008 AMERICARE CERTIFIED SPECIAL SERVICES -SUB-UNIT STREET ADDRESS, CITY, STATE, ZIP CODE 900 MERCHANTS CONCOURSE. SUITE LL-15 WESTBURY NY 11590 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO T111E APPROPRIATE DEFIENCY) (X5) COMPLETION DATE (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFIENCIES (EACH DEFIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG {G 176} Continued From page 2 Documented the patient's lung status as "wheezing" in both lungs and "Albuterol Nebulizer" treatments administered. The nursing {G 176} When there is a conflict in orders or an order is not clear or complete, the fheility's policy and procedure on contacting the appropriate health professional is to be followed. All medications discrepancies and/or conflicts will he bro the phvsician's immediate attention by the Arnericare visit reports lacked documentation of the patient's usage of the Combivent Inhaler as prescribed by the physician. The visit reports lacked documentation that the physician was notified of the patient not taking the Combivent Inhaler. Further-review of the agency's Medication Profile Nurse Responsible Person: Americare CSS Nurse in the ACF is responsible for surveillance of medication administration. The Supervisor/DPS for each uh"f tes branch Is nosible for oversig - "eRN lacked documentation of the corrected frequency of Comb ivent Inhaler."Combivent Inhaler dated 01/04/081listed The Medication Profile 2 puffs TID (three times daily) and a fourth dose to be given pm (as needed) in between or after standing dose" yet the Supplemental order dated 01/14/08 ordered the Combivent two (2) times a day. During interview with the agency's supervisor on ._# -*, 5 / ,/ ,/ 0 00ao~9 -, 17 02/13/08 at 10:15 AM, the supervisor acknowledged the findings. The agency continued to fail to ensure effective coordination of services between the ACF staff and the agency's nursing staff to provide the medications ordered for this patient Chronic Airway Obstruction and documented Wheezing. {G236) {G23} RPEA ROM12/2/07SUREY REPEAT DEFCIECY FROM 12/27/07 SURVEY DEFICIENCY 484.48 CLINICAL RECORDS A clinical record containing pertinent past and current findings in accordance with accepted professional standards is maintained for every patient receiving home health services. In addition to the plan of care, the record contains apro (G236) {to track nursing visits: Those nurses that have not submitted notes within 7 days of the date of visit will be notified to come into the office. Paychecks of frequent offenders will have to be picked up in the Westbury office and will not be released till the documentation is complete in accordance Clinical Asnericare CSS has a computerized tracking system Feb. 22 2008 & ongoing & ongoing - Record Policy 48448. Americare CSS will ensure that the nursing staff initiates the POC and revises the POC as needed to meet patienilresident needs. Anericare CSS will provide as in-depth in-service to all ACF nurses Event ID: IRIJI2 Facility ID: 4706A If continuation sheet Page 3 of 4 appropriate identify'ing information; name of FORM CMS-2567 (02-99) Previous Versions Obsolete t " (ARTMENT OF HEALTH AND HUMAN SERVICES k,.NTERS FOR MEDICARE AND MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X I) PROVIDER/SUPPLIERICLIA IDENTIFICATION NUMBER: 337301 B. WING (X2) MULTIPLE CONSTRUCTION PRINTED: 02/28/2008 FORM APPROVED OMB NO. 0938-0391 A.BUILDING (X3) DATE SURVEY COMPLETED R 02/13/2008 AME]RICARE CERTIFIED SPECIAL SERVICES SUB-UNIT STRIET ADDRESS, CITY, STATE, ZIP CODE 900 MERCItANTS CONCOURSE SUITE LL-15 .WESTBURY, NY 11590 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD 13E CROSS-REFERENCED TO TlE APPROPRIATE DEFIENCY) (XS) COMPLETION DATE (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFIENCIES (EACH DEFIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG (G236} Continued From page3 physician; drug, dietary, treatment, and activity orders; signed and dated clinical and progress notes; copies of summary reports sent to the attending physician; and a discharge summary. This STANDARD is not met as evidenced by: Based on the agency's Plan of Correction, the completion date for the corrective actions for this deficiency is 04/14/08. Therefore, the agency {G236} regarding use of the Medication review form, Pharmacology,and Behavioral Health Assessment no later than March 27, 2008. Americare CSS supervisors and/or DPS will review a minimum of 10% of each Adult Care facility patient clinical records on a monthly basis. Based on the findings ongoing education will take place and the audit results will he placed in the nurses personnel file to be reflected on their annual performance evaluation. March 27, 2008 April 14,208 could not be found in compliance with this regulation. Responsible Person: The Scheduler/Office Manager ineach branch is responsible for tracking of nursing visits on a weekly basis. The Clinical Supervisor/Manager &/or DPS for each branch is responsible ft oversight of the nurses. Anericare CSS Governing body will ensure that the required education and in-services take place and the Agency's have the continued support to resolve all identified deficiencies and prevent any reoccurrences of deficient practices. FORM CMS-2567 (02-99) Previous Versions Obsolete Event ID: IRU 12 Facility ID: 4706A If continuation sheet Page 4 of 4 my.O Richard F.Daines Commissioner STATE OF NEW YORK DEPARTMENT OF HEALTH Metropolitan Area Regional Office 90 Church Street, New York, NY 10007 Wendy E.Saunders Chief of Staff March 12, 2008 Ms. Nancy Hahn Administrator Americare of New York City 205 Kings Highway Brooklyn, NY 11223 Re: Response to Plan of Correction Survey Date: December 5, 2007 License: LC0423A Dear Ms. Hahn: Please be advised that the plan of correction relating to the recent Article 36, survey of your agency have been reviewed by this office. All items were found to be acceptable and it is expected that you will implement this plan within the time frames that were submitted. A post approval review will be conducted to Verity the correction of deficiencies. If you have any questions regarding this matter, please contact (212) 417-5888. Sincer"ly - Cheryl Phoenix-Tannis,. RN. MSN, CS Program Manager. Home Health and Hospices Services Metropolitan Area Regional Offices PRINTED: 02/01/2008 FORMAPPROVED lew York State Department of Health TATEMENT OF DEFICIENCIES "LAN OF CORRECTION (XI) PROVIDER/SUPPLERICLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A.BUILDING (X3) DATE SURVEY COMPLETED LC0423A AME OF PROVIDER OR SUPPLIER B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 1210512007 AMERICARE OF NEW YORK CITY (X4) ID PREFIX TAG 205 KINGS HIGHWAY BROOKLYN, NY 11223 10 PREFIX TAG PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATEDEFICIENCY). . X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H 000 initial Comments H 000 (See H204 Paragraph #1) (A) Director of Quality Assurance presented 1111/08 Full Survey was conducted at Americare of New anId discussed revised policies and procedures for grievance / complaints and patient bill of rights, during a performance improvement meeting on January 11, 2008. (See enclosed York City on 12/5/07. Six Patient Care Records were reviewed and are identified as Patients #1 to #6. Six Personnel Records -were reviewed and are identified as Employees #1 to #6. attachment) (A) Policies were approved by the Administrator and were given to the Department Directors and Managers to disseminate to staff for orientation and implementation. Information was disseminated The Policy and Procedure manual, Federal Tax ID, Home Health Aide Training Quality Improvement/Quality Assurance Committee Meeting Minutes, Governing Authority Meeting through one or more of the following:'printed, electronic,'and presentation materials. (A) Minutes of PI meeting was sent to the Governing Board for effective planning, directing, implementing, coordinating, and monitoring care and service activities.. The revised policies and procedures will be reiterated to the Governing Body on 3112/08 Minutes, Complaint Log and Admission Packet were reviewed, An observation of a HHA training class was done. H 204 766. !(a)(1) Patient rights H 204 during our Quarterly Professional Advisory Committee (PAC). Section 766.1 Patient rights. (a) The governing authority shall establish written policies regarding the rights of the patient and shall ensure the development of procedures implementing such policies. These rights, policies and procedures shall afford each patient the right to: (A) The Quality Management Customer Relations Representative translated our Americare Inc. patient bill of rights in several languages (English, Spanish, French, Creole, Russian, etc.) in order to accommodate diversified patients served. (See H204 Paragraph #2) (1) The revised Bill of Rights is available to the patient during care of care and initial nursing visits: Americare Inc. patients are informed of their rights, and they have the right to exercise such rights. This measure was put in place to ensure that deficient practices do not recur. (1) be informed of these rights, and the right to exercise such rights, in writing prior to the: initiation of care, as evidenced by written documentation in the clinical record; (2) be given a statement of the services available by the agency and related charges; (3) be advised before care is initiated of the RATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE iX) (1 DATF STATE FORM Q0N21M91 1 If continuation sheet lof 15 PRINTED: 0227/2008' New York State Deoartment of Heafth A. , MENT OF DEFICIENCIES ?LAN OF CORRECTION FORM APPROVED (X2) MULTIPLE CONSTRUCTION A. (i) o PROVIDEPJSUPPUEFJCUA IrF_ CTION NUMBER: (X3) DATE SURVEY EUILDING WNG ___________ COMPLE COMPLETED LC0423A NAME OF PROVDER OR SUPPLUER 5. 12J05/2007 STREET ADDRESS, CflY, STATE ZIP CODE AMERICARE OF NEW YORK CITY (4) (0 PREFIX TAG 205 KINGS HIGHWAY BROOKLYN, NY 11223 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEF1CIENC-0 (XS COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H 204 766 1aV1 - n Patient rights oH 204 ' (See H204 Paragraph #2) (1) The development of a Quality Management Continuous Impi'ovement Program and strategy to promote patients rights and responsibilities has to be carefully prepared by Director of Quality Assurance. (See H204 Paragraph #2) (1) The processes and structures of Quality Management Continuous Improvement Program will work toward the following objectives: Educating the staff on patient rights * Creating positive outcomes Efficient and effective services , Complying with standards (See H204 Paragraph #2) (1) Clinical Manager is providing direct oversight of the Nursing Department and is effectively ensuring thatevery patient is given a Patient's Bill of Rights sheet with every initial visit and reviewed 'with the patient by the nurse. This measure was put in place to ensure that deficient practices do not recur for those patients found to have been affected by the deficient practice. (See H204 Paragraph #3) (2) Americare, Inc. provides a list of the charges for our private paying cases only. This list includes rates for R.N. initial visits, R.N. re-visits, HHA f PCA hourly rates and rates for 24-hour live-ins. These rates are given to the patient or guarantor prior to setting up an initial visit. The patient or guarantor is personally responsible for these charges. Ongoing (See H204 Paragraph #4) (3) The cases that are not private paying are vendor generated. The vendors (Provider Relation and Case Managers) are responsible for supplying the patient with a listing or their services and all information on payments (including third party payor.) LAZORATORY DIRECTOR'S.OR PROVIDEFJSUFPLER REPRESENTATIVES SIGNATURE TTLE MSjDATE STATE FORM QN9M11 If =rrf cn sh?t I PRINTED: 02/0112008 FORM APPROVED New York State De artment of Health TATEMENT OF DEFICIENCIES Akin PLAN OF CORRECTION Xl)COMPLETED STATMEN (X) PROVIDER]SUPPLIERJCLIA OF IDENTIFICATION NUMBER: EFIIENCES A. BUILDING (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY LC0423A NAME OF PROVIDER OR SUPPLIER B.WING STREET ADDRESS, CITY, STATE, ZIP CODE . 1210512007 AMERICARE OF NEW YORK CITY (X4) ID PREFIX TAG . 205 KINGS HIGHWAY BROOKLYN, NY 11223 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) TA SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X5) COMPLETE DATE H 204 Continued From Page 1 extent to which payment forparty payors and the be expected from any third agency services extent to which payment may be required from., patient. tient of any (i) The agency shall advise t py. H204 (See H204 Paragraph #5) I) Carol Rizzuto, Contract Supervisor, assures that financial receive patients Inc. Americare may information as followed: . .. . Insurance information Ongoing Knowledge of charges not covered days Receiving information within 30 becomes .the aware of any changes incharges Having access to all bills upon request However, if services are being provided thru a verbally and in writing if Americare changes in information provided under this paragraph or paragraph-(2) of this subdivision as managed care vendor / agency (Guildnet, CCM to the patient / client. soon as possible, but no later than 30 calendar sfrom the date the agency becomes aware, daysfroha e the change. of Vera institute, Senior Health Partners, etc), it is their responsibility to provide financial information . (ii) All information required by this paragraphshall be provided to the patient both orally and in writing; (4) be informed of all services the agency is to provide, when and how services will be provided, and the name and functions of any person anda arevised affiliated agency providing care ardservices.: - (See H204 Paragraph #6) (ii) The Americare Inc. nurses, vendor Case Managers and Provider Relation staff are responsible for providing the patients with this information orally and in writing. (See H204 Paragraph #7) (4) 1131/08 Administrator, Director of Quality Assurance and, Director of Patient Services our Licensed Home Health Services Information For Patient and Care Partner Booklet. The booklet was developed to provide patients and caregivers general information about Americare meet patient Inc., including available services tobe ready for a home care needs. The booklet will mass patient distribution by 3108. The department heads will monitor the booklet and updates will be provided as needed. (See enclosed attached booklet) (See H204 Paragraph #7) (4) Clinical Manager is effectively ensuring that that Nursing Department nurses are distributing and explaining the patient bill of rights, forms, care plan, patient booklet, patient related information and services to all patients. (See H204 Paragraph #7) (4) The vendor's (Guildnet, CCM Vera institute, Senior Health Partners, etc.) Case Manager is responsible for fulfilling the patient's needs, i.e. PT, OT Speech Therapy, etc. The vendor will fax authorization request. for nursing and HHA services only. All Americare, Inc. personnel wears I.D. Badges and identify themselves and as well as the reason for their visit. Ongoing Initiated 1/31/08 Expected ' This Rule is not met as evidenced by: Based on record review and interview, the agency failed to inform the patients of their right or to be informed of any changeslin information (5) 30 days. This was evident in services within I out of (6) patient care records reviewed (Patients # 2-6). Failure to provide the patient the right to be sovbe ati n e pro Filuormed of ~informed of change in information ror services within 30 days of knowledge places the patient at risk for not being able to make decisions regarding their care in a timely manner. The findings are: The agency: " Patient Bill of Rights '" ocLuments the following information: E FORM . Completion 3/08 . shall be given a statement of the services' Every patient QN9M1 1 If continuation sheet 2 of 15 PRINTED: 021271200Z FORM APPROVED New York State Deoartment of Health EMENT OF DEFICIENCIES ANhL PLAN OF CORRECTION (X1) PROVIDEPSUPPLIEFJCLA IDENTIFICATION NUMBER (X2) MULTIPLE CONSTRUCT.ON (X3) DATE SURVEY COMPLETED ___ A. BUILDING B. WVING________ LC0423A NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY. STATE 7JP CODE 1210512007 AMERJCARE OF NEW YORK CITY (.4) ID PRFIX TAG 205 KINGS HIGHWAY BROOKLYN, NY 11223 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEF1CIENCY) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H 204 Contnued From Page 2 H 204 (See H204 Paragraph # 8) The record reviewed during 12105/07 survey was contracted (Guildnet, CCM, Vera institute, Senior Health Partners, etc.) therefore it is the vendor's Case Manager's responsibility to inform their " clients of any change to their services i.e. frequency of nursing and HHA. (See H204 Paragraph # 8) Based on the contractual agreements, when we coordinate and arrange Home Health Aides and I or a nurse for our client the patient is informed of any changes in information or services within 30 days. , 12/10/07 Ongoing (See H204 Paragraph # 9) *The record reviewed during the audit was a contracted (Guildnet, CCM Vera institute, Senior Health Partners, etc.) therefore it is the vendor's Case Managers and Provider Relation staffs is responsibility for providing the patients with this information. Based on the contractual agreements, when we coordinate and arrange Home Health Aides and / or a nurse for our client the patient is informed of any'changes in information or services within 30 days. (See H204 Paragraph # 10) Only the private paying patients are provided with a listing of the services available and the fee schedules. These are discussed with the patient and/or the guarantor before accepting the case. (See H204 Paragraph # 10) In cases where it is a vendor case, is the responsibility for that vendor staff or Case Manger to notify the patient of available services. Americare Inc. can only provide services with authorizations from vendors. Ongoing LABORATORY DIRECTOR'S OR PRCVIDEFJSUPPUER REPRESENTATIVES SIGNATURE TITLE DTE P(sC STATE FORM QNGM11 . = dcnsr 'c PRINTED: 02/01/2008 FORM APPROVED New York State De artment of Health STATEMENT OF DEFICIENCIES A' PLAN OF CORRECTION I (Xl) PROVIDER/SUPPLIERJCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A- BUILDING ____________ B. BUING WING (X3) DATE SURVEY COMPTED COMPLETED LC0423AB. NAME OF PROVIDER OR SUPPLIER 12/0512007 STREET ADDRESS, CITY, STATE, ZIP CODE. AMERICARE OF NEW YORK CITY (X4) ID PREFIX TAG TAG 205 KINGS HIGHWAY BROOKLYN, NY 11223 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE i SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL O IR OR LS IE REGAT REGULATORY OR LSC IDENTIFYING INFORMATION). H 2041 Continued From Page 2 charges and available by Americare and relatedor responsible H 204 billing mechanisms. Each patient 1 examine, question and receive a full explanation of any bill, regardless of payment source...." person is informed of and agrees to a written reimbursement/billing mechanisms. Each patient or responsible person is informed of and.. agrees to a written reimbursement /billing plan .as t prior to the initiation of care and has the right to (See H204 Paragraph # 11) Health We currently have a Licensed Home Partner Services Information For Patient and Care Booklet. The booklet was developed to provide patients and caregivers general information about Americare Inc., including available services to meet patient home care needs. The booklet will be Initiated 1/31/08 ready for a mass patient distribution by 3/08: This put in place to ensure that found to measure was not recur for those patients deficient practices do have been affected by the deficient practice. Expected Completion 3/08 There is no documented evidence of the agency agreeing to notify the patient as soon as possible, but no later than 30 calendar days-from the date the agency becomes aware of the (Ans. for H204 paragraph 12 See H204 Paragraph .7) change. On 12/5/07 at 12:17 PM the Director of Patient Services was interviewed and stated: "it will go (See H222 Paragraph #1) (a) Americare Inc. recognizes the vital nature of staff and their contribution to our agency. Their into effect in January." H222 766.1(a)(8) Patient rights H 222 SSection 766.1 Patient rights, (a) The governing authority shall establish written patient d of hepoced and policies regarding v the shaliesreardig the rightst of the shall ensure the development of procedures implementing such policies. These rights, policies and procedures shall afford each patient ' the right to: (8) voice complaints and recommend changes in policies and services to agency staff, the New York State Department of Health or any outside representative of the patient's choice. The: expression of such complaints by the patient or his/her designee shall be free from interference, i coercion, discrimination or reprisal. input and involvement is essential in order to get the best results from the service and any improvement activity. (See H222 Paragraph #1) (a) Americare Inc. currently have policies and procedures and avenues for patients I clients and families to address the rights of clients, obtain explanations, address grievances and serve as an advocate for clients who feel that their rights have Currently not been properly respected. The Director of Quality Assurance conducts continuous monitoring of the process. (See enclosed attachment) . EFORM 0211M QN9M11 If continuation sheet 3 of 15 PRINTED: 02101/2008 FORM APPROVED New York State De artment of Health STATEMENT OF DEFICIENCIES OLAN OF CORRECTION (X1) PROVIDERJSUPPLIERCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION ___________ ,AUING B. WING_________ (X3) COMPLETED C PTE LC0423A NAME OF PROVIDER OR SUPPLIER . B.WING STREET ADDRESS. CITY, STATE, ZIP CODE 12105/2007 AMERICARE OF NEW YORK CITY (X4) ID PREFIX TAG 205 KINGS HIGHWAY BROOKLYN, NY 11223 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSSDREFERENCED TO THE A PROPRATE (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 222 Continued From Page 3 H 222 (See H222 Paragraph #1) (Continuation of (a)) l Americare Inc. assures that effective leadership, practices, and procedures, communications, hiring many other activities also help improve performance. The best decisions on how to achieve performance improvement have been based on the value that different approaches. Which: approach has been most. successful depends on the specific objectives to be achieved. In order to accomplish goals and objectives, (a) The Administrator has developed a series of organizational structures as outlined below: (a) Director Level Meetings: Directors Americare Inc. meet weekly to review major system policy formulate to developments, recommendations, and facilitate program planning, strategic planning and continuous quality improvement regarding the rights of the patients. (a) Middle Management Meetings: These meetings meet monthly are largely Home Health Aide (HHA) and patient focused, but also serve to identify problems in the functioning of the service system. Identified systems problems are referred to the appropriate committee for review and action (a) Staff General Meetings: These meetings meet every six months focuses on staffs involvement with continuous quality improvement within, Americare Inc. Continuous I- ... EFORM QN9M11 PRINTED: 02/01/2008 FORM APPROVED. New York State Department of Health TEMENT OF DEFICIENCIES PLAN OF CORRECTION (Xl) PROV1DERISUPPLIERJCLIA IDENTIFICATION NUMBER: ((X3 A. BUILDING DATE SURVEY LCO423A NAME OF PROV1DER OR SUPPLIER B.WING STREET ADDRESS, CITY, STATE, ZIP CODE 12/0512007 AMERICARE OF NEW YORK CITY (X4) ID PREFIX TAG 205 KINGS HIGHWAY I BROOKLYN, NY 11223. ID PREFIX . TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) I (X5) COMPLETE DATE H 222 Continued From Page 3 H 222 . (See H222 Paragraph #2) (8) Our Americare Inc. patients have the right to voice grievances without fear of recrimination. The , Quality Management Department Grievance I Coordinator , QM Liaison and Director, investigate complaints made by a clienlfamily. regarding treatment or care that is furnished, or fails to be furnished. A grievance I complaint can be made 12106/07 by contacting our Care Coordinator at 718-4345100. (8) The Director of Quality Assurance will perform the following systemic changes: randomly checking, and ensuring that process for improvements are working properly. Any deficiencies will be corrected on the spot, and the findings of the quality-assurance checks will be documented and submitted at the monthly qualityassurance committee meeting for further review or corrective action. i K I (See H222 Paragraph #2) (Continuation of (8)) The Coordinator is currently documenting both the existence of the complaint and the resolution of the I complaint. If the patient feels that satisfaction action has not been taken they may contact our newly hired Grievance Coordinator for further assistance. Currently writing' Patients are advised in via patient booklet, patient bill of rights as well as verbally by the staff to contact the New York State Department of Health and the Joint Commission on Accreditation of Healthcare Organizations if their complaint was not addressed properly by an Americare.lnc. staff or administration. STATE FORM QN9M1 1 PRINTED: 02/0112008 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES PLAN OF CORRECTION (Xl) PROVIDERISUPPLIERCLIA IDENTIFICATION NUMBER: MULTIPLE CONSTRUCTION (X(2) A BUILDING ___________ ABUING (X3) DATE SURVEY COMPLETED LC0423A NAME OF PROVIDER OR SUPPLIER B.WING STREET ADDRESS, CITY, STATE, ZIP CODE 12105/2007 AMERICARE OF NEW YORK CITY (X4 PREFIX TAG 205 KINGS HIGHWAY BROOKLYN, NY 11223 tO PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) I H 999 Continued From Page 4 H 222 (Continuation of H222 Paragraph # 4) The Americare inc. staff was given the correct complaints. related number for patient Furthermore, the Clinical Manager, Nursing Department Case Managers and Field Nurses assures that hot line complaint numbers are given nursing visit. to all patient during their initial by the nurses includes: Numbers provided a Americare Contacts * a Department of Health Complaint # Joint Commission Complaint # implemented (See H222 Paragraph #5 Unfortunately the State Department of Health Phone Number 212-268-7001 provided is disconnected. (See H222 Paragraph #5) A mass mailing was conducted by the Administrative staff and sent to 2,084 Americare Inc. patients with the correct contact information. The letter advised patients to contact the State Department of Health Phone Number at 1-8006285972 or 212-417-5888. The State Department Of Health Hours of operations are 8:30am-4: 30pm, Monday through Friday, excluding State and federal Holidays. (See enclosed attachment) Immediately implementec (See H222 Paragraph # 6) Our Licensed Home Health Services Information For Patient and Care Partner Booklet currently has the correct information for the New York State Department of Health. This measure was put in place to ensure that deficient practices do not recur for those patients found to have been affected by the deficient practice. F I -S,,,E FORM MIN QN9M11 PRINTED: 02/01/2008 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES P' CLAN OF CORRECTION (Xl) PROVIDER/SUPPLIERICLIA IDENTIFICATION NUMBER SUEY DXE2) MULTIPLE CONSTRUCTION (X2)MULIPLECONTRUCIONCOMPLETED A. BUILDING LC0423WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 12/05/2007 AMERICARE OF.NEW YORK CITY (X4) ID TG PREFIX SUMMARY STATEMENT OF DEFICIENCIES 205 KINGS HIGHWAY BROOKLYN, NY 11223 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE TO THEAPORTE TGCROSS-REFERENCED ACTION SHOULD BE PREFIX E APPROPRIATE DEFICIENCY) ID OR (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY O LSC IDENTIFYING INFORMATION) (X5) DE COMPLETE DATE H 222 Continued From Page 3 this Rule is not met as evidenced by: Based on record review and interview, the H 222 (See H222 Paragraph # 3) on 12/11/07 by Immediately implemented Quality, Nursing and Marketing Administrator, Department. Patient information letters, manuals and materials now includes the following: I correct information to contact the New York agency failed to provide the patients with the (See H222 Paragraph # 3) The public may contact-the State Department for patient complaints at 1-800 628-5972 or 212-417- 'II 5888. -The State Department Of Health Hours of State Department of Health. This-was evident operations are 8:30am-4: 30pm, Monday through for (2) out of (6) patient care records reviewed.( Friday, excluding State and federal Holidays. Patients # 3 and 4) (See H222 Paragraph # 3) They may also contact Joint Commission's Ofice Failure to provide the correct telephone number or of Quality Monitoring to report any concerns to the patient places the patient at risk for notreitrcmansabuaJotCmiso-complaints about a Joint Commissionregister accredited health care organization by either being given the opportunity to lodge a complaint emailing or. 1/800-994-6610 calling with the New York State Department of Health c6mplaint(cicaho.orq. (See enclosed attachment) Iand it violates the patient' s right. (See H222 Paragraph # 3) 12/11/07 The findings are: The agency: " Patient Complaint/ Grievance PofInc. Procedure " documents the following information: " You may express complaints about the care and services provided and have Americare investigate such complaints. The State Department of health Phone Number is 21State DepartmentSofthealthrPhone Numberlis 212-268-7001. The State Department of Health Hours of Operation are 8:30. 4:30 P.M., Monday through Friday, excluding State and federalHly . Holidays. I The documented telephone number is not the correct contact information for the New York State Department of Health. Our patient letters were translated into several languages ( English, Spanish, French, and Russian ) and were mailed to 2,084 Americare patients. (See H222 Paragraph # 3) Our onewlyo hired 2/11/08 Quality Management Customer Relations Representative ensures continuous compliance by tacking and mailing the letter to new patients. This measure is put in place to ensure that deficient practices do not recur. (See H222 Paragraph # 3) Clinical Manager is ensuring the receipt by every patient. Every patient is asked upon a revisit if they have received it. If not, then the nurse will hand out a packet and request a signature on an orientation form, which confirms receipt of it. This signature page will be placed in the pt's chart. Every initial visit will have this packet as part of the initial is paperwork. This way every one of our patients info. this with supplied The patient care records for Patient #3 and #4' s have the forms with the incorrect information. (See H222 Paragraph # 4) All current patients have been sent a letter signed by administration with the correct telephone number for Department of Health. All future patients will receive this documentation during start of care, with the correct numbers. On 12/5/07 at 4:07 PM, the Director of Patient .... everyone Services, stated: January 1st" will get that information as of " QN9M11 SE FORM ifContinuaion sheet 4 of 15 PRINTED: 02101/2008 FORM APPROVED New York State Department of Health F "EMENT OF DEFICIENCIES )LAN OF CORRECTION (XI) PROVIDERISUPPLIEPJCLA IDENTIFICATION NUMBER: MULTIPLE CONSTRUCTION ()2D) A. BUILDING B. WING COMPLETED 12105/2007 LC0423A NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE AMERICARE OF NEW YORK CITY (X4) ID PREFIXP TAG I 205 KINGS HIGHWAY BROOKLYN, NY 11223 ID PREFIX TAG ON C PROAIDERS PLAN OLD BE (EACH CORRECTIVE AO CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (See H222 Paragraph # 7) (X5) CPTE DATE SUMMARY STATEMENT OF DEFICIENCIES DEFICIENCY MUST BE PRECEDED BY FULL ,(EACH REGULATORY OR LSC IDENTIFYING INFORMATION) H 222 'Continued From Page 4 H 222 Currently changed, as documented above. o implemented Immediately (See H222 Paragraph # 8) 12/10/07 Patient letters informing Americare inc. patients with the correct contact information (hotline number, email, and mailing address) on of contacting the New York State Department Health and the Joint Commission on accreditation of Healthcare Organizations was translated in several languages. (English, Spanish, French, and Russian) and was mailed to 2,084 Americare Inc. patients. The revised Information For Patient and Care Partner Booklet will be ready for a mass patient. distribution by 3/08. 12/10/08 IS STATE FORM 199 QN9M11 PRINTED: 02/01/2008 FORM APPROVED New York State De artment of Health STATEMENT OF DEFICIENCIES PLAN OF CORRECTION (X1) PROVlDERISUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. (X3) DATE SURVEY COMPLETED BUILDING ___________ LC0423A NAME OF PROVIDER OR SUPPLIER B.WING STREET ADDRESS, CITY. STATE, ZIP CODE 12/0512007 AMERICARE OF NEW YORK CITY (X4) ID PREFIX TAG 205 KINGS HIGHWAY BROOKLYN, NY 11223 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 404 i Continued From Page 4 H 404; H 404 766.3(b) Plan of care 766.3.Plan Of Care. The governing authority or operator shall ensure H 404 that: Manager (b) Clinical Paragraph currently monitors and ensures that the Home Health Certification and See H-404 Plan of Care (form 485) are updated within 48 hours of the submitted revisit paperwork. A copy of this 485 currently kept on the chart (to show that is was done) while the original is sent out the physician for his/her review and signature. (b)Revisits are routinely done every 3 months or as per the request of the vendor (on their authorizations.) The time frame indicated on this #1) Ongoing ...... I service to be provided, medications, treatments, I diet regimens, functional limitations and I rehabilitation potential. I This 1 (b) a plan of care is established for each patient based on a professional assessment of the patient's needs and includes pertinent diagnosis, prognosis, mental status, frequency of each form 485 coincides with the authorization time frame. There are instances when a revisit is scheduled for a date that is past the time frame on this form 485. That is due to the fact that the previous visit was done in the middle of the time frame of 'the previous form 485. Many authorizations are coming in with a time period of longer than a 3-month time span. Rule is not met as evidenced by: " Based on record review and interview, the agency failed to ensure that all plan of cares (See H404 Paragraph # 2) " Clinical Manager currently monitors and ensures were available for review. This was evident in (3) out of (6) patient records reviewed. (Patient #4, #5 and #6). that the patient charts are being reviewed by their case managers and the copy of the form 485 (Home Health Certification and Plan of Care) is currently kept on the chart until the signed original one is returned. This procedure currently in effect. All plan of cares will be available for review during surveys. Currently Plan of Cares are Failure to ensure that available for review places the patient at risk for not receiving all the services that patient is entitled to receive. e fthe SThe findings are: ', . (See H404 Paragraph # 3) approval. The Nursing Clinical Manager currently monitors and ensures that the nurses complete a health Care plan with physician's 1) Patient #4 has diagnoses which includes Hypertension and Osteoarthritis. The agency : "Home Health Certification and i Plan of Care" documents the last certification , period as- "4/3/07-7/31/07." i Care for 8/1/07 until present (1 0 Department currently includes the specific types of services required, the method of providing those services, and the expected duration of the services. (See H404 Paragraph #3) Clinical Manager is responsible for assuring that the medical records in the health care plan include whenever appropriate the following: Ongoing O - o Diagnosis & prognosis ? * Transfer forms Progress notes There is no documented evidence of a -Plan of 1212007. 2) Patient #5 has diagnoses which includes. .rE FORM 0211M o Physician's certification and orders Drug administration records . Treatment records Emergency instructions QN9M11 If continuation sheet 5 of 15 PRINTED: 02/01/2008 FORM APPROVED New York State Department of Health TEMENT OF DEFICIENCIES PLAN OF CORRECTION (X1) PROVIDERJSUPPLIERJCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CO JSTRUCTION (X3) DATE SURVEY COMPLETED A_BUILDING B.WING 120/2007 LC0423A NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE AMERICARE OF NEW YORK CITY (X4) ID PREFIX TAG 205 KINGS HIGHWAY BROOKLYN, NY 11223 171 PREFIX TAG PROVIDER'S PLAN OF CORRECTION ACTION SHOULD BE (EACH CORRECTIVE TO THE APPROPRIATE CROSS-REFERENCED DEFICIENCY) SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) I (X5) COMPLETE DATE H404 Continued From Page 5 H 404 1) Department Clinical Manager/ Case managers is effectively conducting weekly ground round meetings including chart and reviews with staff for updates and .medication processes for improvements. When applicable the Clinical Manager determines activities, which constitutes a high-risk process, and conducts a Performance improvement activity, including data collection, analysis, aggregation and improvement measurements. This systemic approach will ensure that the deficient practice does not recur. (See H404 Paragraph # 4) Weekly (See H404 Paragraph # 5 As part of our newly implemented practice, we are placing copies of Plan of Care (form 485) on the chart while we are waiting for the original signed ones to be returned form the doctor. This is just a confirmation that one has been time period. appropriate done for the Ongoing (See H404 Paragraph # 6 During this time frame the Nurse Case Manager for Guildnet was called repeatedly requesting a new authorization. Americare, Inc. does not an send in a nurse to a patient's home without authorization. There is Documentation in the chart showing the time we called Guildnet. Ongoing .S STATE FORM fl2 19 , QN9M11 PRINTED: 02101/2008 FORM APPROVED New York StateDepartment of Health !TATEMENT OF DEFICIENCIES PLAN OF CORRECTION . (X1) PROVIDERISUPPLIER/CLIA IDENTIFICATION NUMBER: (X2)MULTIPLE CONSTRUCTION A BUILDING B. WING (X3)DATE SURVEY COMPLETED. 12/05/2007 LC0423A NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 205 KINGS HIGHWAY AMERICARE OF NEW YORK CITY BROOKLYN, NY 11223 (X4) ID i SUMMARY STATEMENIT dF DEFICIENCIES ID PREFIX TAG (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE . (Xh) COMPLETE DATE H 4041 Continued From Page 5 H 404 Hypertension, Diabetes and Arthritis, IThe agency: "Home Health Certification and Plan i of Care" documents Plans of Care for "2/1/06 ? 1 //6 8/1106A 511/06, //61//0,1120-1171/32/06-2//07, 4/l/07-7/31/07 and 7/24/07-11130/07." (See H404 Paragraph # 8) I Clinical Manager assures that all copies of the Plan of Care (form 485) are kept in the chart until the Nursing Department receives the original signed ones from the doctor. There was no documented evidence of a-Plan of Care for 5/2/06-7/31/06 and 2/2/07 - 3/31/07. has a diagnoses which includes Gout, 3) Patient#6 hhigh-risk Gout,Arthritis and Hypertension. The agency:"Home Health Certification and Plan of Care" documents Plans of Care for 121/06-4/1/07 and 9/1/07 - 11/30/07. There was no documented evidence of a Plan of Care from 4/1/07-8/31/07 and 1211/07 till current I (See H404 Paragraph #9) Department Clinical Manager /Case Managers is effectively conducting weekly ground round meetings including chart and medication reviews with staff for updates and processes for improvements. When applicable the Clinical activities, which Manager determinesand conducts a constitutes a Performance process, improvement activity, including data collection, improvement and aggregation analysis, Weekly measurements. (Ans. for H404 paragraph 10 See H404 Paragraph # 9) Same as above (Ans. for H404 paragraph 11 See H404 Paragraph On 12/5/07, the Administrator was interviewed # 9) Same, as above . H 6161 766.5(b)(2) Clinical supervision I and was unable to provide an explanation. H16. . " .(See H 616 The Administrator is overseeing that the' Clinical H404 Paragraph # 12) 766.5 Clinical supervision. The governing that: .. l sf d n c(Ans. authority shall ensure for all health care services (b) all staff delivering care in pat~ent homes are adequately supervised. The department shall consider the following factors as evidence of -(See I adequate supervision: (2) staff are assigned to the care of patients in accordance with their licensure, and their training, orientation, and demonstrated skills.. This Rule is not met as evidenced by: Based on record review and interview the agency failed to ensure that new Home Health Aides ,,TE FORM 021199 Manager assures that all copies of the Plan of Care (form 485) are kept in the chart until the Nursing Department receives the original signed ones from the doctor. for H 616 paragraphl See H616 Paragraph # 2 & 3) Immediately ipeet 2 H616 Paragraph #2) (b)The Clinical Manager evaluates all field nurses implemented annually. The evidence of adequate supervision place inthe employee's HR file. Annually QN9M11 If continuation sheet 6 of 15 PRINTED: 02/01/2008 FORM APPROVED New York State Department of Health Sr-.ITEMENT OF DEFICIENCIES PLAN OF CORRECTION (Xl) PROVIDERISUPPLIEWICLA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A BUILDICOMPLETED CXO)PDATEDE LC0423A NAME OF PROVIDER OR SUPPLIER WING B. STREET ADDRESS, CITY, STATE, ZIP CODE 12105/2007 AMERICARE OF NEW YORK CITY (X4) ID PREFIX TAG 205 KINGS HIGHWAY BROOKLYN, NY 11223 ID PREFIX TAG . - SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROViDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) I (XS) COMPLETE DATE : H 616 Continued From Page 6 H 616 (See H616 Paragraph #3) (2) The Clinical Manager assigns the internal and external staff according with their licensure, and their training, orientation, and demonstration. (2) Routine nursing training meetings are held individually with clinical manager as a follow-up measure to ensure that deficient practices do not Updated information , policies, and recur. procedures are distributed to staff. (2) Meetings were held by clinical., manager with each nurse individually on theses dates, 11/06/07,11/27/07,12/1110712/28/07,1/25/08,2/28/ 08. Monthly (See H616 Paragraph # 4) Response from DOH. can take up to a year to receive determinations. A new procedure to indicate that the fingerprints were definitely sent and received by the DOH is commenced immediately. When prints are forwarded we receive a confirmation from the DOH. A copy of this confirmation is now placed into the HHA file as a matter of record. Plans for improvement entails the following which is currently in practice: first on-site supervision is completed by a nurse (RN or LPN) Subsequent on-site supervision and the off-site supervision is completed by utilizing an individual employed by the covered provider with a minimum of one year's experience. Director of Quality Assurance implemented a CHRC process in 09/07. The Director of Quality Assurance hired 7 Home Health Aides in September and October with a one-year tenure with Americare inc. to work as CHRC Representatives for phone call and offsite supervisions. *3 English Speaking Representatives 1 Spanish Speaking Representative 1 Chinese Speaking Representative 2 Russian Speaking Representatives * I' .The Bi-weekly STy E FORM . a19" QN9M11 PRINTED: 02/0112008 FORM APPROVED New York State D ' armnof Health (X 1) PROVIDERJSUPPLIERICLIA IDENTIFICATION NUMBER: A- BUILDING (X3) DATE SURVEY COMPLETED OF -TEMENT DEFICIENCIES PLAN OF CORRECTION LC0423A NAME OF PROVIDER OR'SUPPLIER R. WING STREET ADDRESS, CITY, STATE, ZIP CODE 121.05/2007 AMERICARE OF NEW YORK CITY (X4) ID PREFIX TAG -616 205 KINGS HIGHWAY BROOKLYN, NY 11223 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCEDTO THE APPROPRIATE (Continuation of H616 Paragraph # 4) The Quality Management Department created a new CHRC tracking database as well as new CHRC forms in order to further assist with the newly revised CHRC process. The CHRC Nursing Supervision Visit form The CHRC Staff Supervision Visit form o The Provisional Sup5ervision Time- slip All staff that provides supervision of home health aides was in-serviced on the rules for supervisory visits and the agencies policy for supervision by the Director of Quality Assurance. Although we were deficient with the supervisory visits. Future supervisory visits will be in compliance from 2/19/08. Supervisory visits have been added to the agencies QA and will be audited for comliance to the rules. The Administrator will take appropriate action if noncompliance is still found. The Director of Quality Assurance and Administrator is responsible for this plan of correction. " (X5) COMPLETE oSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued H616 H 1 Page Cot dFrom 6 S1 ATE FORF *99 QNSM11 PRINTED: 02/01/2008 FORM APPROVED New York State Department of Health F STATEMENT O DEFICIENCIES '""'LAN OF CORRECTION (Xl) PROVIDERSUPPLIERJCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED . LC0423A B.WING 12/0512007 NAME OF PROVIDER OR SUPPLIER AMERICARE OF NEW YORK CITY SOBROOKLYN, (X4) I PREFIX TAG STREET ADDRESS, CITY. STATE. ZIP CODE 205 KINGS HIGHWAY NY 11223 PROVIDER'S PLAN OF CORRECTION ID SUMMARY STATEMENT OF DEFICIENCIES (EACH CORRECTIVE ACTION SHOULD BE PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG SDEFICIENCY) CROSSDREFERENCED TO THE APPROPRIATE (X5) COMPLETE DATE - REGULATORY OR LSC IDENTIFYING INFORMATION) H 616 Continued From Page 6 according to Ta Criminal were supervised q e ns the wpull wee H su e . H 616 The Quality Management Department is working (See H616 Paragraph #5) for (4) out of (6) employee records reviewed, (Employees # 1, #2, #3 and #4). Ep epredefined closely with the HR and Nursing Departments to together the information needed to make decisions and comply with the Criminal History check regulations and policies and procedures. In' addition, performance is being tracked using indicators and thresholds. All staff that provides supervision of home health aides was in-serviced on the rules for supervisory visits and the agencies policy for supervision by the Director of Quality Assurance. Although we Continuous Failure to provide supervision during a Criminal History check, places the patient at risk for unsafe care. The findings are, 1) Employee # 1 is a Home Health Aide with a' documented hire date of "10/1/07." The Criminal History background check is documented as sent on " 9/30/07". The clearance letter from the-Department of Health is dated 10/29/07. The personnel record does not include documented evidence of supervision during this T Cinof were deficient with the supervisory visits. Future supervisory visits will .be in compliance from 2/19/08. Supervisory visits have been added to the agencies QA and will be audited for compliance to' the rules. The Administrator will take appropriate action if, noncompliance is'stil found. The Director Quality Assurance and Administrator is responsible for this plan of correction. (See H616 Paragraph #6) 1) The employee first day of work is 10/1/07 and the hire., date is 9/30/07. Human Resources department is in the process of auditing all files Currently from 2006 until 2007. (See H616 Paragraph # 7) Resources DepartmentJPersonnel Records Itime. 2Human - a Home Health Aide With a 2) Employee #2 is date of "6/25/07." documented hire The Criminal History background check form is documented as sent on "6/21/07." The clearance letter from the Department of ' Health is dated "8/9/07." The personnel record does not include documented evidence of supervision during this time and Employee #2 was working a 24 hour case. department ismaking sure all files have the correct hire date, and no longer use the first day of work as the hire date on paperwork; (See H616 Paragraph #8) Currently HR Manager was hired on 12/07 to oversee the .problem Furthermore, she hired a CHRC Authorized Person and Supervisor 1/08 in order to track, trend, monitor , follow-up all fingerprinting Fingerprinting Department. She has identified the adheres to all regulations. and Ongoinc correspondence from the DOH. 3) Employee #3 is a Home Health Aide with a documented hire date of "7/13/07." TE FORM 021199 QN9M 11 If continuation sheet 70; PRINTED: 02/01/2008 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES 'LAN OF CORRECTION (X1) PROVIDER/SUPPLIERJCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUC.TION .A BUILDING B.WING. STREET ADDRESS, CITY, STATE, ZIP CODE (X3) DATE SURVEY" COMPLETED LC0423A NAME OF PROVIDER OR SUPPLIER 12/05/2007 AMERICARE OF NEW YORK CITY (X4) ID PREFIX TAG 205 KINGS HIGHWAY BROOKLYN, NY 11223 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H 616 Continued From Page 7 H 616 (See H616 Paragraph #9 All staff that provides supervision of home health aides was in-serviced on the rules for supervisory visits and the agencies policy for supervision by the Director of Quality Assurance. Although we were deficient.with the supervisory visits. Future supervisory visits will be in compliance from 2/19/08. Supervisory visits have beenadded to the agencies QA and will be audited for compliance to rules. The Administrator will take appropriate action if noncompliance is still found. The Director of Quality Assurance and Administrator is responsible for this plan of correction. 2/19/08 * * 'the - I (See H616 Paragraph # 10) and 2) The employee first day of work is 6/25/2007 hire date is 6/21/2007(See H616 Paragraph # 11) i department is making sure all files have the correct hire date, and no longer use the first day of work as the hire date on paperwork. (See H616 Paragraph # 12) A new procedure to indicate that the fingerprints were definitely sent and received by the DOH is When prints are commenced immediately. forwarded we receive a confirmation from the DOH. A.copy of this confirmation-is placed into the HHA file as a matter of record. Currently Human Resources Department/Personnel Records IImmediately implemented * .1 (See H616 Paragraph # 13) HR Compliance Supervisor, will conduct a staff personnel record review on a quarterly basis to ensure each personnel record contains the documentation of clinical supervision as required by 02119/08. The prompt for the quarterly review of the staff personnel records by the HR director will be the electronic desk planner of all scheduled facility meetings and activities that is posted on the agency's local area network is responsible for this plan of correction. Quarterly S;,.,fE FORM QN9M11 PRINTED: 02101/2008 FORM APPROVED New York State Department of Health P'-TEMENT OF DEFICIENCIES PLAN OF CORRECTION (X1) PROVIDERSUPPLIERPCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING WING STREET ADDRESS, CITY, STATE, ZIP CODE (X3) DATE SURVEY COMPLETED LC0423A. NAME OF PROVIDER OR SUPPLIER 12105/2007 AMERICARE OF NEW YORK CITY 0. (X4) I PREFIX TAG616Y 205 KINGS HIGHWAY BROOKLYN, NY 11223 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL LSC IDENTIFYING INFORMATION) REGULATORY OR L F NT (X5) COMPLETE DATE H 616 i Continued From Page 7 H 616 (See H616 Paragraph # 14) Human Resources Department/Personnel Records department is making sure all files have the correct hire date, and no longer use the first day of work as the hire date on paperwork. Is2 rE S A, FORM 0ls NM PRINTED: 02/01/2008 FORM APPROVED New York State D DLAN OF artment of Health (X1) PROVIDERISUPPLIEPJCLIA IDENTIFICATION NUMBER: STATEMENT OF DEFICIENCIES E SEC O I CORRECTION (X2) MULTIPLE CONSTRUCTION A- BUILDING (X3) DATE SURVEY COMPLETED COMPLETED LC0423AB. NAME OF PROVIDER OR SUPPLIER WING 12/0512007 STREET ADDRESS, CITY, STATE, ZIP CODE AMERICAREOF NEW YORK CITY (X4) ID PREFIX TAG 205 KINGS HIGHWAY ID PREFIX TAG BROOKLYN, NY 11223 PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCEDYTO THE APPROPRATE (XE) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H 616 Continued .From Page 7 H 616 (See H616 Paragraph #15) A new procedure to indicate that the fingerprints The Criminal Historybackground check form is documented as sent on "7/13/07" and the clearance letter from the Department of health is dated "8/29/07." I The personnel record does not include documented evidence of supervision during this time. 4) Employee #4 is a Home Health Aide with a n documented hire date of"10/18/06." There was no documented evidence ofwhen the background check was sent. The clearance letter from the Department of * Health is dated "8/13/07." The employee has a documented start date as "12/06" I were definitely sent and received by the DOH is commenced immediately. . When prints are forwarded we receive a confirmation from the DOH. A copy of this confirmation is being placed into the HHA file as a matter of record. Immediately implemented (See H616 Paragraph # 16) HR Compliance Supervisor,. will conduct a staff personnel record review on a quarterly basis to ensure each, personnel record contains the clinical supervision as required documentation of prompt for the quarterly review of The by 02/19108. the staff personnel records by the HR director will be the electronic desk planner of all scheduled on the facility meetings and activities that is posted for this agency's local area network is responsible Quarterly plan of correction. (See H616 Paragraph # 18) HR Manager was hired on 12/07 to oversee the I The personnel record did not include documented evidence of supervision from 12/06 until 2/8/07. There is no documented supervision for the month of May and June, 2007 and the Sweek of 7/ 25/07 and 8/1/07. Fingerprinting Department. (See H616 Paragraph # 18) Two new employees have been hired on 12/24/07 fingerprints,CHRC completed has tcoordinator Compliance Supervisor currently reviews all files .The Personnel Record Supervisor is responsible for auditing the file before it is filed away. This ensures all files be completed with evidence that the background check was sent. (See H616 Paragraph # 18) HR Manager will monitor the effectiveness of corrective action on a timely basis until problem resolution occurs. Results of the implemented corrective action have been documented and communicated to the Direct of HR and the Administrator. before given to Personnel Record Department. Ongoing On 12/5/07 at 4:30 PM the Administrator was interviewed and was unable to provide an explanation. 1 0The . H1020 .766.9() Governing authority H1020 Section 766.9 Governing authority, i The governing authority or operator, as defined 700 of this Title, of a licensed home care in Part services agency shall: () ensure the development and implementation of a patient complaint procedure to include: QN9M1 1 If continuation.sheet 8 of 15 FORM i-E 021199 PRINTED: 02/01/2008 FORM APPROVED New York State Department of Health F- -EMENT OF DEFICIENCIES 'LAN OF CORRECTION (XI) PROVIDERISUPPLIERICLA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION DATE SURVEY BCOMPLETED kBUIWING __________ LC0423A NAME OF PROVIDER OR SUPPLIER WING B. STREET ADDRESS, CITY, STATE, ZIP CODE 12J05/2007 AMERICARE OF NEW YORK CITY (X4) ID PREFIX TAG . 205 KINGS HIGHWAY BROOKLYN, NY 11223 I" PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (See H616 Paragraph # 19) HR Manager is overseeing the Fingerprinting Department. She has identified the problem and adheres to compliance. She hired another CHRC Authorized Person and Supervisor 1/08 in order to track, trend, monitor, follow-up and monitor all fingerprinting correspondence from the DOH. (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H1020 Continued From Page 8 H1020 Currently (See H616 Paragraph # 20) HR Compliance Supervisor, will conduct a staff personnel record review on a quarterly basis to ensure each personnel record contains the documehtation of clinical supervision a's required by 02/19/08. The prompt for the quarterly review of the staff personnel records by the HR director will be the electronic desk planner of all scheduled facility meetings and activities that is posted on the agency's local area network is responsible for this plan of correction. Quarterly (Continuation of H616 Paragraph # 20) All staff that provides supervision of home health aides was in-serviced on the rules for supervisory visits and the agencies policy for supervision by I the Director of Quality Assurance. Although we were deficient with the supervisory visits. Future supervisory visits will be in compliance from 2/19/08. Supervisory visits have been added to the agencies QA and will be audited for compliance to the rules. The Administrator will take appropriate action if noncompliance is still found. The Director of Quality Assurance. and Administrator is responsible for this plan of correction. 2/19/08 (See H616 Paragraph # 21) The administrator has put the above process and procedures into affect and will assure continuous compliance. STATE FORM Q1Is9 QN9M11 PRINTED: 02101/2008 FORM. APPROVED New York State Deoartment of Health STATEMENT OF DEFICIENCIES DLAN OF CORRECTION (X1) PROVIDER/SUPPLIERJCLIA IDENTIFICATION NUMBER: MULTIPLE CONSTRUCTION (X2) A-BUILDING " (X DATE SURVEY LC0423A.WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP. CODE 12/05/2007 AMERICARE OF NEW YORK CITY. (X4) ID PREFIX TAG i I 205 KINGS HIGHWAY BROOKLYN, NY 11223 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H1020 Continued From Page 8 H1020 (See H1020 Paragraph #3) - (1) destablished a process for prompt resolution of (1) The Quality Management Department has 1) documentation of receipt, investigation and resolution of any complaint, including the imaintenance of a complaint log indicating the dates of receipt and resolution of all Complainlts received by the agency; (2) review of each complaint with a written response to all written complaints and to oral complaints, if requested by the individuals making the oral complaint: patient complaints. Grievance Coordinator was hired on 11/20/07. A log of all complaints is currently kept by date, person, allegation, follow-up and outcome/ resolution of complaint. (See attachments) (See H1020 Paragraph #3) (1) This log is Continuous serv'ice evaluation for trends, and is available for review by the NY State Department of Health and utilized for statistical evaluation, JCAHO. ~(2) (i) explaining the complaint and the decisions rendered complaint; and H1020 Paragraph #4) (SeeThe Quality Assurance Department ensures nue ()TeQaiyAsrneDprmn investigation findings ()elnnthcopaninetgo that the staff informs patients that they have avenues for expressing concerns and that ""several to date by.the Continuous I agency within 15 days of receipt of such filing a grievance is not the only mechanism to ensure that they receive a satisfactory response. (ii) advising the complainant of the right to appeal complaint the outcome of the agency's procedure to be. Investigation and the appeal inve i to followed; -staff. (See H1020 Paragraph #4) (2) Director of Quality Assurance implemented a 2008 grievance procedure, which encourages an open communication between patients and facility Patients are offered assistance in formulating and submitting grievances and timely resolution of problems by our QM staff. Most complaints may be more effectively addressed and resolved by means. (See H1020 Paragraph #4) (2) In order to prevent a recurrence of this Immediately implemented (3) an appeals process with review by a member or committee of the governing authority within 30 Stinformal days of receipt of the appeal; and the Department of Health's Office of Health 'Systems Management. This Rule is not met as evidenced by: the Based on record review and interview, agency failed to havea complete log which (4) notification to the patient or his or her patient is not satisfied by the designee r oagency's that if the ,the patient may comain to opant agnysresponse, th ainra deficiency .The QM staff was inserviced on patient rights and the fact that that they have the right to 'have their concerns heard by upper management as well. (See H1020 Paragraph #5). (i) The Grievance Coordinator. then Director of Patient Services /Quality Assurance reviews each grievance / complaint and responds to the complaint explaining the agency's decisions and actions within frfteen (15) days of receipt of the grievance /complaint and informs the complainant .of 'I documents the resolution Of COMPln ongoing Failure to have a complete complaint log places tauthority the right to appeal the decision to the governing the patient at risk for poor quality of care. The findings are: The agency ''Complaint Log' rE FORM within 15 days of receiving the decision. Written complaints receive written responses. has no 021 g QN9M11 If continuation sheet 9 of 15 PRINTED: 021011200 FORM APPROVED New York State Department of Health S A T -MENT.OF DEFICIENCIES -AN OF CORRECTION (X1) PROVIDERJSUPPLIEPJCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION o. A_BUILDING B.WING (X3) DATE SURVEY COMPLETED _.__ _ _ __ _ o__ L 4 LC0423A NAME OF PROVIDER OR SUPPLIER 12J05/2007 STREET ADDRESS, CITY, STATE, ZIP CODE AMERICARE OF NEW YORK CITY (X41 PREFIX TAG 205 KINGS HIGHWAY BROOKLYN, NY 11223, ID PREFIX TAG PRO"IDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)l (See H1020_Paragraph #6) (ii) Director of Quality Assurance assumes a proactive role in the prevention, facilitation, and resolution of complaints and grievances, including implementing educational programs that assist * Americare Inc. staff in handling difficult situations. Americare Inc. is authorized to act as an expert investigator, to gather information from the complainant/grievance and/or facility by phone, letter, email, and/or to make on-site reviews and to interview other staff and patients. (See H1020 Paragraph #7) 3) The Grievance Coordinator currently documents receipt of the grievance / complaint, investigation, resolution, PQIC Committee findings and appeals agency clinical record, patient's the in chronological grievance file and log. The Administrator developed an appeals review committee effective 2/08. Members include: Administrator Assistant Director of Operations * HR Manager * SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) I (X5) COMPLETE DATE : H1020 Continued From Page 9 H1020 I I Continuous * - I Ongoing I . * , Contracting Supervisor Grievance Coordinator Director of Quality Assurance (See H1020 Paragraph #7) (3) All grievance / complaints are discussed at the next Performance, Quality Improvement Committee meeting for review and recommendation. (See H1020 Paragraph #8) (4) It is the goal of the Americare Inc. is to meet needs and expectations of our patients. In the event that a patient is not satisfied with the response they receive, they may contact Quality Assurance Director or Administrator. If they are not satisfied with the results of the complaint investigation and resolution they are advised to contact the Department of Heath. Quarterly . ContinuouS STATE FORM =199 QN9M11 PRINTED: 02/01/2008 FORM APPROVED New York State Department of Health F- 'EMENT OF DEFICIENCIES 'LAN OF CORRECTION (Xi) PROVIDEPJSUPPLIERJCLA IDENTIFICATION NUMBER: (_) MULTIPLE CONSTRUCTION A_BUILDING B. WING (X3) DATE SURVEY COMPLETED LC0423A NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY; STATE, ZIP CODE 12105/2007 AMERICARE OF NEW YORK CITY PREFIX TAG 205 KINGS HIGHWAY BROOKLYN, NY 11223 ID PREFIX TAG PROViDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X4 IDSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) i (XS) COMPLETE DATE : ._. i H1020 Continued From Page 9 H1020 (See H1020 Paragraph #9) The Grievance Coordinator currently documents Ireceipt of the grievance / complaint, investigation, resolution, PQIC Committee findings and appeals agency record, clinical patient's in the chronological grievance file and log. Currently I . (See H1020 Paragraph # 10) The Quality Management Department has established a process for prompt resolution of patient complaints. Grievance- Coordinator was hired on 11/20/07- A log of all complaints is currently kept by date, person, allegation, follow-up and outcome/ resolution of complaint. This log is utilized for statistical evaluation, service evaluation for trends, and is available for review by the'NY State Department of Health and JCAHO. Continuous .1 I ! . STATE FORM QN9M11 PRINTED: 02/01/2008 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES -.PLAN OF CORRECTION , (X1) PROVIDER/SUPPLIERJCLIA STATEMNT IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION OFCOMPLETED k BUILDETE B. WING . (X3) DATE SURVEY LC0423A NAME OF PROVIDER OR SUPPLIER 1210512007 STREET ADDRESS. CITY. STATE, ZIP CODE AMERICARE OF NEW YORK CITY (X4) ID PREFIX 205 KINGS HIGHWAY BROOKLYN, NY 11223 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H1020 Continued From Page 9 documented evidence of a date of resolution for the complaints. 1 On 12/5/07 at 4:13 PM, the Director of Patient S services was interviewed and stated "It willb added today." H1036! 766.9(l)Governing authority H1020 (See H1020 Paragraph # 11) A resolution section was added to the complaint log on 12/05/07. 1 Immediately implemented #2) (See H1036 Paragraph H1036 - I Section 766.9 Governing authority. (I) Quality Improvement Meeting was held on Wednesday, January 30, 2008. The Director of Quality. assurance served as the chairperson of the Committee on that day. defined . The governing authority or operator, asom cre(See iteofa icnsd inPat 00ofths Part 700 of this Title, of a licensed home care in . . services agency shall: to . ... (I)appoint a quality improvement committee..... Theof-of care. establish and oversee standardsshall consist a committee quality improvement .. H10360 Paragraph #2) The committee consisted of at least one or more (I) of the following professionals: a. Physician Professional Nurse b.Registered c. Representative of rehabilitative services (See H10360 Paragraph #2) .(I) The committee is scheduled to meet quarterly. r /00 1/30/08 - consumer and appropriate health professional persons including a physician if professional health care services are provided.The committee shall meet at least four times a year to: (1) review policies pertaining to the delivery of the health care services provided by the agency and recommend changes in such policies to the governing authority for adoption; )conduct a clinical record review of the safety, ualitycof rvies provided adequacy, type (2)quct a and quality of services o ided owere which includes: (i) random selection of records of patients currently receiving services and patients discharged from the agency within the past three months; and (ii) all cases with identified patient complaints as of specified in subdivision (j)this section; (See H1036 Paragraph #3) (1) Administrator and Quality Assurance Director practices standardized consistent, ensures company-wide. An updated quality, manual serves this purpose and is updated annually for distribution. C niu u (1) Findings, questions and recommendations, of analyzed and presented by the Manager Clinical Services, to the entire committee. (See H1036 Paragraph #3) E021199 QN9M1 1 If continuation sheet 10 of PRINTED: 0210112008 FORM APPROVED New York State Department of Health STJEMENT OF DEFICIENCIES LAN OF CORRECTION (X) PROVIDEPIsuPPLIEPCLIA IDENTIFICATION NUMBER: MULTIPLE CONSTRUCTION(X3) (X-2) DATE SURVEY : NAME OF PROVIDER OR SUPPLIER LC0423A, B. WING 1210512007 STREET ADDRESS, CITY, STATE; ZIP CODE AMERICARE OF NEW YORK CITY (X4) 0 PREFIX TAG ID BROOKLYN, NY 11223 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE DEFICIENCY) CROSS-REFERENCED TO THE APPROPRIATE (X5) COMPLETE 205 KINGS HIGHWAY SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 1036 'Continued From Pge10 Page H1036 (See H1036 Paragraph #4) (2) Fundamentally; compliance efforts have been designed by the Administrator, Quality Assurance Director, and Clinical Manager to establish and promote prevention, detection, and resolution of instances of conduct that do not conform to. Federal and State law, program requirements Americare Inc. ensures continuous improvement initiatives by: Conducting Nursing and HR chart audits * * * * Identifying the area or activities that we would like to make better Planning what is needed to be done to bring about improvement Making the improvements Deciding what needs to be done and checking how well it worked. The uses of audits and /or other evaluation techniques have been used to monitor compliance and assist in the reduction of identified problem areas. (Targeted date of completion = 4/08). Ongoing (See H1036 Paragraph #4) (2) The Director of Education has developed and implement regular, effective education and training programs for all affected departments and/or employees. The Director of Education trained the nursing staff on compliance, documenting, and 2/28/08. 1/25/08, . on charting 1128/08 (See H1036 Paragraph #5) (I) Random selection of records of patients patients services and receiving currently discharged from the agency within the past three months was conducted by the Clinical Manager and was review, analyzed and presented to the Quality Improvement Committee on 1/30/08. (See H1036 Paragraph #5) (I) Clinical Manager will conduct a client record review on a quarterly basis to ensure each client treatment plan contains a review date. The prompt for.the quarterly review of the client records by the Clinical Manager will be the electronic desk planner of all scheduled facility meetings and activities that is posted on the agency's local area network.. 1130/08 STATE FORM O11 9 QNgM11 PRINTED: 02J01/2008 FORM APPROVED New York State Deoartment of Health STATEMENT OF DEFICIENCIES 'LAN OF CORRECTION , (Xi) PROVIDERISUPPLIERICLA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A BUILDINGOMPLETED B. WING ___________ (X3) DATE SURVEY LC0423A NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1210512007 205 KINGS HIGHWAY , AMERICARE OF NEW YORK CITY (X4) ID PREFIX TAG BROOKLYN, NY 11223 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (XS) COMPLETE DATE I Continued From Page 10 H1036 (See H1036 Paragraph #6) (ii) All records of patients who have filed a gnevancel complaint during the previous three months; were summarized by the Grievance Coordinator and QM liaison in including statistical reports. These reports reflected grievance/incident patient timeframes, explanations, resolution interaction, as well as patient satisfaction. 1/30/08 STA l E FORM q199 QN9M11 PRINTED: 02101/2008 FORM APPROVED New York State Department of Health ST ATEMENT OF DEFICIENCIES FCINCIES STTMNOFOF CORRECTION PLAN (XI) PROVIDERJSUPPLIERICLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED COMPLETED LC0423A rNAME OF PROVIDER OR SUPPLIER B.WING STREET ADDRESS. CITY, STATE, ZIP CODE 12/05/2007 AMERICARE OF NEW YORK CITY (X4) ID i PREFIX TAG I TA 205 KINGS HIGHWAY BROOKLYN, NY 11223 ID PREFIX TAG (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (X5) COMPLETE DATE C ied From Page 10 H1036 1e(3) I of wry 1 (3) prepare and submit a written summary of to the governing authority for review findings necessary action; and (4) assist the agency in maintaining liaison with other health care providers in the community., This Rule is not met as evidenced by: Based on record review and interview, the oImprovement meetings included all required i topics and that a physician and a consumer were Spresent at the meetings. Failure to have a physician and a consumer at the Quality Improvement Meetings and failure to address all required topics places the patient at, i risk for substandard care. ' . (See H1036 Paragraph #7) The responsibilities and reporting of Quality Improvement Committee Members entails the following: Meeting at least four times a year, . Performing Clinical Record Audits Making recommendations to the Governing Quarterly Agency staffing Authority regarding care needs, as well asand patient related community service needs (See H1036 Paragraph #7) - (3)Making recommendations regarding further in- . service educational needs of staff and as it relates to agency failed to ensure that the Quality improved service delivery and clinical trends in care; adequacy, type and quality of services provided Conducting a clinical record review of the safety, Quarterly Submitting a written summary of committee findings and recommendations to the governing authority for review and action i r n (4) The Adminisratr i organizing' and directing (4Te Administrator is the agency's ongoing functions and maintains ongoing liaison among the governing body, the of professional personnel, staff and with Ongoing The fin findings sare: .group other health care providers in the community The agency " Performfnce Improvement as(See Commtteearedocuente Committee Meetings are documented as conducted on "1/4/07, 12/4/07, 10/5/06, and 9/21/06." -There is no documented evidence of physician and consumer presence at the meeting. There was no documented evidence that A physician and a consumer were present during our Quality Improvement Committee on 1/30/08 address all required topics. ( See attachments) (See H1036 Paragraph # 10) H1036 Paragraph # 9) and will be present for all meetings in order to 1/30/08 A physician and a consumer were present during complaints , a random selection of patient records or discharged records were was * discussed. I7 our Quality Improvement Committee on 1/30/08 and will be present for all meetings in order to address all required topics. On 12/5/07 at 2:35 PM, the Administrator was interviewed and stated: .... those things have not occurred (discharged cases)." .rE FORM 0219 QN9M11 If continuation sheet 11 of 15 PRINTED: 02J01/2008 FORM APPROVED New York State Department of Health ST-'TEMENT OF DEFICIENCIES 'LAN OF CORRECTION (XI) PROVIDERISUPPLIERICLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A_ (X3) DATE SURVEY COMPLETED BUILDING ___________ LC0423A NAME OF PROVIDER OR SUPPLIER' B.WING STREET ADDRESS, CITY, STATE. ZIP CODE 12/0512007 AMERICARE OF NEW YORK CITY (X4) ID PREFIX TAG BROOKLYN, NY 11223 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTIO', (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 205 KINGS HIGHWAY SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H1036 H1036 (See H1036 Paragraph# 11) a Physician Americare Inc. policies do not require and a 'consurrier to be present during Performance Improvement Committee meeting. A physician is required to attend our Professional Advisory Committee. We have documented minutes indicating at the a board member, Administrator, Vice President, Physician, and Directors attending the following meeting on 11-14-06, 3-7-07, 7-25-07, 11-21-07. ( See attachments) (See H1036 Paragraph # 11) a Quality has Inc. currently Americare Improvement Committee and is scheduled to meet quarterly. (See H1036 Paragraph # 12) A consumer and a physician are part of the committee and will be present for all meetings. (See H1036 Paragraph # 13) On 1/30/08 Clinical Manager and the Grievance Coordinator presented complaints and discussed a random selection of active and discharged patient records. (See H1036 Paragraph # 13) The Administrator, Director of Quality Assurance ongoing data and Clinical Manager ensures collection for high priorities from all of the departments this measure and process is used to monitor performance, the stability of existing processes, identify opportunities for improvement, and identify changes that lead to improvement, or improvement. sustain (See H1036 Paragraph # 14) The administrator of this agency since July 23, 2007, has put the above regulations into effect, Quarterly 1/30/08 Immediately implemented STATE FORM . * QN9M11 PRINTED: 02/01/2008 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES ' PLAN OF CORRECTION (X1) PROVIDERJSUPPLIERICLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED B. WING ___________ LC0423A NAME OF PROVIDER OR SUPPLIER ' 12/05/2007 STREET ADDRESS, CITY, STATE, ZIP CODE AMERICARE OF NEW YORK CITY (X4) ID PREFIX TAG ' 205 KINGS HIGHWAY BROOKLYN, NY 11223 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE i SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) . H11421 Continued From Page 11 H11421 766.9(o) Governing Authority Section 766.9 Governing authority (o) Health Provider Network Access and Reporting.Requirements. The governing I authority or operator of an agency shall obtain from the Department' s Health -Provider Network asite HPN (N), accounts for each agency that it operates and ensure that sufficient, knowledgeable staff will be available to and shall maintain and keep current such accounts. At a i minimum, twenty-fourhour, seven-dayaaieek dontacts for emergency communication and alerts, must be designated by each agency in the HPN Communications Directory. A policy ,defining the agency HPNcoverage-consistent 's H1142 H1142 (See H1142Paragraph #1) (o) On 12/05/07 the day of the survey,, Director of Quality Assurance was asked to logon to the HPN and demonstrate navigation. She was able to :successfully login and provide compliance. Furthermore, she is a CHRC authorized person and a DOH designee with Administrative rights. The Director assures and maintains compliance by continually updating the managing tool and HPN Inc. our Americare for directories Coordinators since 1/07. 12/05/07 mt os a .(o) with the agency' s hours of operation shall be " created and reviewed by the agency no less than annually. Maintenance of each agency' s HPN accounts shall consist of, but not be limited to, the following: (1) sufficient designation of the agency' s HPN Scoordinator(s)to allow for HPN individual user application; (2) designation by the governing authority r operator of an agency of sufficient staff users of 1/3/08 Americare Inc. currently has a policy defining the agency's HPN coverage consistent with the agency's hours of operation and is created and reviewed by the Administrator no less than annually. (See H1142Paragraph #1) Administrator was issued an HPN account on (See H1142Paragraph #2) (1) Americare Inc. HPN coordinators continues to adhere to all the requirements of the HPN user contract current and complete updates of the communications Directory reflecting changes that Monthly include, but are not limited to, general information and personnel role changes as soon as they occur, and a minimum, on a monthly basis. I the HPN accounts to ensure rapid response to I requests for information by the State and/or local Department of Health; a (See H1142Paragraph #3) (2) The Director of Quality Assurance, Director of Marketing and CHRC Authorized persons at Americare Inc. has HPN accounts. Administrator was issued an HPN account on 1/3/08. 1/3/08 (3) adherence to the requirements of the HPN a cto the (3) Iuser contract; and (4) current and complete updates of the SCommunications Directory reflecting changes that include, but are not limited to, general (See H1 142Paragrph #3). The Administrator ensures rapid response to (2) request for information by the State and/or local Ongoing information and personnel role changes as soon as they occur, and at a minimum, on a monthly E FORM Department of Health. QN9M11 Ifcontinuation sheet 12 of 15 PRINTED: 02101/2008 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES ,0 LAN OF CORRECTION (XI) PROVIDERiSUPPLIERJCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A BUILDINGOMPLETED (X) DATE SURVEY B. WING LC0423A NAME OF PROVIDER OR SUPPLIER "__________ 12/0512007 STREET ADDRESS, CITY, STATE, ZIP CODE AMERICARE OF NEW YORK CITY (X4) ID PREFIX TAG 205 KINGS HIGHWAY BROOKLYN, NY 11223 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H142 Continued FromPage 12 H l142 (See H 1142Paragraph #4) e (3) Americare Inc. HPN coordinators continues to adhere to the requirements of the HPN user I contract current and complete updates of the communications Directory reflecting changes that Continuous include, but are not limited to, general information. and personnel role changes as soon as they occur, and a minimum, on a monthly basis. (See H1142Paragraph #5) (4) The Director of Quality Assurance assures and maintains compliance by continually updating the managing tool and directories for our Americare Inc. HPN Coordinators since 1/07. (4) Administrator was issued an HPN account on 1/3/08. Continuous EI STA IE FORM - 1Is9 - QN9M11 PRINTED: 02/01/2008 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES (XI) PROVIDERJSUPPLIERCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED Ar PLAN OF CORRECTION LC423AB. NAME OF PROVIDER OR SUPPLIER WING 12105/2007 STREET ADDRESS, CITY, STATE. ZIP CODE AMERICARE OF NEW YORK CITY (X4) ID PREFIX TAG 205 KINGS HIGHWAY BROOKLYN, NY 11223 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (eH114Paarp.6)immediately Americare Inc. currently has a written policy and (See enclosed attachment) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H11421I Continued From Page 12 H1142 (See Hl1142 Paragraph#6) basis. implemente I basis. ~procedure for the Health Provider Network (HPN). imeete This Rule is notmet as evidenced by: I (See H11142 Paragraph # 7) Amercare Inc. currently has a written policy and procedure for the Health Provider Network (HPN). Based on record review and interview, the agency failed to have a written policy and procedure for the Health Provider Network (HPN). I implemented Immediately . . - _(See H1 1142 Paragraph # 8) Americare Inc. currently has a written policy and procedure for the Health Provider Network (HPN). - Immediately implemented Failure to have written policies and procedures for HPN places patients at risk in emergency situations .. The findings is: i . (See HI1142 Paragraph # 9) Administrator was issued an HPN account on 1/3/08. 1/3/08 no There is documented evidence of policy and procedure for Health Provider Network.'. On 12/5/07 at 4:15 PM the Administrator was i e Sinterviewed and was unable to provide an explanation. (See H1432 Paragraph #1) (a)The Administrator ensures rapid response to request for information by the State and/or local Department of Health; shall ensure the prompt submission of all records and reports required by the department. Ongoing H14321 766.12(a)(3) Records and reports 766.12 Records and reports. H1432 (See H1432 Paragraph #2) All (3) patient records are being maintained as per regulations. Ongoing (a) The governing authority or operator shall ensure the prompt submissionof all records and reports required by the department and that: at (3) a minimum, the following reports and records are retained by the home care services agency and available to the department upon request: minutes of the meetings of the governing (i) authority and the committees thereof which shall be retained for three years from the date.of the meeting; .- FORM E 021199 QN9M11 Ifcontinuation sheet 13 of15 PRINTED: 02/01/200 FORM APPROVE[ New York State Department of Health ST ^ TEMENT OF DEFICIENCIES f LAN OF CORRECTION (X1) PROVIDERJSUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING ___________ (X3) DATE SURVEY COMPLETED LC0423A NAME OF PROVIDER OR SUPPLIER B_ WING __________ 12105/2007 STREET ADDRESS, CITY, STATE ZIP CODE AMERICARE OF NEW YORK CITY (X4) ID PREFIX TAG 205 KINGS HIGHWAY BROOKLYN, NY 11223 ID PREFIX TAG PROViDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H1432 Continued From Page 13 H1432 (See H1432 Paragraph #3) (I) Quality is everyone's responsibility and it is important that both the medical and the administrative leadership assume a key role in ensuring that the quality program is effectivein achieving its objectives. Leadership is assured through a variety of mechanisms, including representation on the quality committees and substantial involvement in .the development and implementation of the quality program. (See H1432 Paragraph #3) (I) Minutes of PAC meetings of the governing authority and the committee thereof will be retained for three years. from the date of the meeting. Quarterly STATE FORM O2l15 QN9M11 PRINTED: 02/01/2008 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES " PLAN OF CORRECTION (X1) PROVIDERJSUPPLIERCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A.BUILDING B. WING (X3) DATE SURVEY COMPLETED __________ LC0423A NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE 12.0512007 AMERICARE OF NEW YORK CITY (X4) ID PREFIX TAG 205 KINGS HIGHWAY BROOKLYN, NY 11223 PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES "I (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H14321 Continued From Page 13 (ii) records of all financial transactions directly related to delivery of patient care which shall be retained three years from the date of the transaction; H1432 (See H1432 Paragraph #4) (ii) All patient records are being maintained as per Ongoing regulations. (Ans. of question H1432 # 5 See H1432 Paragraph #1-4).See above (iii) personnel records, which shall be retained three years from the date.of employee termination or resignation; . (Ans. of question H1432 # 6 See H1432 Paragraph #1-4) See above (iv) records of grievances and complaints which shall be retained for three years from the date of resolution; (v) all records related to patient care and . (Ans. of question H1432 # 7 See H1432 Paragraph #1-4) See above P h e services; and I (vi) any other records-required to be kept by this Part or Part 765. i ' (Ans. of question H1432 # 8 See H1432 Paragraph #1-4) See above (See H1432 Paragraph # 9)\ This patient is a private patient (Guardianship Project). An initial nursing visit was done. With this vendor, they inform us when a nursing visit should be done (based on the patient needs). This Rule is not met as evidenced by: Based on record maintainand interview, the Sagency failed to review documnentation of patient care and services. This was evident for 1 of 6 patient care records reviewed. (Patient #2). Failure to have documentation of care for a Ipatient placescare and violates the patient' s the patient at risk for unsafe and substandard rights. The findings are: (Continuation of H1432 Paragraph # 9) When our case manager, after reviewing the chart, notes that a visit has not been done for a long period of time (more than 6 months) she can then call the vendor and ask them if they would like us to reassess the patient. Only upon their request can we go in to see the patient. As was in the request was made every 6 case of patient #2. Aand subsequently for revisit in January 2008 Ongoing Patient #2 has diagnoses which include Transient Ischemic attack. months. There was no documented evidence that the patient received the Bill of Rights; was informed of financial liability and received Advanced Directives. ,'E FORM 021199. QN9M11 Ifcontinuation sheet 14 of 15 PRINTED: 02I1/2O FORM APPROVE[ New York State Department of Health S-8,TEMENT OF DEFICIENCIES OLAN OF CORRECTION (Xl) PROVIDEPJSUPPLIERJCLLA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING ___________ (X3) DATE SURVEY COMPLETED LC0423A NAME OF PROVIDER OR SUPPLIER AMERICARE OF NEW YORK CITY (X4) 1D PREFIX TAG * 12105/2007 STREET ADDRESS, CITY, STATE, ZIP CODE 205 KINGS HIGHWAY BROOKLYN, NY 11223 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROViDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE . H1432 Continued From Page 14 H1432 (See H1432 Paragraph # 10) To enhance currently compliant operations and under the direction of the Clinical Manager, on (3/3/08 all nursing staff will receive in-service training regarding care plans, appropriateness and policies and procedures. The training will emphasize the importance of documentation of care as well as reporting problems to the Clinical Manager or Director of Patient services immediately. - . (Ans. of question H1432 # 11 See H1432 Paragraph #12) See above I (See H1432 Paragraph # 12) The Quality Management and Nursing Departments understand the importance of documenting. The nursing staff was in-service by the Clinical Manager on how to document discussions with patients or their surrogates about critical issues, DNR, Do Not Hospitalize orders, decision about artificial nutrition and hydration for unintentional weight loss, palliative versus curative care for pressure ulcers, and other decisions to forego or limit evaluations and interventions for conditions arising at the end of life. Americare Inc. currently has policies and practices in place to address these issues. This measure was put in place to ensure that deficient practices do not recur for those patients found to have been affected by the deficient practice. H1432 Paragraph # 12) On patient #2's revisit, dated 01/24/2008 a Bill of Rights was given to the patient and a signed (by the patient) Patient Orientation Form was place into the chart. 1/24/08 Ongoing r' o(See STA RE FORM z,9 QN9M11 PRINTED: 02101/2008 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES o PLAN OF CORRECTION (XI) PROVIDERJSUPPLIERICLA IDENTIFICATION NUMBER: iX2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED B. WING __________ LC0423A NAME OF PROViDER OR SUPPLIER STREET ADDRESS, CITY, STATE. ZIP CODE 12/05/2007 205 KINGS HIGHWAY BROOKLYN, NY 11223 AMERICARE OF NEW YORK CITY (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)I . (X5) COMPLETE DATE H1432 Continued From Page 14 H1432 There was no documentation of a Plan of Care, medical orders, aide activity sheets or supervisory reports. There was documented evidence of the RN. approval of admission, a Nursing Assessment (See H1432 Paragraph# 13) The Home' Health Certification and Plan of Care was not produced due to the fact that the case was terminated within one week of receiving back the paperwork from the field nurse. (See H1432 Paragraph # 14) and progress notes. On 12/5/07 at 2:50 PM, the Director of Patient Services was interviewed and stated " I'm sure there are medical orders but not in the chart. It is possible the information is not there. " Fundamentally, compliance efforts have been designed by the Administrator, Quality Assurance Director, and Clinical Manager to establish and promote prevention, detection, and 'resolution of instances of conduct that do not conform to Federal and State law, program requirements. Quality Assurance and Nursing Departments is ensuring continuous improvement initiatives by: Conducting Nursing and HR chart audits Identifying the'area or activities that we would like to make better Planning what is needed to be done to bring about improvement Making the improvements Deciding what needs to be done and checking how well it worked 4/15/08 I I 0 :. I (See H1432 Paragraph # 13) The uses of audits and /or other evaluation techniques have been used to monitor compliance and assist in the reduction of identified problem areas. (Targeted date of completion = 4/15/08). (See H1432 Paragraph # 13) The Director of Quality Education developed and implement regular, effective education and training programs for all affected departments and/or employees. The Director of Education trained the nursing staff on compliance, documenting, and charting on 1/25/08,2/28/08. . (See H1432 Paragraph # 15) Department Clinical Manager /Case Managers is effectively conducting weekly ground round meetings including chart and medication reviews with staff for updates and processes for improvements. When applicable the Clinical Manager determines activities, which constitutes a high-risk process, and conducts a Performance improvement activity, including data collection, analysis, aggregation and improvement measurements. This measure was put in place to ensure that deficient practices do not recur. 12/10/07Ongoing 'E FORM 0211 QN9M 1I If continuation sheet 15 of 15 PRINTED: 04/03/2008 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDERJSUPPLIERJCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCI ION A.BIINGCOMPLETED ___________ (X3) DATE SURVEY 1394L001 NAME OF PROVIDER OR SUPPLIER A.BUING NG 03/13/2008 STREET ADDRESS, CITY. STATE, ZIP CODE ALL METRO (X4) ID PREFIX i TAG " 50 BROADWAY LYNBROOK, NY 11563 SUMMARY sTArEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ' PR I PREFIX TAG PLAN OF CORRECTION PROVIDE (EACH CORRECTIVE ACTION SIOULD BE CROSS-REFERENCED tO' HE APPROPRIATE DEFICIENCY) (X) DCOMPLETE DATE H 000 Initial Comments H 000 A Full Survey was performed at All Metro Health I Care on 03112/08 and 03113108. Nine (9) Patient Records were reviewed and are identified as Patients #1 to #9. Two (2) Home Visits were made to Patients #4 !and #6. . " "" The agency's Home Health Aide Training Program (HHATP) was reviewed and eight (8) iHHATP Training Records were reviewed and are identified as Trainees #1 to #8. Eight (8) Personnel Records were reviewed and are identified as Employees #9 to #16. A total of sixteen (16) Personnel Records were reviewed that #8."" the HHATP Trainee records #1 to included I i H204 766.1(a)(1) Patient rights Section 766.1 Patient rights. (a) The governing authority shall establish written policies regarding the rights of the patient and shall ensure the development of procedures implementing such policies. These rights, policies and procedures shall afford each patient the right to: (1) be informed of these rights, and the right to exercise such rights, in writing prior to the initiation of care, as evidenced by written documentation in the clinical record; H 204 (2) be given a statement of the services available by the agency and related charges; LABORAT Y DIRECTR'S O1P I.tDER/SUPPLIER REPRESENTATIVE'S SIGNATURE 72Xj11 TITLE ) .DArE IX- STAEO M 0f IIcon.tlnuafion sheet 1 of 21 All Metro Health Care Plan of Correction 2. The POC lacked any reporting to the Governing Authority rcgarding the QIC activities/review results and/or recommendations to the Governing Authority that would affect the quality of patient care services. \- H1337 - 766.11 (f) (ii) Personnel: 1. The POC failed to-include any ongoing review of the temporary paraprofessional records to ensure compliance and that the actual supervision was performed by the agency and filed into the personnel record. 2. The POC failed to include any reporting to the Governing Authority. Please be advised that pages #19 to #21 were not included with the original Statement of Deficiencies. We apologize for the error and' any inconvenience that has been caused to the agency. Enclosed are pages #1 to #21 inclusive for the agencys review. Thank you. 3. PRINTED: 04/03/2008 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDER/SUPPLIERICLIA IDENTIFICATION NUMBER (X2) MULTIPLE CONSTRUCTION _____ A. BUILDING _____ (X3J DATE SURVEY COMPLETED 8. WANG 1394L001 NAME OF PROVIDER OR SUPPLIER ____________ 03/1312008 STREETADDRESS, CITY. STATE, ZIP CODE ALL METRO (X4 ID PREFIX TAG ) 50 BROADWAY LYNBROOK, NY 11563 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) i ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) I 1 COMPLETE DATE 1 I H 204: Continued From Page1 I . H 204 H204 - 766.1(a)(1) Patient Rights and Rights Patient AMHC's Responsibilities (Exhibit, A) has been amended, deleting the word "Medicare" in section 10. A copy of the amended Bill of Rights shall be mailed/delivered to I all patients currently on services by (3) be advised before care is initiated of the extent to which payment for agency services may be expected from any third party payors and the extent towhich payment may be required from the patient. (i) The agency shall advise the patient of any I changes in informationprovided under this I paragraph or paragraph (2) of this subdivision-as I soon as possible, but no later than 30 calendar days from the date the agency becomes aware of the change. (ii) All information required by this paragraph shall be Swdfdng; provided to the patient both orally and in rnDirector (4) be informed of all services the agency is to provide, when and how services will be provided, and the name and functions of any person and affiliated agency providing care and services. i!alptetscrety'o i 6/30/08 to clear evcsb up any i misunderstanding regarding sources of reimbursement. All associates will be meeting. oriented to this change during a staff I!Medicare. Moving forward, B) has been revised deleting I AMHC's Agreement for Service (Exhibit the term only the o a form shall-be used. t rsnsibe associate i te responsible ase is the The of Clinical Services (DCS) and the Sr. VP of Patient Services who is a member of the Governing Authority. Completion date 5-31-08 . This Rule is not met as evidenced by: t ej Based on review of the admission packet, home visits, patient records review, and staff interview, the agency failed to provide their patients with accurate information regarding the payorsources from which the agency could accept payment and the related charges for the services available by the agency. This was evident in three (3) of nine (9) patient records reviewed (Patients #1, #3, and #9) admitted after 12/05 when the Agreement for Service was revised and in one (1) of two (2) home visits (Patient #6). The failure of the agency to advise the patients of accepted payor sources, and related charges for the services available by the agency places the patients at risk for financial liability for services provided by the agency. STATE FORM. -n - 72XJl11l IfconI~nuoton shoet 2 of 21 PRINTED: 04/0312008 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDERISUPPLIER/CLIA IDENTIFICATION NUMBEIR (X2) MUI.TIPLE CONSTRUCTION A.BUILDING "B, (X3) DATE SURVEY COMPLETED _ WING __ __ _ _ __ .._ 1394L001 NAME OF PROVIDER OR SUPPLIER ALL METRO ) JX4) 1i PREFIX j TAG STREET ADDRESS. CITY. STATE, ZIP CODE 50 BROADWAY 03113/2008 LYNBROOK, NY 11563 ID I 1 PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST 3E PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 1 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE ,CROSS-RCFERENCEO TO THE APPROPRIATE DEFICIENCY) (X5) 1 COMPLETE DATE H 204 Continued From Page 2 Findings include: I Responsibilities, and Agreement for Service in H 204 Review of the Patient Rights and the admission packet and patient records #1,43, #6,and #9, the column #10 on the Patient Bill of Rights reads "As a patient you have the right to I Be fully informed, orally and in writing, at the time of admission, and in advance of the care I provided ... must include allitems and services " for which you may be responsible reimbursement, eligibility for third party I I I I reimbursement, coverage available under i Medicare, Medicaid, and any other federal program of which the agency is aware." Review of the Agreement for Service revised 12/05 documented under the heading Authorization of Payment that "If a Medicaid client, I authorize All Metro Health Care to apply under Title XIX/XX, or to Medicare if a Medicare patient, and authorize payment directly to All Metro Health Care. I authorize release by All Metro Health Care of all records necessary to I obtain payment" During home visit to Patient's #6 home on 03/13/08 at 9:00 AM, review of Patient Rights and Responsibilities and Agreement for Service agreement included the information, that Medicare was a payor source in the admission packet. An interview was conducted on March 12, 2008 at 2:00 PM with the Acting Director of Clinical Services (ADCS), the ADCS acknowledged the survey findings and could not provide an explanation why the information about Medicare was on the Patient Rights and Responsibilities and Agreement for Service was included on the forms since the licensed home care agencies STATE FORM MIN 72XJ1 If tinuation Sheet 3 of 21 iA-22-2009 16:25 ALL METROn HE LTHCARE CONT . 516881,3104 P.05 New York State Department of Health STATEMENT OF; DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIoERmSUPPLIEIOLA IDENTIFICATION NUM6ER: '(X2)MULT A. BUILDING B. WING " PRINTED: 0513120lR * FORM APPROVED LE CONSTRUCTIoN _____ _____ (X3) DATE SURVEY COMPLETED. LCO989A NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 03/13/2008 50 BROADWAY LYNBROOK, NY 11563 ALL METRO (X4) ID SUMMARY STATEMENT OF DEFICIENCIES I0 PROVIDER'S PLAN OF CORRECTION PREFIX TAG (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PREFIX TAG (EAcH CORREClIVE ACTION sHOULD BE " CROSS-REFERENCED TO THE APPROPRIATE r LIEFIGIENCY) COMPLETE DATE H 204 Continued From Page 3 cannot bill Medicare. H1002 766.9(a) Governing authority Section 766.9 Governing authority, The governing authority or operator, as defined in Part 700 of this Title, of a licensed home care services agency shall: (a) be responsible for the operation of the agency-, management and (b) ensure compliance of the home care services agency with all applicable Federal, State and local statutes, rules and regulations_ This Rule is not met as evidenced by: Based on review of the patient's admission information packet, patient records, personnel records and policy and procedure review, and staff interview. the Governing Authority failed to be responsible for the operation and the management of the agency. This was evident in the following deficiencies: H 204, H1002 766.9(a) Governing Authority 766.1(a) Instructors have been reoriented to the H1002 new HHATP revised in April 2006. Particular attention has been given to the need -for all candidates to successfully complete all testing & the components of competency program, with remediation provided for substandard scores in any given area, outlined in the "Guide to HHA an te ainine Evaluation" Training and Competency EvalatonA page 5. This indicates that he program as H0204 - 765.1 (a) (1) Patient Rights H1337 - 766.11 (f) (ji) Personnel Based on review of the Home Health Aide Training Program (HHATP) records, personnel records, policy and procedure review and staff interview, the Governing Authority failed to ensure that the HHATP is In compliance with the New York State Department of Health (NYSDOH) Guide to Home Health Aide Training and Competency Evaluation revised in April STATE FO RIA additional training...and may reevaluate the aide's competency requiring areas those in only Moving forward, such remediation." remediation shall be provided and noted in the training documentation. All Clinical Supervisors have been reoriented to the SCV (Supervised Clinical Visit) form and the correct manner of completion to ultimately include 8 hours of field supervision as well as the documentation of the required care observed. The nursing and 'HR associates have been reinstructed that under no circumstances Is a certificate of training. to be issued until all components of the been successfully training have completed. It has also been restated that henceforth, the graduate is to receive the ORIGINAL Certificate, with a copy being filed in the personnel record. The graduate shall also receive a copy of the Competency Evaluation. The graduate will sign a log indicating that they . ,receiymdttq oriainal certificate "may provide .iof 4 r21 hmd -?/ MRY-22-2p,8 1:- 25 ALL METRO HERLTH{'CIRF CONT - .51688 13104 P.iB5 PRINTED: 051132.008 ,ew York State De r ment of Health STATEMENT OF DEFICIENCIES AND PIAN OF CORRECTION (XI) pROVIDER/SUPPL;ERtCA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTiON A. BULDING A. BULDN FORM APPROVED JX3) DATE SURVEY COMPLETED: COMPETER o NAME OF PROVIDER OR SUPPLIER | LC~ggA LCO A ' a. WING .0311312008 STMEETAODRESS, CITY, STATE, ZIP CODE ALL METRO (X4) ID PREFIX TAG 50 BROADWAY LYNBROOK,NY 11563 SUMMARY STATEMENT OF DEFICIENCIES (EACH OEFtCIENCY MUST BE PRECEDED 1Y FULL REGULATORY OR LSC IDENTIFYING INFORMATIONf ID PREFIX TAG PROVIDERS PLAN OF CORRECTION (EACH COflRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X) COMPLETE DAE H1002 Continued From Page 4 H1002 2006 The Governing Authonty's failure to be responsible for the agency's HHATP places the patients at risk for the delivery of poor patient Supervision of the HHATP instructors will be completed during each scheduled training class by the DCS. Supervision of the Program Director will be care by the home health aides who have not satisfied the NYSDOH. forth by the training program requirements set Findings include: On 03/13/08. the agency's HHATP was reviewed onsite. The review was performed on the agency's last HHATP class that was conducted on 11101/07 to 11116/07. Eight (B)Trainee records and Personnel records were reviewed and are identified as Trainees #1 to associate is the Director.of Clinical Services (DCS), the HR Coordinator and the VP of Patient Services. Next training class has been scheduled from 5/21/08-6/6/08. The VP of Patient Services is a member of the Governing Authority. As a member of the Governing Authority, the VP of Patient Services communicates on a weekly basis with the other members of audit reports are sent to all members of the GA and the VP of Pt Services GA the results and also reviews the quarterly PAC activities with the GA. All changes in policy and procedure are reviewed With the GA prior to being published and the GA monitors the submission of continuous quality activities on a quarterly basis to ensure that the standards of care continue to be met. Completion Date 5/31/08 reviews with the other members of the the' Governing Authority. All record completed by the VP of Patient Services. The responsible The major issues that were identified are as follows: 1. The trainee records and the personnel records were incomplete regarding remediation, observation and re-testing for failing grades during the HHATP. This was evident in eight (8) of eight (8) records reviewed., 2. The trainee records failed to document that the all the trainees were provided the required eight (8) hours of SPT (Supervised Practical Training) in the. patient care setting. The trainee records lacked documentation to verify that the Registered Nurse (RN) had observed the required skills/tasks for all trainees in the HHATP. Certificates of Completion were issued to the Trainees prior to completion of the SPT andlor STATE FORM I 72XJ11 Ifcoruawn she 5o-1 i MAY-22-208 16:25 ALL METRO HEALTHCARE CONT 5168813104 P.07 PRINTED: 05/13/2008 of Health - New York State Department STATEMENT OF DEFICIENCIES AND PLAN OF CORRECION " o (X) MULTIPLE CONSTRUCTION A A. GUIWDING _________ B: WING FORM APPROVED (Xl) PROVIOERISUPPLIERCUA IDENTIFICATION NUMBER (X3) DATE SURVEY COMPLETED LCOS89A NAME OF PROVIDER OR SUPPLIER 0311312005 STREET ADDRESS. CITY, STATE, ZIP CODE ALL METRO X4) IC PREFIX TAG 50 BROADWAY LYNBROOK, NY SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG S63o PROVIDER'S PLAN OF CORRECT)ON (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETE DATE H1002 Continued From Page 6 Skills/Tasks Observation by the RN_ 3. The trainee and the personnel records lacked documentation that the agency provided the H1002 trainees the original Certificate of Completion and a copy of the Competency Evaluation form upon completion of the HHATP. This was evident in eight (8) of eight (8) trainee and personnel records reviewed. For example: 1. The "Independent Inservices" form documented the following: Trainee #,3 had the following test scores for: Module II 60), Module VII (50), Module VIII (65) and Midterm exam (70). The Trainee's record lacked documentation that the agency provided any form of remediation testing, teaching and or ubservation for Modules II,VII and VIII. The record included the copy of the Certificate of Completion dated 11/26/07. Trainee # 1 had the following test scores for: Module 11 (55), Unit C (62), Unit F (65) and Final exam (68). The Trainee's record lacked documentation that the agency provided any form of remediation testing, teaching and or observation for Module Ii and Unit F. , The record included the copy of the Certificate of Completion dated 12/14/07. Trainee # 7 had the test score of. (60) for Moddle II - The Trainee's record lacked dcumentation that the agency provided any form of remediation testing, teaching and or observation for Module STATE FORM ,720J44 If con tin a.t 6 of 21 NRY-22-2008 16:25 ALL METRO HEALTHCARE CON" 5168813104 P.08 New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDFRJSUPPUERJCLIA IDENTIFICATION NUMBER; Q(2) MULTIPLE CONSTRUCTION AX3) A. BUILDING B. WNG -103/13/2008 PRINTED: .0/13/20068 FORM APPROVED (X3) DATE SURVEY COMPLETED LCO989A NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE ALL METRO (X4)10 PRJEFnX TAG ._ .. 50 BROADWAY LYNBROOK, NY 11863 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACHCORRECTIVE ACTION SHOULD BE CROSS-REFERENCEo TO THE APPROPRIATE DEFICIENCY) (V5) COMPLETE DATE H1002 Continued From Page 6 The record included the copy of the Certificate of Completion dated 11/26/07. Trainees #6 and #4 had the test score of (65) for Module VIII. Trainee #4 and #6 records lacked documentation that the agency provided any form of remediation testing, teaching and or observation for Module VIII. The record included the copy of the Certificate of Completion dated 11/26/07 for Trainee #6- H1002 Trainee #4 record lacked documentation of the copy of the Certificate of Completion. The record also lacked documentation to explain why the Certificate of Completion copy was not in the HHATP file and the Personnel record. Trainee # 8 had the following test scores for: Module If (65), Modules III IV (60), Module and VIII (60), and Unit C (70). The Trainee's record lacked documentation that the agency provided any form of remediation testing, teaching and or observation for Modules II,III, IV,VII and Unit C, The Trainee's record lacked documentation of the required Modules # I to # XlI and Units A to H tests/quizzes. The record included the copy of the Certificate of Completion dated 11/08/07. Trainee # 2 had the following test scores for Module 11 (60), Unit C (55) and Unit F (70). The agency provided any form of remediation testing, teaching and or observation for Module IIand Units C and F. STATE FORM .11f Trainee's record lacked documentation that the 72XJ1 I I'w.t!mtle, o Met 7 of 21 MAY-22-2008 16:26 ALL METRO HEALTHCARE CONT 5168813104 P.09 New York Department fHealth (X1) PROVDER/SUPPLIERWCLIA IDENTIFICATION NUMBErt (X2) MULTIPLE CONSTRUCTION A. BUILDINU PRINTED: 05/1312008 FORM APPROVED M(X) DATE SURVEY COMPLETED COMPLETED STATEMENTOF DEFICIENCIES AND PLAN OF CORRECTION LCOS99A NAME OF PROVIDER OR SUPPLIER B.WNG STREET ADDRESS. CITY. STAtE, Z1P CODE S 0311312008 ALL METRO (X4) Io PREFIX TAG 50 BROADWAY LYNBROOK, NY 11663 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY Oil LSC IIEN1FYNG INFORMATION) Io PREFIX TAG PROVIDEHrS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFIGIENCY) COMPLETE DATE 11002 Continued From Page 7 The record included the copy of the Certificate of Completion dated 10129/07. Trainee #5 had the following test scores for: Module V (50) and Unit F (70). The Trainee's record lacked documentation that the agency provided any form of remediation testing, teaching and or observation for Module V and H1002 Unit F. The record included the copy of the Certificate of Completion dated 11/26/07. Review of the agency's policy and procedures for the HHATP did not include the agency's acceptable passing grades for the all te ts/quizzes. During interview on 03/13/08 at 11:10AM with the Acting Director of Clinical Services (ADCS), the Director could not locate or provide the missing documentation for the HHATP records. The .Director further could not provide an explanation for the agency's failure to ensure that all the Trainees fulfill and complete the HHATP requirements- 2. Review of the 'ClInical PCA/Home Health Aide Training - Skills Checklist" form listed forty three (43) skills. The form was used to document the listed skills that were observed by the RN and document that the Trainee was competent in the observed skills. The "Supervised Clinical Visit Home Health Aideo Trainee" form listed thirty nine (39) tasks- The form did not include the required tasks of 'TPR'" (temperature, pulse and respiration), meal STATE FORM' 72XJ11 . " ifcontnuanin ahm 8 ofW MAY-22-2008 16:26 ALL METRO HEALTHCARE CONT 5168913104 P.10 PRINTED: 05113/20os New York State Depgrtment of Healh .STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDER/StJPPLIER/CaLIA (X2) MULTIPLE CONSTRUCTION FORMAPPROVED () DATE SURVEY IDFNTIFICATION NUMBER COMPLETED A.BUILDING COMPLETED LCO989A NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE, ZIP CODE 03113/2008. 50 BROADWAY LYNBROOK, NY 11563 ALL METRO (x4) IO SUMMARY STATEMENT OF DEFICIENCIES ID PROviDER'S PLAN OF CORRECTION PREFIX TAG (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X5) COMPLETE DATE PREFIX TAG (EACH CORRECTIVEACrQN SUOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) H1002 Continued From Page 8 H1002 preparation, measure intakeloutput and the taking of the patient's Blood Pressure. The form in the upper right hand COmer documented numbers from #1 to #16. The form failed to explain the meaning of the listed numbers. The form lacked documentation of how many hours of SPT in the patient care setting was provided by the agency. The Trainee records #1 to #8 lacked documentation that the agency provided the required eight (8) hours of SPT in the patient care setting. This form was used by the agency for the SPT in the patient care setting. Trainee *1 record lacked documentation that the required SPT Inthe patient care setting was provided by the agency- The record also lacked documentation that the RN had observed the required skills for the SPT. The Trainee and the personnel records lacked documentation of the "Supervised Clinical Visit Home HealthAide Trainee" form used to document that the SPT was performed by the RN. The "Clinical PCNHome Health Aide Training Skills Checklist" form dated 11/08/07 documented by the RN, that only ten (10) of the forty three (43) skills were documented that competent demonstration of the skills was performed by the Trainee. The remaining skills were documented with an arrow running down the page. Only two (2) skills were initialed by the nurse and the remaining were dcumented withJ an arrow running down the page, STATE FORM "-=z1 72XJ11 ft monanu&Wn she 9of 21 M Y-22-2008 16:26' ALL METRD HEALTHCARE CONT 5158813104 P.11. New York State Depart ent of Health STATEMENT OF FCNCIES PRINTED: 05/13/2008 FORM APPROVED (X2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION (XI) PROVIDERISUPPLJEWCLiA IDENTIFICATION NUMBER (X3) A. BUILDING B. .WIING COMPLETED DATE SURVEY LC0989A NAME OF PROVIDER OR SUPPLIER 03/13/2008 STREET AlDRESS, CITY' STATE. ZIP CODE ALL METRO (X4) ID PREFIX TAG 50 BROADWAY I.LYNBROOK, NY 1153 (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) SUMMARY STATEMENT OF DEFICIENCIES ID PREFIX TAG (EACH CORRECTIWE ACnON SHOULD u CROSS-REFERENCED TO THEAPPROPRIATE DEFICIENCY) PROVIDER'S PLAN OF CORRECTION COMPLETE DATE H1002 Continued From Page 9 The Certificate of Completion was dated 12/14/07. Trainee #2 record documented the "Supervised H1002 Clinical Visit Home Health Aide Trainee" form dated "11/26107". The form documented that the RN had observed the Trainee for eight (8) of the thirty nine (39) listed tasksThe "'ClinicAl PCA/Home Health Aide Training Skills Checklist" form dated 11108107 documented by the RN, that only seven (7) of the forty three (43) skills were documented that competent demonstration of the skills was performed by the Trainee. The remaining skills were documented with an arrow running down the page. Only two (2) skills were initialed by the. nurse and the remaining were documented with an arrow running down the page. The Certificate of Completion was dated 1 1126/07 Trainee #3 record documented the "Supervised Clinical Visit Home Health Aide Trainer form RN had observed the Trainee for seven (7) of the thirty nine (39) tasks only- dated "11/26/07". The form documented that the The "Clinical PCA/Home Health Aide Training Skills Checklist" form dated 11108/07 documented by the RN, that only seven (7) of the forty three (43) skills were documented that competent demonstration of the skills was performed by the Trainee: The remaining skills were documented with an arrow running down the page- Only two (2) skills were initialed by the nurse and the remaining were documented with STATE FORM 72XJ11 IL;lr;uWr. ht.ei 10off21 n *MRY-22-2008 16:26 ALL METRO HEALTHCARE CONT 5168813104 P. 12 PRINTED; 05/13/2008 New York State Departnentof HealthR STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDERJSUPPIUERPCUIA IDENTIFICATION NUMBSER. (X2) MULTIPLE CONSTRUCTION FORM APP'ROVED ALBD. IHNG LCOS9A B.WING $TREETADDRESS, CITY, STATE, ZIP CODE - (X) DATE SURVEY COMPLETED 03/13/2008 NAME OF PROVIDER OR SUPPLIER ALL METRO x4) iD PREFX TAG 50 BROADWAY LYNBROOK, NY 11563 I PREFIX TAG PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X) CONPLETE DATE SUMMARY STATEMENT'OF DEFICIFNCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION H1002 Continued From Page 10 an arrow running down the page. The Certificate of Completion was dated H1002 10/26107. Trainee #4 record documented the "Supervised Clinical Visit Home Health Aide Trainee" form dated "12/14107". The form documented that the RN had observed the Trainee for ten (10) of thek thirty nine (39) tasks only, The "Clinical PCAHome Health Aide Training Skills Checklist" form dated 11/08/07 documented by the RN. that only seven (7) of the forty three (43) skills were documented that competent demonstration of the skills was performed by the Trainee. The remaining skills were documented with an arrow running down the page. Only two (2) skills were initialed by the nurse and the remaining were documented with an arrow running down the page. The HHATP record lacked documentation of the copy for the Certificate of Completion. Trainee #5 record documented the "Supervised Clinical Visit Home Health Aide Trainee" form dated "11/26/07. The form documented that the RN had observed the Trainee for eight (8) of the thirty nine (39) tasks only. The "Clinical PCAfHme Health Aide Training Skills Checklist" form dated 11/08107 documented by the RN, that only seven (7) of the forty three (43) skills were documented that competent demonstration of the skills was performed by the Trainee- The remaining skills were documented with an arrow running down STATE FORM *T72XJll the page. Only two (2) skills were initialed by the . Isconrnu~tion hee IIof21 MAY-22-2008 16:26 ALL METRO HEALTHCARE CONT 5168813104 P.13 PRINTED: 05/132008 .NewYork State Departmen t f Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRi--TON (Xl) PROVIDERSUPPLIMICLIA IDENTIFICATION NUMBER' (X2) MULTIPLE CONSTRUCTION A. BULDNG' FORM APPROVED (X3) DATE SURVEY COMPLETED LCO989A NAME OF PROVIDER OR SUPPUER A.WING 2 MN o 200o STREET ADDRESS, CITY, STATE. ZIP CODE ALL METRO (14) ID PREFIX TAG 50 BROADWAY LYNBROOK, NY 11553 SUMMARY STATEMENlT OF DEFIcIENCIES (EACH DEFICIENCY MUST BE PRECEDIED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECIVEACION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X6) COMPLETE DATE H1002 Continued From Page 11 nurse and the remaining were documented with an arrow running down the page. The Certificate of Completion was dated 10/26/07. Trainee #6 record documented the "Supervised. Clinical Visit Home Health Aide Trainee" form dated "11/26107". The form documented that the RN had observed the Trainee for nine (9) of the thirty nine (39) tasks only. The "Clinical PCNHome Health Aide Training Skills Checklist" form dated 11/08/07 documented by the RN, that only eight (8) of the forty three (43) skills were documented that Competent demonstration of the skills was performed by the Trainee. The remaining skills were documented with an arrow running down the page. Only two (2) skills were initialed by the nurse and the remaining were documented with an arrow running down the page. The Certificate of Completion was dated 10/26107 Trainee #7 record documented the "Supervised Clinical Visit Home Health Aide Trainee" form dated "11126/07" The form documented that the RN had observed the.Trainee for nine (9)of the thirty nine (39) tasks. The"Clinical PCNHome Health Aide Training Skills Checklist" form dated 11/08/07 documented by the RN, that only seven (7).of the forty three (43) skills were documented that competent demonstration of the skills was performed by the Trainee. The remaining skills were documented with an arrow running downt4 STATE FORM Mf H1002 72XJ11 Iontln hee, l1O,'2 MAY-22-2008 16:26 PLL METRO HEPLTHCARE CONT 5168813104 P.14 New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (xl) PROVDER/SUPPLIlFCLIA IDENTIFICATnON NUMBER: PRINTED: 051132008 FORM APPRO VED (X2) MUnLTIPE CONSTRUCTION A. BUILDING (X3) DATS SURVEY COMPLETED LCO989A NAME OF PROVIDER OR SUPPLIER B. WNG STREETADORESS, CIrY, STATE, ZIP CODE 0311312008 ALL METRO Q(4) ID PREFIX TAG 50 BROADWAY LYNBROOK, NY 11563 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Io PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EAC,,CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (XE) COMPLETE DATE H1002 Continued From Page 12 the page. Only two (2) skills were nritialed by the nurse and the remaining were documented with an arrow running down the page. The Certificate of Completion was dated 10/26107. Trainee #8 record documented the "Supervised H1002 Clinical Visit Home Health Aide Trainee" form dated "12/.14107"- The form documented that the RN had observed the Trainee for eight (8)of ihe thirty nine (39) tasksThe HHATP record lacked documentation of the "Clinical PCA/Home Health Aide Training - Skills Checklist" form. The record also lacked documentation to verify that the required skills were observed by the RN. The Curtificate of.Completionlwas dated 11108107. During interview on 03/13/08 at 11:10AM with the ADCS, the agency's staff was provided the opportunity to provide/locate any additional documentation. The Director stated that the HHATP instructor must have the other tests and training forms inher file. 3. Trainee and Personnel records #1 to #8 lacked documentation that the agency had provided the original Certificate of Completion and a copy of the Competency Evaluation forms to each Trainee upon completion of the HHATP. Trainee record #4 and the Personnel record lacked documentation of the copy of the Certificate of Completion. STATE FORM oi"72XJ11foduiln4et1o~ MAY-22-2008 16:2? ALL METRO HEALTHCARE CONT 5168813104 P.15 New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION, (XI) PROVIDERISUPPUER/CUA IDENTIFICATION NUMBER (XZ) MULTIPLE CONSrTRUCTION A BUILD(NG PRINTED; 05/13/2008 FORM APPROVED (X3)DATE SURVEY COMPLETED LCO989A NAME OF PROVIDER OR SUPPLIER . ING STREET ADDRESS, CITY, STATE, ZIP CODE 0313/2008 ALL METRO (M)ID PREFIX TAO LYNBROOKNY 11553 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL RFGULATORYORLSCIDENTIFYINGINFORMATIOIN In PREFIX TAG PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) pcs) COMPLETE DATE 50 BROADWAY H1002 Continued From Page 13 - H1002 The Trainee and Personnel records #1, #2,#3, #5, #6, and #8 included a copy of the #7 Certificate of Completion. The records lacked to the Trainees that completed the HHATP. documentation that.the Certificates were issued During interview on 03/13/08 at 11:10AM with the ADCS, the Director could not verify that the agency had provided the original Certificate of Completion and a copy of the Competency Evaluation forms to all the Trainees that completed the HHATP H1035 766.9(I) Governing authority : Section 766.9 Governing authodty. , The governing authority or opegor,as defined in Part 700 of this Title, of a $nsed home care services agency shall: (I) appoint a quality irrovement committee to establish and over e standards of care. The quality improve nt committee shall consist of a consurner an ppropriate health professional persons inC ding a physician if professional health ca services are provided.Thecommittee Hi030- shall m at least four times a year to:. (1) Iew policies pertaining to the delivery of th ealth care services provided by the agency d recommend changes in such policies to the overning authority for adoption; (2)conduct a clinical record review of the safety, adequacy, type and quality of services provided which includes:, (i) random selection of records of patients STATE FORM. A. )72XJjl ffcllnualonS hee 1421 MAY 22-2008 16;2? -o L i .ETRO .HEPRLThC CeNT RE 5.t68 3i 04, 'P. I . PR IN TED : 0 5,-1 3/2 008 New York State Department of Heat STATEMENT OF DEFICIENCIES, AND PLAN OF CORRECTON PROVIDER/SU PL ERCLIA 0(1) IDENFICATION NUMBER X2) MULTIPLE CONSTRUCTON ILI A BUIfLDIN4G FORM APPRO)VED DATE ,3) , SURVEY COMPLETED COMPLETED_____ LC8,89A NAME OF PROVIDER OR SUPPLIER B.W-NG STREET ADDRESS, CITY. STATE. ZIP CODE 03113/2008 ALL METRO PREFIX 50 BROADWAY (EACH DEFICIENCY MUST BE PRECEDED BY FULL (X4) I TAG O SUMMARY STATEMENT OF DEFICIENCIES REGULATORY OR LSC IDENTIFYING INFORMATON) PREFIX ID TAG OEflCIENCY} CROSS-REFERENCED TO THE APPROPRIATE (EACH CORRECTIVE ACTION SHOULD BE PROIOER'S PLAN OF CORRECTION COMPLETE (5) DATE H1036 Continued From Page 15. the last three (3) mo H1036 agency's services and p Zts discharged within _ The QIC meeti minutes further lacked review of the patien ecords regarding the safety, adequa y/ipe and quality of home care servic provided by the agency. *ng interview on 03/12/08 at 1PM with the acknowledged the survey findings. H1337 766.11(f)(ii) Personnel Section 766.11 Personnel ng Director of Clinical Services, the DirectOr H1337 H1337 - 766.11 (f)(ii) - Personnel The entire branch staff has been reoriented to the process for supervision of provisional individual responsible for scheduling the employees, and the The governing authority or operator shall ensure for all health care personnel: (f)(fi) a criminal history record check to the extent required by section 40023 of this Tifle . . This Rule is not met as evidenced by: both the visits and the' telephonic. supervisions, which she completes. The associates responsible are the nursing visits has been replaced. She has also developed a tracking log for DCS, with the CHRC requirements. The DCS' review all of all rovisionar employe .ill Coordinator, who shall review the logs (See attached) weekly for compliance Branch Manager and Clinical Based on personnel record review, Home Health Aide Training Program review, policy and procedure review and staff interview, the agen failed to ensure that the temporary ( paraprofessional staff were supervised as required while awaiting the Criminal History Record Check (CHRC) results In one (1) of onel (1) temporary paraprofessional staff (Employee . #10), requiring CHRC and in eight (8) of eight (8) Trainee records reviewed (Trainees #1 to #8). The agency's failure to provide the required supervision of the temporary paraprofessional staff, that required the direct onsite observation STATE FORM 6 ti, ensure that 'the actual supervision was performed and filed in the personnel record. This will be documented on the log which will be sent to the VP of Patient Services for Aeview. The logs will also be reviewed during quarterly quality audits. The VP of Patient Services will review the logs and report to the GA on a quarterly basis the adherence to this process., This reporting will be done via verbal communication and written audit reports. Completion date - 5/31/08 and ongoing lip. "es to 72XJll, i- .0a'21 RY-22-2008 16:27 ALL METRO HEALTHCARE CONT 51GBB13104 P.17 PRINTED: 05(13(2008 New York State DePartment of Hearth.FORM IANrEMENT OF DEFICIENCIES (XI) PROVIDERISIPPUER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: APPROVED (X2) MULTIPLE CONSTRUCTION A. BUILDING B. Vi NO M(S) DATE SURVEY COMPLETED LCO989A NAMEOF PROVIDER OR SUPPLIER o 1 STREET ADDRESS, CITY. STATE, ZIP CODE 03/1312008 ALL METRO PREFIX TAG (X4) ID SUMMARY'STATEMENT OF DEFICIENCIES 50 BROADWAY LYNBROOK, NY 11563 (EACH DEFICIENCY MUST BE PRECEOEID BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PREFIX TAG ID (EACH CORRECTI/E ACTiON SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) PROVIDEg S PLAN OF CORRECTION COMPLETE DATE H1337 Continued From Page 16 by the nurse fur the first week and alternate weekly supervision by direct observation and telephonic supervision, places the patients at risk for poor quality care. Findings include: Review of the policy and procedure titled "NYS CHRC Policy" documented "Direct on-site observation is required for the first week the provisional employee or temp staff is used. After the first week, AMHC (All Metro Health Care), may alternate weekly, direct on-site observation with off-site, telephonic evaluation until CHRC determination is received. Off-site evaluation is conducted via a phone call to the care recipient The on-site supervision must be completed by a nurse (RN or LPN) and the off-site by either a licensed health care professional or coordinator. The results of the observations must be documented in the temporary employee's personnel file and signed by the person providing the supervision." Employee #10 was hired on 11/12/07 and placed on her first case on 11/17107. The initial supervision was conducted via telephone call on 12/01/07 two (2) weeks later instead of the required initial supervision being conducted onsite bythe Registered Nurse (RN) while awaiting the CHRC results. -During an interview with the Area Director of Clinical Services (ADCS) on 03/13/08 at 12:30 PM, the ADCS acknowledged that the agency was having a problem with conducting provisional supervision as required. Trainee #1 was hired by the agency on 12/12/07. Me personnel record documented that ti STATE FORM H133" he 12 72XJI1 IfIrtnainset1 f2 MAY-22-2008 16:2? ALL METRO HEALTHCARE CONT 5168613104 P.18 PRINTED: 05/13/2008 New York State Deuartment of Health AND PLAN OF CORRECTION STATEMENT OF DEFICIENCIES (Xl) PROVIDERISUPPIERCLIA -IDENTIFICATION FORM APPROVED NUMBER: (X2) MULTIPLE CONSIRUCION A_ BUILDING __________ (X3)DATE SURVEY COMPLETED LC0989A NAME OF PROVIDER OR SUPPLIER WNG ' 03113/2008 STREETADORESS, CITY. STATE, ZIP CODE ALL METRO (X4) ID PREFIX TAG 60 BROADWAY I LYNBROOK. NY 11563 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE (1.5 COMPLETE DATE DEFICIENCY) H1337 Continued From Page 17 agency provided onsite supervision by the RN on 01/02 and 01/29108. The offaite telephone supervision was performed on 01/18/08. The personnel record lacked documentation of any subsequent supervision by the agency of thb temporary paraprofessional staff from 01103 to 01/17/08 and 01130/08 to 03/13108The personnel record lacked documentation to explain why the agency did not providerperform the required supervision- H1337 Trainee #2 was hired by the agency on 10/29/07. The personnel record documented that the agency performed offsite telephone supervision on 11/28 and 12/04/07, 01/08,1/20 and 02107108. The personnel record lacked documentation that the RN had performed any onsite supervision of the temporary paraprofessional staff from 11128/07 to 02/07/08. The personnel record tacked documentation of any subsequent supervision by the agency of the temporary paraprofessional staff from 10/29/07 to 11/27/07 and 02/08/08 to 03/13/08. The personnel record lacked documentation to explain why the agency did not provide'perform the required supervision. Trainee #3 record lacked documentation when the agency hired the temporary home health aide. The record documented that CHRO application STATE FORM . 72XJl1 Ifcontinuallan shet 16oft21 MAY-22-2008 16:27 ALL METRO IEflLTHCARE CONT 5168813104 P.19 PRINTED: 05/13/2006 New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION FORM APPROVED (X2) MULTIPLE CONSTRUCTION A. BULDNGCOPLETED (X3) DATE SURVEY (X. DA ETE URVEY (X1) PROV1DER15UPPLIERCLIA IDENTIFICATION NUMRBER: LCO989A NAME OF PROVIDER OR SUPPLIER . NG STREET ADDRESS, CIY. STATE. ZIP CODE 1312008 ALL METRO 0(4) ID PREFIX TAG 80 BROADWAY LYNBROOK, NY 11563 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATON) I PREFIX TAG" . PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCZD TO THE APPROPRUATE DEFICIENCY) COMPLETE DATE H1337 Continued From Page 18 form was signed and dated by the aide on H1337 11/26/07 for submission for the CHRC review. The personnel record lacked documentation that the agency provided/performed the required onsite and offsite supervision of the temporary paraprofessional staff from 11/26/07 to 03/13/08. The personnel record lacked documentation to explain why the agency did not provide'perform the required supervision. Trainee #4 was hired .by the agency on 12/03/07. The record dOcumented that CHRC application form was signed and dated by the aide On 1130/07 for submission for the CHRC review. The personnel record lacked documentation that the agency provided/performed the required onsite and offsite supervision of the temporary paraprofessional staff from 12/03/07 to 03/13/08. The personnel record lacked documentatiorn to explain why the agency did not provido'perform the required supervision. Trainee #5 was hired by the agency on 11/26/07, The personnel record documented that the agency provided onsite supervision by the RN on 12/03/07, 01104, 01118 and 02/05/08. The offsite telephone supervision was performed on 12/24/07, 01/25 and 02113108. The personnel record lacked documentation of any subsequent supervision by the agency of the temporary paraprofessional staff from 12/04/07 STATE FORM 72XJ 11 cmllnudori %hest19 of 21 i MAY-22-2008 16:27 ALL METRO HEALTHCARE COINT 5168813104 P.20 New York State Department of Helth STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PRINTED: 05113/2008 FORM APPROVED (X2) MULTIPLE CONSTRUCTION N AB2 (KS) DATE SURVEY COMPLETED (I)PROvIDERSUPPLIER/CLIA IDENTIFICATION NUMBER: A. BUILDING _______________ LCO989A NAME OF PROVIDER OR SUPPLIER STREET ADORESS, CITY, STATE, ZIP CODE 03/13/2008 50 BROADWAY LYNBROOK, NY 11563 ALL METRO (X4) iD PREFIX SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL IO PRFFIX - TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THI-EAPPROPRIATE DEFICIENCY) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTVE ACTION SHOULD BE (W COMPLETE DATE H1337 Continued From Page 19to 12/23/07, 01105 to 01/17108 and 02/14108 to 03/13/08. The personnel record lacked documentation to explain why the agency did not providelperform the required supervision. Trainee #6 was hired by the agency on 11/26/07. The personnel record documented that the agency provided onsite supervision by the RN on 11/30/07, 01117, 01/24 and 02/16108. The offsite telephone supervision was performed on 12121/07, 01/14, 01/15, 01/25 and 02108108. The personnel record lacked documentation of any subsequent supervision by the agency of the temporary paraprofessional staff from 12/01 to H1337 12/20/07, 01/26 to 02/07/08 and 03/13/08. 02/17/08 to The personnel record lacked documentation to explain why the agency did not provide/perform the required supervision. Trainee #7 was hired by the agency on 11126/07. The offsite telephone supervision was performed on 12/18/07 and 01/03108. The personnel record lacked documentation that the RN had performed any onsite supervision of the temporary paraprofessional staff from 11/26/07 to 01/03/08. The personnel record lacked documentation of any subsequent supervision by the agency of the temporary paraprofessional staff from 12/19/07 to 01/02/08 and 01/04/08 to 03/13/08. STATE FORM n 72XJ11 If ortkuaflon shet 20 of 21 I- MAY-22-2008 .16:28 ALL METRO HEALTHCRRE CONT 5161813104 P.21 New York St& Department of Health (XI) PROVIDER-SUPPLIERJCLIA IDENTIFICATION NUMBER (X2)MULTIPLE CONSTRUCTION A.BUILDING ,* PRINTED: 05/13/2008 FORM APPROVED (XS) DATE SURVEY COMPLETED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION LCO989A NAME OF PROVIDER OR SUPPLIER 0. WING STREET ADDRESS, CITY, STATE. ZIP-CODE 03/1312005 ALL METRO (X4) ID PREFIX TAG S0 BROADwAY 11563 LYNBROOK, NY SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TA(Q PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTiON SHOULD BE CROSS-REFERENCED 10 TI-EAPPROPRIATE DEFICIENCY) COMPLETE DATE H1337 Continued From Page 20 H1337 The personnel record lacked documentation to, explain why the agency did not provide'perform the required supervision. Trainee #8 was hired by the agency on 11/15/07, The personnel record documented that the agency provided onsite supervision by the RN on 01/10 and 03/05108. The offsite telephone supervision was performed on 02/10108. The personnel record lacked documentation of any subsequent supervision by the agency of the temporary paraprofessional staff from 11/15/07 to 01J09108 02/11108 to 03/04108 and 03/0608 to 03/13/08. During interview on 03/13108 at 10:15AM with the ADCS, the survey findings for Trainees #1 tb #8 were reviewed with the agencys staff. The agency's staff was provided the opportunity to provide/locate any additional documentation- The agency's staff did not provide any additional documentation during the survey. The Director stated that the CHRC report results have not yet been received by the agency. The Director could not provide an explanation for the agency's failure to provide the required supervision of the temporary paraprofessional staff while awaiting the CHRC report results and in accordance with the agency's policy and procedure. STATE FORM 72XJ11 If wntinualln sheet 21 of2l TOTAL P.21 U-1 r-q C3 3 "Postage $ Cefiad Foo Postmark Here RCtur Receipt Fee (EndorsementRequired) Fee Delivery Restricted (Endomement Required) m1 Na M I omt 1-3 Posag ~ ~ Soa T&pF e * ---X des!ied. ---------pace permits..,' i iterfif frvnt:f Sr Delivery is-------i or Oh4theRestricted []Attachitli scard to the back ofthe mailpieCe ..... X your Pr15int nane and add e on tlie reverse /t ------ " -'" ... [Agn drse Ad r 1. .... . .,e~ 6... . .. D Is delivery address drfe r. , 1 . ) 1.Art~la ddresfie:d . Mai..O pssM ." , "f Iegi~ste-d C fRtuim Receipt for Merclhandise .......... i Reslictd 4./f~'~ Delivery ( r Fe) Q g2n952-M 1.. Form 38i1 Febrlary 2004 aPS omestc Return Recpt .1 New York State Department of Health .STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVDER!SUPPLIERCLA IDENTIFICATION NUMBER: " (X2) MULTIPLE CONSTRUCTION A. BUILDINGCOPTE PRINTED: 06/02/2008 FORM APPROVED (X3) DATE SURVEY COMPLETED _ _ 0308L001 NAME OF PROVIDER OR SUPPLIER B. WING BW _ _ _ _ _ _ _ 05/22/2008 STREETADDRESS, CITY, STATE, ZIP CODE SELFHELP COMMUNITY SERVICES. INC. (X4) ID PREFIX TAG 50 CLINTON STREET HEMPSTEAD, NY 11550 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H 000 Initial Comments H 000 A Full Survey was conducted at Selfhelp Community Services, Inc on May 21 and May 22, 2008. Seven (7) Patient Record were reviewed and identified as patients #1 - #7. Eight (8) Personnel Records were reviewed and identified as employees #1 - # 8. Two (2) Home Visits were conducted and identified as patients #3 and #5. Five (5) Trainee Records were reviewed from the agency's Home Health Aide Training Program and identified as Trainees #1 - #5. H 404 766.3(b) Plan of Care 766.3 Plan of care The governing authority or operator shall ensure that: (b) a plan of care is established for each patient based on a professional assessment of the patient's needs and includes pertinent diagnosis, prognosis, mental status, frequency. of each service to be provided, medications, treatments, diet regimens, functional limitations and rehabilitation potential. This Rule is not met as evidenced by: Based on patient record review, and staff intervieW, the agency failed to develop a Plan of Care which was complete and included medications, frequency of services, and the patient's rehabilitation potential in seven (7) of seven (7) records reviewed. (Patients #1, #2, #3, #4, #5, #6, and #7)LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE Plan of Care: H 404 I. Clients H l-7: An interim order will b( 6/30/08 sent to each primary M.D. and the rene al of the Plan of Care will incorporate spe ific client medications ,specific services,frec uency of services and rehabiltitative potential. II.During the start of care ,assessments (f new clients re-assessment of current cli ts, the nurse will address the'rehabiltitive potential and identify goals that are reali tic and correlate with the plan of treatment. The identified d fr o medications,fequency services ,specific services and rehabilita ive potential will be reflected on all 'Plan ol Care"to be reviewed and signed by clie t's physician. TITLE /x6FUfr STATE FORM o21, VJ6011 If-continuation sheet 1 of 13 PRINTED: 06/0212008. FORM APPROVED New York State Department of Health STATEMENT OF DE-ICIENCIES 'AND PLAN OF CORRECTION (X1) PROVIDERISUPPUERICLA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WNG ____________ (X3) DATE SURVEY COMPLETED 0308L001 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE. ZIP CODE 0512212008 50 CLINTON STREET HEMPSTEAD, NY ,11550 ID PREFIX TAG SELFHELP COMMUNITY SERVICES. INC. (X4) IO PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE (X5) COMPLET DATE 613010 h H 404 Continued From Page 1 The agency's failure to ensure that the patient's Plan of Care is Complete places all patients at risk for poor quality care. Findings are: Review of the Plans of Care for patients #1, #2, #3, #5, #6 and #7 lacked documentation that the. H 404 II. The Clinical Manager will conduct In -Services for all nursing staff by Jun 30 on appropriately assessing/documenting client's potential for rehabilitation, medications and frequency of services nd identifying realistic goals that correlate ith 'Plan of Care'. agency developed a Plan of Care for each patient which included the patient's rehabilitation potential. Patient #7 was admitted to the agency on 01/i8/08 with diagnoses of Hypertension, Early IV. A focused audit will be conducted every 60 days to determine the level of compliance of 100% of client files by th Clinical Manager.The utilizationof a reh biltation potential will be included on the medica record tool and will reviewed at the quarterly Dementia, and Depression. Review of the Plan of Care dated 01/11106111/08 lacked the amount and frequency for the following medications: Nitroglycerine, Aricept and Amoxicillin. The Plan of Care also included medication Coumadin 5mg and Coumadin1 mg, yet the plan of care lacked which days the patient was to receive 5 mg and which days 1mg tablet. Further review of the record documented that the patient was also on Actonel 35 mg 1 pill once a week before breakfast, which was not included on the Plan of Care. Review of the record documented that the nurse was visiting the patient once a week to pre-pour the medications. Review of Skilled Nurse (SN) Professional Advisory Committee meeti ig. " / P ft 7: Patient # 7: ) An onterim order, which will carriy over to the Plan of Care renewal time ' frame,was sent to the primary MD incorporating dosage and frequency for Nitroglycerine, Aricept and Actonel on 6/4/08. An Interim order effective 3/7 to 4/17/08 sent to Primary MID to reflect / visit note dated 03/07108 documented that the Coumadin dosage was on Mondays and Thursdays 5mg and Sunday, Tuesdays, Wednesday, Friday and Saturday the patient was to receive 6mg of Coumadin. The record lacked documentation that the nurse obtained an interim order for the change in Coumadin dosage. On 05/22108 at 11:30 AM, the Clinical Director STATE FORM 021109 change in Coumadin dosage. 11) During SOC assessment of new, clients and re-assessment of current clients the Clinical Manager will identify and reflect all clients' medications on the Plan of Treatment to be reviewed and signed by the client's physician. To be completed by 6/30/0 VJ6011 IfC tinuation shet 2 of 13 or "orm 'lJlu I EU UI/UZ/ZUUO FORM APPROVED New York State Department of Health STATEFr4ENT OF DEFICIENCIES 'ANDPLAN OF CORRECTION (X1) PROVIDER(SUPPLIERICLIA IDENTIFICATION NUMBER: "B (X2) MULTIPLE CONSTRUCTION A. BUILDING ______ _____ (X3) DATE SURVEY COMPLETED WING ___________ 0308L001 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CIrY, STATE, ZIP CODE 05/2212008 50 CLINTON STREET ID PREFIX TAG SELFHELP COMMUNITY SERVICES. INC. (X4) 10 PREFIX TAG HEMPSTEAD, NY 11550 PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H404 Continued From Page 2 H404 PA, qi )lj-h o the survey findings. order dated was informed of presented an interim Later, the Clinical Director 04117/08 which included change in Coumadin dosage to 5 mg by mouth every Mondays, m) The Clinical Manager will revie all RN visit reports onl a weekly basis to ensure documentation standards are Wednesdays and Fridays and 6 mg on Tuesdays, Thursdays, Saturdays and Sundays, this interim order was already reviewed by the surveyor during Clinical record review. The Clinical Director could not provide an explanation for which days the nurse was pre-pouring 5mg and 1mg of Coumadin. Patient #4 was admitted to the agency on' 01/23108 including diagnosis of Hypertension. The Plan of Care dated 02/11 - 07/11108 ordered home health aide service. The Plan of Care , documented "Private HHA (home health aide)PRN (as needed)". The orders lacked frequency and what tasks the aide was to be' assisting the patient with. Review of the aide duty sheets documented that the patient received aide services on the following days: 03/06, 03/20 and 04/29/08 to accompany patient to the physician's office. On 05/21/08 at 1:30 PM; the DPS and Assistant Vice President were informed of the survey findings and were given an opportunity to provide an explanation. On 05/22/08, the DPS acknowledged the survey findings. H68In-Services H 618 766.5(b)(3) Clinical supervision maintained. Commeaced 6/2/08., lV)A focused audit of 100% of client records will be conducted by the Clinica Manager within 30 days with follow-u every 60 days by the Clinical Manager arid DPS to determine level of P Plan of Care Patient #4 . An interim order hasbeen sent to M.D Addressing Home Health Aide services to accompany client to M.D.visits only. Maximum frequency nine hours with ~complianlce. 6/30/08 , the duration of every two weeks for clie it private hours. Notation : This client primarily is an El' EP and the Care Plan ,Plan of Care A.D.L. tasks. are reflected on this contracted cli nt. I1.During the start of care an assessmen of new clients the nurse will address the Home Health oAide tasks,frequency dand pre ies at ad H and duration of services provided. II1 The ClinicalalManager will conduct nursingstfbyJn for s staff by June r i I 30' on appropriately assessing Idocumne itation the Home Health Aide tasks ;frequency nd duration of services rendered by the PIl of Care. W. Focusedaudit will be conductedby Cal H618 766.5 Clinical supervision. The governing authority shall ensure for all health care services that: b).all staff delivering care in patient homes are adequately supervised. The department shall STATE FORM ," Manager every 60 days to deterne co pliance o the Pl~n of Care. vJe011I PRINTED: 06/02/2008 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND pIAN OF CORRECTION (Xl) PROVIDERJSUPPLIERJCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING ______ _____ (X3) DATE SURVEY COMPLETED 0308L00i NAMEOF PROVIDER OR SUPPUER B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 05/22/2008 SELFHELP COMMUNITY SERVICES, INC. (X4) ID PREFIX 50 CLINTON STREET HEMPSTEAD, NY 11550 IO PREFIX SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE (EACH CORRECTIVE ACTION SHOULD BE DEFICIENCY) PROVIDER'S PLAN OF CORRECTION (X5) COMPLETE DATE H 618 Continued From Page 3 consider the following factors as evidence of adequate supervision: (3) Clinical. records are kept complete and changes in patient condition, adverse reactions, and problems with informal supports or home environment are charted promptly and reported to supervisory staff. This Rule is not met as evidenced by: . Based on patient record review, home visits (HV) and staff interview, the agency failed to ensure adequate supervision of nursing staff and the agency failed to ensure that the patient records were kept complete in three (3) out of three (3) patient records reviewed. (Patients #5, #6 and # 7). H 618 H618 Clinical Records (Supervision of. Nursing staff) 1. Nursing staff have been evaluated an 6/5/08 assessed in the field. I..Annually in June nursing staff will h; ve their anmual clinical field evaluations. Ii.In order to ensure that clinical evalu tions are accomplished in June the utilization of the same time sequence as the organi tion's ne. employee appraisal performance time fEr IV. The new guideline for clinical field evaluations will be in place for the calcr dar month of June. The agency's failure to ensure that the nursing staff is adequately supervised in the administration and documentation of medications placeis all.the patients at risk for poor patient &C Pa iCA(O outcome. Findings include: Patient #5 wasadmitted to the agency on 12/05/07 with diagnoses of Bladder Polyps, Cancer of Bladder and Hypertension. The Plan'of Care dated 12/05/07- 06105/08 ordered a Foley catheter. The Aide's Plan of Care dated 12/05/07 listed tasks for the aide to assist patient with Foley care and to empty the Foley bag. A home visit was conducted on 05/21/08 at 2:50 PM accompanied by the agency's Director of Patient Services (DPS). During the home visit, the patient and spouse were interviewed and reported that the patient STATE FORM miss '5-S e e _.5 g1. VJ6011 If continuaton sheet 4 of 13 / PRINTED: 06/02/2008 FORM APPROVED' New York State Departnment of Health * TATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDER1SUPPLIER/CLIA IDENTIFICATION NUMBER; (X2) MULTIPLE CONSTRUCTION A BUILDING B. WING STREET ADDRESS, CITY, STATE, ZIP CODE (X3) DATE SURVEY COMPLETED 0308L001 NAME OF PROVIDER OR SUPPLIER 05122/2008 SELFHELP COMMUNITY SERVICES, INC. (X4) ID PREFIX TAG SUMMARY sTATEMENT'OF DEFICIENCIES 50 CLINTON STREET HEMPSTEAD, NY 11550 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC iDENTIFYING INFORMATION) H 618 Continued From Page 4 had a Foley catheter from the start of care 12/05/07 until the patient had surgery in February 2008. During the months of December 2007 through May 2008i the agency's nurse and home health aide provided home care services. The record lacked documentation that the patient had a Foley catheter during the months of December 2007, January 2008 and February 2008. Review of the nursing visit notes dated 01/12/08 and 02/08/08, the nurse failed to document if the patient had a Foley catheter and the nurse failed to document the supervision of the aide in performing tasks related to the Foley catheter. Further review of the patient record, the nurse failed to revise the Plan of Care after February .2008 to refect changes with the patient's Foley. status. The record lacked documentation that the patient's physician was notified of these ' changes. Review of the aides service reports for dates of service of 12/05/07 - 02/29/08, the aide failed to document specific tasks performed to assist the patient with Foley catheter care. On 05121/08 at 1:30 PM, the DPS and Assistant Vice President were informed of the survey findings and were given an opportunity to provide an explanation. On 05/22/08, the Administrative staff acknowledged the survey findings. Patient #6 was admitted to the agency on 12/10/07 with diagnoses of Macular H 618 on 6/4/08 to reflect d/c of Foley catheter. Plan of Treatment was updated and sent to Primary MD on 6/10/08. RN counseled on 6/4/08 re: documentation standards. The Home Health Aide was counseled by the DPS on 5131/08 re: following the patient's plan of care and reflecting tasks perfornied con sistently on the duty peey I) The Clinical Manager will be responsible for conducting a focused audit of 100% of active clinical records for similar deficiencies to ensure all records meet regulatory standards. I)By 6/30/08 all RNs will receive inser0vice conducted by the Clinical Manager regarding standards for Macgraegrdngsanars.o maintaining patient records according to guidelines including plan of care, toguelines nd plan of progrcss notes and notification of physician for significant changes to the OC. lV)Audit findings Will be reported quarterly at die PAC meetings. - Degeneration and Hypertension. Pa - 4L, pajL-. - The Plan of Care (POC) dated 12/10/07 ordered the Registered Nurse (RN) Q weekly (every week) to pre pour medications and do TATE FORM VJ6011 If confinuation sheet 5 of 13 PRINTED: 06102/2008 Iew York:State Department of Health TATEM* NT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROV1DERJSUPPLIERFCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING FORM APPROVED (X3) DATE SURVEY COMPLETED 0308L001 NAME OF PROVIDER OR SUPPLIER B.WING STREET ADDRESS, CITY. STATE, ZIP CODE 05/22/2008 SELFHELP COMMUNITY SERVICES. INC. (X4) ID PREFIX TAG 50 CLINTON STREET I HEMPSTEAD, NY 11550 ' SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MuST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (Xd) COMPLETE DATE H 618 Continued From Page 5 medication teaching. The POC listed seven (7) medications for pre pour which includes: ASA (Aspirin), Prilosec, HCTZ (Hydrochlorothiazide), Verapamil, Zocor, Zoloft, and Oscal. Review of the nursing visit reports lacked documentation of the name, dosage, route and frequency of medications pre poured. For example, nursing visits of 12/17/08, 12/27/08, 01/07/08, 01/14/08, 01/24/08, 01/31/08. 02/07/08, 02/14/08, 02/20/08, 02/28/08, 03/06/08, 03/12/08, 03/20/08, 03/26/08,and 04/04/08 the nurse consistently documented "pre pour meds". The visit notes lacked documentation of the name, dosage, route and frequency of the medications pre poured on these dates. H 018 Patient 6: On 01/14/08, the nurse documented "ordered refill on Zoloft, Omeprazole, HCTZ (Hydrochlorothiazide), Zocor. Need MD to fax' new script for Verapamil with correct dosage". The record lacked documentation of the names of medications pre-poured on this date and the follow-up revisit date for the nurse to pre pour the remaining medications. Further review of the nursing visit reports, on the visit dates of 04/09/08, 04/18/08, 04/25/08, 05/02/08, 05/07/08, and 05/15/08 the nurse documented that six (6) medications were pre poured. The nurse failed to document the pre pour of the Oscal. The visit report of 04/18/08, the nurse documented that the patient was started on Aricept 5 mg po QHS (orally every night). The nurse failed to document the pre pour of the Oscal on 04/09/08. The nurse failed to document the pre pour of Oscal and Aricept on lATE FORM oZ1. 1)M) orders for period 1210/07 to 6) 0/0 st R r ek y p/0po 6/10/08 state "RN Q Weekly prepour medications" with medications listed a d ication heading. On 5/22/08 an Interim order was sent to the primary MD reflecting the addition of Aricept to pt's medications as of 4/18/08. This order was returned signed by the iD and dated 5/27/08. Ui) 100% focused audit comparing medications listed on MD orders and those documented in the RN report is (0 being conducted on all active cases by th Clinical Manager; to be completed by 6/30/08. III) All RNs will receive in-service on/) documentation standards relating to prepour of medications by 6/30/08. IV) Ongoing audit of MD orders by the Clinical Manager and DPS will continue every 60 days after 6/30/08. Audit findings including compliance with MD orders standards with be reported* quarterly at the PAC meetings. , V i VJ6011 Ifcontinuation sheet 6 If 13 PRINTED: 06/02/2008 FORM APPROVED New York State Department of Health oSiATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A BUILDING ___________ _ _ _ _ _ _ _ _ _ (X3) DATE SURVEY COMPLETED 0308L00W NAME OF PROVIDER OR SUPPLIER B. WING _ 0512212008 STREET ADDRESS, CITY, STATE ZIP CODE , SELFHELP COMMUNITY SERVICES. INC. (X4) ID PREFIX TAG 50 CLINTON STREET HEMPSTEAD, NY 11550 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SIIOULD RE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H 618 Continued From Page 6 04125/08-05115/08. On 05/21/08 at 1:30 PM, the DPS and Assistant Vice President were informed of the survey findings and were given an opportunity to provide an explanation. On 05/22/08, the Administrative staff acknowledged the survey findings. Patient #7 was admitted to the agency on 01/18/08 with diagnoses of Hypertension, Early Dementia and Depression. The Plan of Care dated 01118 - 06/18/08 ordered the RN to pre pour medications weekly and perform medication and therapeutic diet teaching. The Plan of Care listed seventeen (17) medications that the patient was receiving such as: Toprol, Cozaar, Hydrochlorothiazide, Lasix, Potassium Chloride, Lexapro, Citracal + Vitamin D,Aspirin, Protonix, Lipitor, Coumadin, Slow Magnesium, Aricept,.Valium, Amoxicillin, etc. Review of the Skilled Nurse (SN) visit notes dated 01/19, 01/25, 02/01, 02/08, 02/15, 02/22, H 618 P ti IX) The Clinical Manager will review all RN visit reports on a weekly basis to ensure documentation standards are maintained with regard to medication and route dosage, frequency aame, of This procedure has administration. commenced 6/2/08. All 011) nurses will be educated on standards for maintaining patient records according to guidelines by 6/30/08. IV)On.gorngfocusedauditsbythe 02/29, 03/07,.03/14, 03/21, 03/27, 04/03, 04/10, 04117, 04/24, 05/02 an 05107/08 consistently documented that the nurse pre poured the medications but lacked documentation of the medications name, dosage, and the frequency. On 05121/08 at 1:30 PM, the Director of Patient Services (DIPS) and Assistant Vice President were informed of the survey findings and were given an opportunity to provide anexplanation. On 05/22/08, the Administrative staff acknowledged the survey findings. Clinical Manager and DPS of RN visit reports will begin by 6/30/08 with follow-u every 60 days. ;TATE FORM WI N VJ6011 If continuation sheet 7 of 13 PRINTED: 06/02/2008 FORM APPROVED NE1 ork State Departrient of Health (Xl) PROVIDER/SUPPLIERJCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED S"rATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION A. BUILDING 0308L001 NAME OF PROVIDER OR SUPPLIER B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 05122/2008 SELFHELP COMMUNITY SERVICES, INC. (X4) ID PREFIX TAG 50 CLINTON STREET HEMPSTEAD, NY 11550 ID PREFIX . TAG SUMMARY STATEMENTOF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X) COMPLETE DATE H1002 Continued From Page 7 H1002 766.9(a) Governing authority Section 766.9 Governing authority, The governing authority or operator, as defined in Part 700 of this Title, of a licensed home care services agency shall: (a) be responsible for the management and operation of the agency; (b) ensure compliance of the home care services, agency with all applicable Federal, State and local statutes, rules and regulations. This Rule is not met as evidenced by: Based on review of the Home Health Aide Training Program (HHATP) trainee files and staff interview, the Governing Authority failed to ensure that the HHATP maintain sufficient documentation to demonstrate that the requirements of the standard are metin five (5) out of five (5) trainee files reviewed. H1002 H1002 -I11002 Home Health Aide Training Program . Attendance sheet will document the 7/1/08 number of hours of classroom, testing and S.P.T hours to comply with certific, ion criteria. See attachment A. (Training Program Attendance sheet) 1I.A new attendance sheet has been instituted to identify program hours. See attachment A III. Revisions to attendance scheduled I ours will be monitored on a monthly basis IV. To ensure best practice: the revisio s to the attendance "sign -in" sheet will be identified at Selihelp's quarterly Home Health Aide Training program Professional Advisory Committee. The Governing Authorities failure to ensure that the HHATP maintain sufficient documentation to demonstrate the standards are met places the HHATP at risk for inadequate training of home health aides. Findings include: Review of trainee files #1 thru #4 documented that the trainees completed the HHATP on 03/03/08./ Review of trainee file #5 documented that the trainee completed the HHATP on 10/08/07. The trainee files for trainees #1, #2, #3, #4 and #5 lacked documentation of the number of STATE FORM 0211W Ac. . p> f - / , , U >, VJ601i If continuatioa sheet 0-of 13 PRINTED: 06/02/2008 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDERISUPPLIERJCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A BUILDING (X3) DATE SURVEY COMPLETED 0308L001 NAME OF PROVIDER OR SUPPLIER " W 05/2212008 STREET ADDRESS, CITY, STATE, ZIP CODE SELFHELP COMMUNITY SERVICES. INC. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES 50 CLINTON STREET HEMPSTEAD, NY 11550 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) P(5) COMPLETE DATE (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H1002 Continued From Page 8 trainee hours received: The files contained only documentation of the sixteen (16) Supervised' Practical Training (SPT) hours received. Further review of the 'HHATP Training Program Attendance" sign-in sheet lacked documentation of the time trainees arrived to class and time trainees left Class. The record lacked documentation of the number of hours in classroom training. received. An interview was conducted with the Assistant Vice President of Home Care, Director of Patient Services, and the Clinical Manager on 05/22/08 at 01:30PM, they acknowledged the survey findings. H1014 766.9(g) Governing authority Section 766.9 Governing authority. The governing authority or operator, as defined in Part 700 of.this Title, of a licensed home care H1002 H1014 I. MSW will be put into place and the employee ile 7/21/08 Will be compliant by 7/21108 I. existing Selhelp Community Services, Inc An Social worker is in place with a verified active Ii nse registration, remaining components of empl yee file To be completed by 7/21/08 II. calendar month of June will be a guidelin to keep The The employees file in compliance. IV.A monitoring system incollaboration with our uman resources Will flag employees file for complianc services agency shall: servics aAnd (g) employ or contract for a sufficient number of staff to coordinate, direct and deliver services to patients accepted for care in accordance with prevailing standards of professional practice. This Rule is not met as evidenced by: Based on request for personnel/contracts for' services available by the agency and staff interview, the agency failed to employ or contract for sufficient staff to ensure the delivery of services identified on the agency's license. The agency's failure to employ or contract staff to provide the services on the license places the patients at risk for not.having their Medical Social Work (MSW) needs met. 3TATE FORM 0z,1n p\. (7 2 ' VJ6011 If continuation sheet 9of 13 PRINTED: 06/02/2008 FORM APPROVED New York State Department of Health. STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER(X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED 0308L001 NAME OF PROVIDER OR SUPPLIER B.WING STREET ADDRESS, CITY, STATE, ZIP CODE 05122/2008 SELFHELP COMMUNITY SERVICES, INC. (X4) ID PREFIX TAG 50 CLINTON STREET HEMPSTEAD, NY 11550 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H1014 Continued From Page 9 Findings are: Review of the agency license included MSW as a service that the agency is able to provide. An interview with the Director of Patient Services (DPS) on 5/22/08 at 1:40 PM, the DPS stated that the agency does not have an employee or contract to provide MSW services to the patients. H1142 766.9(0) Governing Authority Section 766.9 Governing authority H1014 H1142 See page 11 for Plan of Correction Related to H1142 ."IU 6C (o) Health Provider Network Access and Reporting Requirements. The governing authority or operator of an agency shall obtain " from the Department' s Health Provider Network (HPN), HPN accounts for each agency that it operates and. ensure that sufficient, knowledgeable staff will be available to and shall maintain and keep current such accounts. At a minimum, twenty-four hour, seven-day a week contacts for emergency communication and alerts, must be designated by each agency in the HPN Communications Directory. A policy defining the agency' s.HPN coverage consistent with theagency' s hours of operation shall be created and reviewed by the agency no less than annually. Maintenance of each agency' s HPN accounts shall consist of, but not be limited to, the following: (1) sufficient designation of the agency' s HPN coordinator(s) to allow for HPN individual user application; (2) designation by the governing authority or operator of an agency of sufficient staff users of 3TATE FORM 02" . N VJ6011 If continuation sheet 10 of13 . I PRINTED: 06/02/2008 FORM APPRO VED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPUERJCLA IDENTIFICAT ION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING ______ _____ (X3) DATE SURVEY COMPLETED 0308L001 NAME OF PROVIDER OR SUPPLIER 05/22/2008 STREET ADDRESS, CITY, STATE, ZIP CODE SELFHELP COMMUNITY SERVICES. INC. I (X4) ID PREFIX TAG 50 CUNTON'STREET I HEMPSTEAD, NY 11550 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H1142 Continued From Page 10 the HPN accounts to ensure rapid response to requests for information byfthe State and/or local Deparment Heath; Department of Health: (3) adherence to the requirements of the HPN user contract; and (4) current and Complete updates of the Communications Directory reflecting changes that include, but are not limited to, general information and personnel rolechanges as soon as they occur, and at a minimum, on a monthly basis. and This Rule is not met as evidenced by: policy Based on request for the agency's policy and procedure, and staff interview, the Governing Authority (GA) failed to establish written policiesand procedures defining the agency's Health Providers Network (HPN) coverage. The GA's failure to establish andmaintain an HPN policy and procedure places the agency at risk for poor patient care practice. Findings include: On 05121/08 the surveyor requested a copy of the HPN policy and procedure. The Director of .Patient Services reported that the agency does not currently have a policy and procedure on HPN. On 05/22/08 at 02:00PM, the DPS .acknowledged the survey findings that the agency is operating without the requirement of an HPN policy and procedure. H1142 H1i142 Policy and Procedures H]PN network 7/30/08 . The :Policy and Procedure for the Health 'Provider Network will be in place 7/30/08 will be in placead30/08 ide eo lI.The policy willbe in place and revised ainually or of Health. Dept as necessary required by the standards If the Ill. The review of policy and procedures by die Corporate Compliance department annually. IV. Review of Health Provider Network on a daily basis. 2"(U j ;TATE FORM 0211 VJ6011 Ifcontinuation sheet 11 of 13 PRINTED: 06/02/2008 FORM APPROVED New York State Departrrent of Health 'STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDERISUPPI.IERICLIA IDENTIFICATION NUMBER: (X2.)MULTIPLE CONSTRUCTION A BUILDING __________ (X3) DATE SURVEY COMPLETED 0308L001 NAME OF PROVIDER OR SUPPLIER B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 0512212008 SELFHELP COMMUNITY SERVICES. INC. (4) ID PREFIX TAG 50 CLINTON STREET HEMPSTEAD, NY 11550 'Io PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 0(5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H13501 Continued From Page 11 I H1350 H1350 I. In-Home annual performance is in placeand completed by 615/08 H1350 766.11(k) Personnel 766.11 Personnel. The governing authority or operator shall ensure for all health care personnel: (k) that an annual assessment of the performance and effectiveness of all personnel is conducted including at least'one in-home visit to observe performance, if applicable. This Rule is not met as evidenced by: Based on review of personnel files and staff interview, the agency failed to ensure that all health care personnel receive an annual. assessment of the performance and effectiveness which includes at least one (1) in-home visit to observe performance. 'This was evident in two (2) of two (2) professional employees that required annual performance evaluations. (Employees #4, and #5) The agency's failure to ensure that all employees receive annual performance evaluation including in home visit observation places the patients at risk for receiving poor quality care. Findings are: Review of personnel file of Employee #4 included an annual Employee Performance Appraisal for years 2006 and 2007 but lacked evidence of in-home visit observation. The employee has been employed with the agency since January 11, 1996. Review of personnel file of Employee #5 included an annual Employee Performance Appraisal for year 2006 but lacked evidence of in-home visit observation and Jacked annual evaluation for 'TATE FORM O2119 W in 1. Annually in June field staff will be assessed for their field evaluations. Ill. In order to ensure that clinical evaluations and employee appraisals are completed guidelines are in place for the calendar month June utilizing the same time sequence as the organization's employee appraisal sequence. IV. The new guidelines for clinical evaluations are in place. -. _ VJ6011 If continuation sheet 12 of 13 PRINTED: 06/02/2008 FORM APPROVED Ne w York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION () PROVIDER/SUPPIUER/CLA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A BUILDING BI. WING _ (X3) DATE SURVEY COMPLETED _ _ _ 0308L001 NAME OF PROVIDER OR SUPPLIER _ _ _ _ _ 05/22/2008 STREET ADDRESS, CITY, STATE, ZIP CODE SELFHELP COMMUNITY SERVICES. INC. (X4) ID PREFIX TAG 50 CLINTON STREET HEMPSTEAD', NY 11550 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H1350 Continued From Page 12 year 2007, which was due in July of 2007. The employee has been employed with the agency H1350 since 02/18/04. On 05/2208 at 10:00 AM, the Director of Patient Services (DPS) and Assistant Vice President -' were informed of the survey findings. The DPS' acknowledged the findings and stated that the nurses are evaluated in the field but acknowledged that the files lacked documentation of the in-home observations. STATE'FORM VJ601 1 If continuation sheet 13 of 13 o" ' (X2) MULTIPLE CONSTRUCTION A. BUILDING PRINTED: 08/0420b0 .FORM APPROVED (X3) DATE SURVEY COMPLETED NYS Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDERJSUPPLIERICLIA IDENTIFICATION NUMBER: 1086L007 NAME OF PROVIDER OR SUPPLIER .0710912008 STREET ADDRESS. CITY, STATE, ZIP CODE PREMIER HOME HEALTH CARE SERVICES (X4)ID PREFIX TAG 696 DUTCHESS TURNPIKE ID PREFIX TAG. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION). H 000 Initial Comments H 000 An Article 36 survey was conducted at the agency on 718/08 ,and 7/9/2008. Ten (10) patient care records Were reviewed (Patient #1through #10) including two (2) home. visits (Patient #4, #8). Ten (10) personnel files were reviewed (Employee # 1 through #10). H 404 766.3(b) Plan of care 766.3 Plan of care. T g rg tireoheu. The governing authoity or operator shall ensure that -practice: (b) a plan of care is.established for each patient based on a professional assessment of the patient's needs and includes pertinent diagnosis, prognosis, mental status, frequency of each, service to be provided, medications, treatments, H 404 found to be affected by the deficient Corrective action for those patients Patient #1: The patient's physician will be contacted regarding the change in the plan of care and orders obtained. Patient #8: A new POC'will be written to reflect the HHA service times and hours. The new POC will be sent to the patient's diet regimens, functional limitations and rehabilitation potential. This RULE is not met as evidenced by: Based on record reviews and interview, the agency failed to ensure that Plans of Care (POC) physician for approval. Patient #9: A new POC will be written to were complete and identified all care needs., This was evident in four (4) of ten (10) patient care records reviewed. (Patient # 1, 8, 9, and 10). -Patient Failure to insure and through and complete POC which addresses all patient needs has the reflect the HHA service times and hours. The new POC will be sent to the patient's physician for approval.. #10: A new POC will be written to reflect the HHA service times and hours. In addition, the patient's physician will be notified of the skin tear and if it remains unhealed, treatment orders will be obtained. The new POC will be sent to the patient's for approval. poewich adresesl need patient The findings include: t sas he e f g "physician 1) Patient #1 has a start of care of 2/28/08 with .TATE FORM T f ECTOSOR PRO'JSUPPER RRESENTAT IGAUET A ORM "cotiuaio /3 e PRINTED: 08104/2008 FORM APPROVED NYS Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDERJSUPPLIER/CUA IDENTIFICATION NUMBER (X2) MULTIPLE CONSTRUCTION A.BUILDING (X3) DATE SURVEY COMPLETED 1086L007 NAME OF PROVIDER OR SUPPLIER B.WING__________ STREET ADDRESS. CITY, STATE, ZIP CODE 0710912008 PREMIER HOME HEALTH CARE SERVICES (X4) ID PREFIX TAG 696 DUTCHESS TURNPIKE ID. PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) o.Identification of other patients having the potential to be affected by the deficiency and what corrective action will SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X) COMPLETE DATE H 404 Continued From Page 1 diagnoses which include UTI (urinary tract H 404 infection), Hypertension and Dementia. The nursing note dated 4/5/08 documents a telephone call between the nurse and the patient's primary caregiver Stating "patient be taken: All private pay and case managed patients have the potential to be affected by the was/is constipated." "Instructed re: purchase glycerin-suppository since that has been successful in the past." deficient practice. These applicable clinical records will be audited by the Office Administrator and Field Nurse Supervisor to There is no documentation to reflect the patient' s physician was notified of this modification to the POC. 2) Patient #8 has a start of care of 1/2/07 with diagnoses which include Generalized Osteoarthritis and Congestive Heart Failure. The POC dated 6/2 through 12/25/08 documents: "supervise HHA" (Home Health Aide) "assist with ADL" (activities of daily living). The POC lacks documentation to reflect the times and hours the HHA is to work. 3) Patient #9 has a start of care of 1/17/07 with diagnoses which includes Alzheimer's Disease. The POC dated 7/18108 documents: "supervise develop a new plan of care and send them to the patients' physicians for approval. Ill. Measures that will be put in place to ensure that the deficient practice will not determine compliance with the regulation. For the patients found to be out of compliance; the Field Nurse Supervisor will reoccur: All Field Nurse Supervisors will be in. serviced on Policy 11.6 by the Office Administrator or Regional DPS which directs nursing staff to conduct home visits for reassessment as needed, but in no case, not less than every 6 months. In addition, they will also be in-serviced on the necessity of updating plans of care/treatment when and hours changes, limited to service times including but not HHA". The POC lacks documentation.to reflect, the times and hours the HHA is to work. 4) Patient #10 has a start of care of 511/07 with diagnoses which include CVA (Cerebral Vascular Accident) and Hypertension. The nurses will be instructed that the patient's physician must be notified of any changes. The POC dated 5/12/08 documents: "supervise HHA to assist with ADLS, safety. The POC lacks documentation to reflect the times and hours the HHA Is to Work. The nursing visit note dated 9/6/07 documents: ;TATE FORM ;TATE FORM ozil@ FSMU11 f continuation sheet 2of 3 NYS Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROV1DERISUPPUER/CLA IDENTIFICATION NUMBER. (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING_______ ___ PRINTED: 08104/2008 FORM APPROVED .X3) DATE SURVEY CO,_____________ 10861007 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 0710912008 696 DUTCHESS TURNPIKE ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE (XS) COMPLETE DATE PREMIER HOME HEALTH CARE SERVICES (X4) I PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) DEFICIENCY) H 404 Continued From Page 2 H 404 [V. How will the corrective action be monitored toensure the deficient practice will not reoccur? 10% of the private and case-managed records will be audited each quarter for a one year period to ensure compliance with left buttock no documented There was skin tear .,.. Neosporin applied" evidence that the physician was notified of this modification of the Psc. During interview with the agency Administrator on 7/9108 at"should have" Administrator stated the nurses 11:45AM the documented~the freqnurec fho d Hso th ve" POC andPresident the frequency for the HHA's on the POO and "notified the patient's physician's of treatments." the regulation. The Regional DPS and Regional Vice TeRgoa P n einlVc will review the audits every quarter to ensure compliance with the regulation. Persons responsible for the correction and on-going compliance are: Field Nurse Supervisors (FNSs) Office Administrator Regional DPS (Director of Patient Services) Regional Vice President Date of Correction: 12/09/08 . TATE FORM 3TATE FORM 01M FSMU11 1 continuation sheet 3 of 3 )EPARTX,.ENT OF HEALfH AND HUMAN SERVICES DICARE AND MEDICAID SERVICES !Ok 'ENTERS F STATEMENT OF DEFICIENCIES ,AND pLA OF CORRECTION - .... FMi AO VED 0MB NO. 0938-0931 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY. COMPLETED C (XI) PROVIDER/SUPPLIER/CLIA UMBER. IDENTIFICA ADPAOFCORCA.BUILDING._________ 337290 08/27/2008 B.WING STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER. INC. & CHHA AMERICARE CERTIFIED SPECIAL SERVICES (X4) ID PREFIX TAG 5923 STRICKLAND AVENUE BROOKLYN, NY 11234 (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFIENCY) FULL (EACH DEFIENCY MUST BE PRECEEDED BY REGULATORY OR LSC IDENTIFYING INFORMATION) SUMMARY STATEMENT OF DEFIENCIES ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (X5) COMPLETION DATE G 000 INITIAL COMMENTS A complaint investigation was done on 08/27/08 for Complaint # NY00061500. Three patient records were reviewed and are identified as Patient 1-3. G 000 G 165 484.1.8(c) CONFORMANCE WITH PHYSICIAN ORDERS DRgs and treatments are administered by agency g -staffcnly as ordered by the physician. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to provide treatment as ordered. This was evident for lof 3 sampled patients. (Patient 1) Failure to follow treatment order has the potential fo c~e o ptien subtandrd . for smbstandard patient care. -onitoring G 165 Corrective Action Upon fUrther investigation the physician had postponed physical therapy due to the patient not being able to tolerate active therapy. The Case Manager was issued a disciplinary warning for failure to document timely in the medical record and failure to obtain an interim order. "not Measure to promote systemic changes and occur." to ensure deficient practice will The case managers were assigned to teams Each " 08/27/08 * . The finding is: - " " . . - area. according to geographic 02/01/09 Patient # I was admitted to the Home Health Dementia, Hypertension and Diabetes. Agency on "3/25/08" with a diagnosis of Senile geographic, area has a designated Supervisor. The Supervisor will complete periodic chart audits on all patients receiving ancillary services including physical therapy to ensure orders are current and that the order dated 7/17/08 documents an The Physicianpatien to receive phy7ica tueray. e physical thrp. ore for the T-der frtepient t The patient care, record documents that the agency' did not sent a physical therapist to evaluate the .patient until "8/8/08". that physician -. otne therapy.. documentation supports the need for continued therapy. o Requests for physical therapy are being centralized and a clerk has been assigned to ensure that all referrals are placed timely. 08/27/08 On 8/27/08, the Director of Patient Services-was interviewed and stated that the agency "does not have" a valid reason for the delay in physical therapy services. G227 484.36 (C) (2) ASSIGNMENT AND DUTIES OF HOME HEALTH AIDE G227 . " LABORATORY DIRECTOR'S OR.PROVIDER:SUPPLIER RERATURE Patient # 1 -The DPS did an investigation regarding the training of both HHAfs. Both HHA's received their Certification from Bronx Institute. TITLE (X).DATE from correcting providing it is determiine9 denotes a fcticiency whic the institution may be excused the findings stated above are disclosable 90 Any deficiency statement ending with an asteisk (*) sing homes, . n protection to the patients. (See instructions.) Eyept that other safeguards provide sufficient plan of correction is provide . F .nu days following the date of survey whether or not a the date these documents are made availabl disclosable 14 days following continued program participation. Oil vent ID: . FORM CMS-2567 (02-99) Previous Versions Obsolete mes, theaboy findings and plans of correction are an approved plan of correction is requisite to )D 6 -aili fcontinuation sheet Page I of 3 )EPARTMENTjOF HEALTH AND HUMAN SERVICES .ENTERSFOR MEDICARE AND MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDER/SUPPLIERICLIA IDENTIFICATION NUMBER-' 337290 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION " ABUILDING ________ PRINTED: 12/31/2008 FORM APPROVED OMB NO. 0938,0931 (X3) DATESURVEY COMPLETED _ B.WING .8127109 0___ STREET ADDRESS. CITY, STATE, ZIP CODE AMERICARE CERTIFIEDSPECIAL SERVICES INC. & CHHA (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFIENCIES (EACH DEFIENCY MUST BE PRECEEDED BY FULL, REGULATORY, OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG 5923 STRICKLAND AVENUE BROOKLYN, NY 11234 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFIENCY) (X5) COMPLETION DATE Continued from page 1 HOME HEALTH AIDE Any home health aide services offered by an HtA must be provided by a qualified home health aide. This STANDARD is not met as evidenced by based on record review and interview, the agency failed to assign a trained Home Health.Aide skilled in Hoyer .. lift usage. This was evident for one of three sampled patients (Patient # 1). Failure to ensure the skills of a Home Health Aide (I--A) places the patient at risk for substandard - p s ttraining care. G 227 The DOH Certification curriculum clearly indicates that transfer training and use of the hoyer lift be satisfactorily completed and demonstrated in order to obtain Certification. (See attachment 41) Both aides received their Certification (2005 & 2007)*indicating-thai they did have training and successfully completed a return demonstration. (See attachment #2 & 3). " Since the complaint both aides have undergone. further training on the hoyer lift At the request of the CHHA all HHA's placed on cases must have a transfer /hoyer lift redone on aii annual basis as part of their annual in-service requirements. . 08/17/08 " The finding is: 1. Patient # 1 was admitted on "3/25108" with a diagnosis of Senile Dementia, Hypertertsion and Diabetes Acomplaint received by the NYSDOH (New .Yok alleges Stale Department of Health) dated 8/18/08 algsupdated that the "HI-A did not know how to use the Hoyer In order to ensure continued compliance the Case Manageis are required to update the HHA Plan of Care every 60 days ormore frequently if changes occur. Responsible Person: RN/Case Manager will update HHA POC every 60 days. The Nurse Supervisor & DPS will ensure Care Plan is 12/31/08 & ongoing " by performing chart review. lift on Sunday 8/17/08" The patient care record documents ithat the patient is incontinent of urine and feces; requires total assistanve inall areas of daily living non- " ambulatory and requires a Hoyer lift for transfers from bed to chair. The supplemental patient care plan dated "5/26/08" docunments that-the patient is to be transferred using a "Hoyer lift". . All active patients that have a hoyer-lift in the home the aides will have re-training in the . proper use, techniques and transfers using the buyer lift. The RN will document in her supervisory note that the aides satisfactorily completed areturned demonstration. (See attachment # 4) Responsible Person: RN assigned to the case will supervise HHA's using hoyer lift., and document in the nurses visit note. Americare's DPS will ensure supervision occurs. Measure to promote systemic changes and not occur. 12/02/08 & ongoing , 12/2/0 & ongoing The patIient care plan dated 5/26108 contains a note home which documents .......health aides are monitoring to ensure deficient practice will Americare Inc. HHA's with Certificates from Bronx Institute will under go training and a return demonstration on use of the hoyer lift. ongoing 12/31/08 & - - FORM CMS-2567 (02-99) Previous Versions.Obsolete Event ID: 7KI01 I Facility ID: 4706 . If continuation sheet Page 2 of 3 U ' oo ' pARTMENT OF HEALTH AND HUMAN SERVICES -NTERS FOR MEDICARE AND MEDICAID SERVICES T. TAEMNT OF DEFICIENCIES kND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIERCL1A IDENTIFICATION NUMBER: 337290 , PRINTED: 12/31/08 FORM APPROVED OM AO VED - o .. ____ COMPLETED (X3) DATE SURVEY CMLTD .. (X2) MULTIPLE CONSTRUCTION A.BUILDING_____ B. WING _08/27/08 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE AMERICARE CERTIFIED SPECIAL SERVICES INC. &CHHA 5923 Strickland Ave Brooklyn, NY 11234 (X4) ID PREFIX TAG, SUMMARY STATEMENT OF DEFIENCIES (EACH DEFIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION. (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFIENCY) 0(5) COMPLETION DATE G277 G 277 Continued From page 2 to be instructed and supervised with return demonstration of these duties ...... Teagency HH.ceuedae 81/8hours. The ageyHA schedule dated 8/17/08 assigned Health Aide was documents that a Home to care for the patient. The personnel record of the Home Health Aide . assisgned on 8/17/08 does not include documentation fo training for Hoyer lift usage in patient transfers. On 8/27/07 at 12pm, the Director of Patient Services was interviewed and stated that there was nothing to indicate that the Home Health Aide has been instructed and/ort. supervised in Hoyer lift usage. The home health aide was not available for interview. o Measure to promote systemic changes and monitoring to ensure deficient practice will not occur. On an annual basis all active HHA's will be required to undergo training in.transfers and the use of Hoyer lift as part of their in-service Responsible Person: Americare Inc. inservice educatoirs, QI Director and Administrator Will ensure retraining is completed on an annual basis. 12/31/08 & ongoing ' FORM CMS-2567 (02-99) Previous Versions Obsolete 7Event ID: 7K101 I Facility ID: 4706 If continuation sheet Page 3 of 3 Guide to Home Health Aide Training And Competency Evaluation INTRODUCTION The purpose of this Guide is to clarify for certified home health agencies (CHHAs), long term home health.care programs (LTHHCPs), licensed home care services agencies (LHCSAs), and hospices, hereafter referred to as home care agencies, the NewYork State home health aide training and evaluation requirements, and the process and procedures for Department of Health approval of home health aide training programs. Effective October 1, 2006, any applicant seeking initial approval of a home health aide training program or any existing approved program seeking reapproval must comply with the requirements set forth in this Guide. These requirements supersede the requirements set forth in the New York State Department of Health's Guide to Home Health Aide Training and Competency Evaluation (1992). The training and evaluation requirements and approval process set forth in this guide are consistent with Part 484 of Title 42 of the Code of Federal Regulations (42 CFR) and Section 700.2 of Title 10 of the New York Code, Rules and Regulations (10 NYCRR). In order to provide home health aide services in New York State, a person must successfully complete a training and competency evaluation program or competency evaluation program only conducted by an approved home health aide training program. TRAINING REQUIREMENTS A liorre health aide training program must include classroom and supervised practical training. The aide trainee must receive a minimum of 75 hoursof training including 16 hours of supervised practical training. Supervised practical training means training in a laboratory, patient's home or other health care. setting in which the trainee demonstrates knowledge while, performing tasks on an individual under the direct At supervision of a registered nurse or licensed practical nurse. o a minimum, fifty percent (50%) of each aide's supervised practical training must be provided in a patient care setting. The setting(s) used for practical training and the number of training hours provided should bebased on each student's learning needs. CURRICULAR CONTENT Each home health aide training program must identify and clearly state its goals and objectives and must include measurable performance criteria specific to both the curricular subject material and-clinical content required by the Department. We recommend that the curriculum be taught at a sixth grade reading level. The curriculum must include the content outlined below: 1. Orientation to home care and the role of home health aides; 2. understanding basic human needs of individuals and families including understanding the elderly, infants and children, persons with physical illnesses, persons with physical disabilities and persons with mental disabilities; 3. communication skills; 4. basic elements of body function; 5. patient rights and HIV confidentiality; 6. safety, accident prevention and responses to emergencies; 7.' infection control and universal blood and body fluid precautions; 8. personal hygiene and grooming including bed, sponge, tub or shower baths; skin, tub or bed shampoos; nail and skin care; oral hygiene; toileting and elimination; 9. use of prescribed medical equipment arid supplies; 2 10. rehabilitation including safe transfer techniques and ambulation; normal'range of motion and positioning; * assistance with use.of crutches, walkers, and hoyer lifts; and prescribed exercise programs;.. 11. nutrition and fluid intake, to include'preparation of meals for simple and complex modified'diets; 12. temperature, pulse, respiration, and blood pressure; 13. simple test and measurements; 14. maintaining a clean, safe environment; *15. assistance with medication administration; 16. special skin care; 17. simple dressing changes; IS. I ostomy care; 19. handlingpatient's money; and 20. observing, reporting, and recording. The training program's teaching staff may exercise discretion in determining the amount of time required to adequately teach each of the subject areas, however, the minimum training time required must be met for each subject area and the training hours must total a minimum of 75 hours. STANDARDIZED TRAINING CURRICULA In order to assure that all home health aide training programs are teaching comparablecontent, home health aide training programs are required to use this curricula as the basis for the home health aide training program. The revised objectives and outline must.be followed and all material must. be covered,. The Home Care Core Curriculum (HCCC) and the Health Related Task Curriculum (HRTC) developedin 1992 by-the State University College of Buffalo under contract with the State Department of Social Services (SDSS) may be used as an adjunct to the information contained in.the revised objectives and outline. These curricula may be obtained from: Health Education Services P.O. Box 7126 Albany, NY 12224 (518) 439,7286 fax: (518) 439-7022 www.hes.org d Other resources may be used at the discretion of the Registered Professional Nurses supervising the approved Personal Care Aide/Home Health Aide Training Programs. Training programs should supplement to standardized curricula with other training materials as necessary to provide adequate instruction in the curricular content outlined on pages. 1 and 2 of this Guide. For example, the above curricula should be supplemented to address patient rights, HV confidentiality and universal blood and body fluid precautions, (items 5 & 7 of the curricular outline). Therefore, training programs are required to use Part 63 or 10 NYCRR (Confidentiality of HIV-related information); Sections 763.2, 766, 1,'or794.1 of 10NYCRR, (Patient rights concerning CHHA; LTHHCP, LTHHCP and hospices respectively); and the Department of Health Memorandum 90-1 (Recommendations for the Prevention and Management of Bloodborne Disease Transmission inHomeCare Settings)in the instruction of these topics. COMPETENCY EVALUATION PROGRAM The home health aide training piogram is also responsible for ensuring that each home health aide trainee is competent in each skill and procedure taught in the training program. Competency evaluation may. be integrated throughout the training program or may be conducted subsequent to classroom and supervised practical training. .Initial competency must be evaluated by a registered.nurse using the following methods: o written and/or oral examinations that demonstrate' the aide's knowledge of the information presented in the classroom training; and * observation and demonstration by the aide of his/her competency in performing skills in the laboratory or patient care setting. The tasks associated with personal hygiene, rehabilitation and vital signs (the subject areas.listed in items 8, 10 and 12 of the curriculum outlined on page 2 of this Guide)must be evaluated after observation of the aide's performance of the task with a person in the laboratory or patient care setting during the sutervised.practical training. To evaluate each home health aide trainee's competence in performing the minimally required number of home health skills, each home health aide training program should utilize the following: " The written unit tests found on the Health Depaitment's Health Provider Network; and " The skills checklists found in the appendices of the Home Care Curriculum (HCC) and the HealthRelated Tasks Curriculum (HRTC). A home health aide training program may also supplement the written unit tests and performance ex aminations contained in the HCC and HRTC with evaluation processes developed by training programs to assure that the aide is competent in the content and skills learned throughout the training program. o "For each home health aide who has completed classroom and supervised practical training, all competencies must be documented on a competency evaluation formdeveloped by the home health aide. training program and approved by the.Department of Health. The competency evaluation form must list the competencies which are subject to evaluation; the method of evaluation and the satisfactory or unsatisfactory outcome of the evaluation; and the identity, by name and license number, of the registered. nurse who has o evaluated the aide's performance of each task. Classroom and supervised practical training and competency evaluation must be completed within two months of each aide's entry intothe training program. COMPETENCY EVALUATION ONLY In lieu of the standardized training and competency evaluation, the home health aide training program must.make available to eligible individuals a competency evaluation program only. The competency evaluation program should be derived from the written unit tests and skills demonstration checklists included in the HCC and HRTC curricula. The written and skills demonstration portions of the competency evaluation program must contain sufficient content to assure that the aide is competent in the information and skills set forth in the curricular outline on pages 1 and 2 of this Guide. The subject areas listed in items 8, 10, and 12 of the curricular outline must be evaluated after observation of the aide's performance of the task with a person in the laboratory or patient care setting. " Individuals eligible to complete the competency evaluation program only, in lieu of training, include: 4 sTATE OF NEW YORK DEPARTMENT OF HEALTH Metropolitan Area Regional Office New York, NY 10007 90 Church Street Richard F. Daines, M.D., Commissioner Wendy E. Saunders Executive Deputy Commissioner February 6, 2009 Gentiva Health Services Attn: ,Mr. Keith Curtis, RN Administrator/Dir. Clinical Operations 50 Court St., #1202 Brooklyn, NY 11201 Re: Acceptable Plan of Correction SurveyDate: January 4, 2009 License: #LC0497A Dear Mr. Curtis: Please be advised that the Plan of Correction relating to the recent Article 36 survey of your agency have been reviewed by this office. All items were found to be acceptable and it is expected that you will implement this plan within the time frames that were submitted. A post approval review will be conducted to verify the correction of deficiencies. If you have any questions regarding this matter, please contact (212) 417-5888. Sini Cheryl Phoenix-Tannis, RN, MSN, CS Program Manager Home Health and Hospices Services .Metropolitan Area Regional.Offices /jt * GENTIVA7 February 3, 2009 Department of Health Metropolitan Area Regional Office 90 Church Street Brooklyn, New York 10007 Attn: Cheryl Phoenix-Tannis, RN, MSN, CS Program Manager Home Healthcare & Hospice Services Survey: Re: Gentiva Health Services License Number LC0497A Survey date: 1/14/09 Dear Ms. Phoenix-Tannis: Please see the amended Plan of Correction and attachments developed in response to the summary statement of deficiencies for the Article 36 survey. Please contact me at 718-237-2389 if you have any questions related to this response. Smcerel f .iTPj fini eith Curtis RN. 'Administrator/Dir. Clinical Operations ....... .................... 2 50 court St. *.#1.202 *brooklyn, ny 11201 t 7 18.237.2389 *f 7 18.237.0632 www.gentiva.com PRINTED: 01/22/2009 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIOERSUPPLIEM/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING ______ _____ (X3) DATE SURVEY COMPLETED LC0497A NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 01/1412009 50 COURT ST. #1204 BROOKLYN, NY 11201 ID PREFIX TAG PROVIOER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE GENTIVA HEALTH SERVICES - BROOKLYN (X4) ID PREFIX TAG' SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H0001 Initial Comments , , A State Relicensure Survey was conducted at Gentiva Health Services on January 14, 2009. Five (5) Patient Care Records were reviewed and are identified as Patients #1 to #5. Four (4) Personnel Records were reviewed and are identified as Employees #1 to #4. The agency Policy and Procedure Manual, Quality Improvement Committee Meeting Minutes, Complaint Log and Admission Packet were reviewed, H 204 766.1(a)(1) Patient rights Section 766.1 Patient rights. (a) The governing authority shall establish written policies regarding the rights of the patient and shall ensure the development of procedures implementing such policies. These rights, policies and procedures shall afford each patient the right to: (1) be informed of these rights, and the right to exercise such rights, in writing prior to the initiation of care, as evidenced by written documentation in the clinical record; (2) be given a statement of the services available by the agency and related charges; (3) be advised before care is initiated of the extent to which payment for agency services may be expected from any third party payors and the extent to which payment may be required from the patient. rATEof Health Systems Management / Office of Long Term Care H 000 H 204 766.1 (a) (1) PATIENT RIGHTS For the patient found to be deficient in obtaining the correct consent on admission, the Area Director immediately contacted the patient and obtained informed consent with updated consent addenda. To identify other patients who may have potentially been affected by this, 100% of Licensed Agency patients clinical records were immediately audited for consents matching services ordered and provided during that certification period by the Area Director. This was completed by 1/16/09. The Area Director (AD) and Area Clinical Specialist (ACS) will provide re-education.on proper procedures for completing consent including the expected services. This education will be competed on 1/29/09 at mandatory staff meeting. In an effort to make sure the deficient practice is not repeated, the agency will audit 100% of all licensed agency records from admission date for compliance with completing consent information with correct expected frequency of services to be provided, and if a need is present for an alteration in the plan, an consent addenda for the corrected and agreed .upon frequency and duration will be ocompleted. H 204 NBORATnRY DIRECTOR'S OR PRO VIDER/SUPPLIER REPRES ENTATIVE'S SIGNATURE TATE .M Version 09/12/08 6899 k3P1 1 if continuation sheet 1 of 11 PRINTED: 01/22/2009 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES nND PLAN OF CORRECTION (X1) PROVIDERSUPPLER/CLIA IDENTIFICATION NUMBER: LC0497A NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING__ _ ______ _ _ _ _ _ _____ _ _ _ (X3) DATE SURVEY COMPLETED 01/1412009 " STREET ADDRESS, CITY, STATE, ZIP CODE GENTIVA HEALTH SERVICES - BROOKLYN (X4) ID 50COURTST. #1204 BROOKLYN, NY 11201 ID PREFIX TAG PROVIDERS PLAN OF CORRECTION (EACH.CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE _DEFICIENCY) COMPLETE DATE j SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PREFIX I TAG * H 204 Continued From page 1 (i) The agency 'shall advise the patient of any changes in information provided under this paragraph or paragraph (2) of this subdivision as I soon as possible, but no later than 30 calendar days from the date the agency becomes aware of the change. (ii)All information required by this paragraph shall be provided to the patient both orally and in I writing; (4) be informed of all services the agency is to provide, when and how services will be provided, and the name and functions of any person and affiliated agency providing care and services. This Regulation is not met as evidenced by: Based on record reviews and staff interview, the agency failed to ensure all patients are informed. i of any changes in services and payment. This 1was evident .for one (1) of five (5) patient care records reviewed. (Patient #3.) Failure to ensure all patients .are informed of any. changes in services and payment places patients at risk for not being able to fully exercise all of their rights. The finding is: Patient #3 has diagnoses which include: Leukemia, Pulmonary Embolism, Diabetes Mellitus and Acute Pericarditis. The patient care record includes a "Home Care Consent" which documents the following information: "The services which Gentiva Health Services will provide for me are indicated below. Skilled Nurse 1 x/wk for 1 week (skilled nurse once a week for one week.) . . . Expected H204. The agency will continue to monitor compliance in this effort with ongoing audits of 100% of all Licensed Agency clinical records for compliance with the consents matching the physician ordered plan of care. For any alterationin the plan of care, the clinician will obtain consent addenda to validate the agreement and patient responsibility. Results of the ongoing audits will be collected and reported to the PI and PAC committee quarterly. Responsible party(s): AD; ACS. charges $198.00 per visit." The patient care ce of Health Systems Management / Office of Long Term Care Version 09/12/08 \TE FORM 6899 KH3P11 , If continuation sheet 2 of 11 PRINTED: 01/22/2009 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xi) PROVIDERJSUPPLIERJCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED _ _ _ A. BUILDING B. WING _ _ _ _ _ _ LC0497A NAMt- OF PROVIDER OR SUPPLIER BW0111412009 STREET ADDRESS, CITY, STATE, ZIP CODE GENTIVA HEALTH SERVICES (X4) ID PREFIX TAG - BROOKLYN 50 COURT ST. #1204 BROOKLYN, NY 11201 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H 204 Continued From page 2 record documents more than one visit by the H 204 nurse. There is no documented evidence of a "Home Care Consent" which informs the patient of.the change in services. On January 14,2009 at 1:35 PM, the Assistant Director was interviewed and did not provide an explanation. H 324 766.2(a)(9) Patient service policies and H 324 procedures I 766.2 Patient service policies and procedures. (a) The governing authority shall ensure for each health care service provided that: (9) a patient is discharged by the agency after H324 766.2 (a) (9) PATIENT SERVICE POLICIES AND PROCEDURES The Area Director andArea Clinical Specialist will provide a mandatory staff meeting regarding compliance with this regulation on 1/29/09. A review of 100% of the Licensed Agency clinical records that were ' discharged in 4 t quarter 2008 will be* completed by 2/27/09. All of the patient's physicians will be contacted regarding the discharge of the patient notification of the authorized practitioner, as defined in subdivision (b) of section 766.4.of this Part, and consultation with the patient and any other professional staff involved in coordinating the plan of care, no less than 48 hours prior to 1 patient discharge.. This Regulation is not met as evidenced by: Based on record reviews and staff interview, the agency failed to ensure authorized practitioners are notified no less than 48 hours prior to a patient's discharge. This was evident for two (2) of five (5) patient care records reviewed, (Patients #4 and #5.) Failure to to ensure authorized practitioners are notified no less than 48 hours prior to a patient's, discharge places patients at risk for poor continuity of care., from service and the disposition of the patient at discharge if there is no devidence of physician contact in the record. 100% of all Licensed Agency clinical. records will be audited prior to discharge with a mandatory case conference with the MCP to ensure compliance with this regulation and to The findings are: 1) Patient #4 has diagnoses which include: ffice of Health Systems Management / Office of Long Term Care rATE FORM Version 09/12/08 e prevent recurrence of this deficient practice. ~e KH3P1 1 If continuation sheet 3 of 11 PRINTED: 01/22/2009 FORM APPROVED New York State Department of Health TATEMENT OF DEFICIENCIES ,ND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING _____ _____ (X3) DATE SURVEY COMPLETED LC0497A lAME OF PROVIDER OR SUPPLIER B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 01114/2009 3ENTIVA HEALTH SERVICES - BROOKLYN (X4) ID PREFIX TAG 50 COURT ST.. #1204 BROOKLYN, NY 11201 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H 324 Continued From page 3 Revised Hip Replacement, Hyperlipidemia and Osteoarthritis.autwilicueadtfromine The patient care record documents a discharge date of "2/19/08". There is no documented evidence on the' discharge summary of physician notification. 2) Patient#5 has diagnoses whichinclude: Non-Healing Surgical Wound. The patient care record documents a discharge date of "2/11/08". There is no documented evidence on the discharge summary of physician notification. On January 14, 2009 at 1:35 PM, the Assistant Director was interviewed and did not provide an explanation. H 4081 766.3(d) Plan of care, 766.3 Plan of care. The governing authority or operator shall ensure that: ...... (d) the plan of care is reviewed and revised as frequently as necessary to reflect the changing care needs of the patient, but no less frequently than every six months; '(1) each review shall be documented in the clinical record; and (2) agency professional personnel shall promptly alert the patient's authorized practitioner and other affected care providers to any significant changes in the patient's condition that indicate a need to alter the plan of care. ;e of Health Systems Management / Office of Long Term Care Version 09/12/08 TE FORM H 324 Part of the focused clinical record audit will include audit for compliance with this regulation. 100% of all discharged Licensed Agency clinical records will be audited for compliance. This information will be reported to the PI committee and PAC Committees quarterly.. Responsible party(s): AD; ACS; MCP H 408 H408 766.3 (d) PLAN OF CARE For the patient found to be deficient in Complete plan of care matching the ordered frequency of professional services to the provided frequency of professional services, the Area Director immediately obtained signed orders form the physician for the visits completed 11/6/08-11/9/08, patient was hospitalized 9/12/08-11/5/08 The clinician immediately contacted the physician regarding the correct . frequency the visits were planned for and obtained orders for visits completed and omitted in error on completion of the plan of care. 6S99 KH3P1 1 If continuation sheet 4 of 11 PRINTED: 01/22/2009 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIERCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. WIN N_________ SB. BUILDING __ _ _ _I_ _ (X3) DATE SURVEY COMPLETED I__ LC0497A NAME OF PROVIDER OR SUPPLIER . STREET ADDRESS, CITY, STATE, ZIP CODE 01/1412009 GENTIVA HEALTH SERVICES - BROOKLYN (X4) ID PREFIX TAG 50 COURT ST. #1204 BROOKLYN, NY 11201 ID PREFIX TAG . SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (x5) COMPLETE DATE H 408 Continued From page 4 This Regulation is not met as evidenced by: Based on record reviews and staff interview, the agency failed to ensure the plan of care is revised as necessary and the authorized practitioner is informed of the need to change the plan of care. This was evident for one (1) of five (5) patient care records reviewed. (Patient #3.) Failure to ensure the plan of care is revised as I necessary and the authorized practitioner is H 408 In an effort to prevent the same deficient practice with other Licensed Agency patients, 100% of all Licensed Agency clinical records will be audited for compliance with orders of services matching services provided by 2/27/09. The Area Director and Area Clinical Specialist will re-educate the staff on compliance with providing services as ordered at a mandatory staff meeting on 1/29/09. Ongoing audits of 100% of all Licensed Agency clinical records will, be reviewed for compliance of ordered frequency matching provided frequency. This information will be presented to the PI and PAC Committees quarterly. Responsible party(s): AD; ACS informed of the need to change the plan of care places patients at.risk for receiving poor quality care., The finding is: Patient #3 has diagnoses which include: Leukemia, Pulmonary Embolism, Diabetes Mellitus and Acute Pericarditis. The patient care record includes a "Home Health Certification and Plan of Care" dated "09/11/08 to 11/09/08" which documents orders for: "SN 1 X WK X 1 WKS" (Skilled Nurse once a week for one week). The patient care record documents more than one visit by the nurse. There is no documented evidence of a revised plan of care and the physician was informed of the need to change the plan of care. On January 14, 2009 at 1:35 PM, the Assistant Director was interviewed and did not provide an explanation. H 5121 766.4(c) Medical Orders I H 512 I 766.4 Medical orders. ...... Such orders shall be reviewed and- revised as (C) . H512 766.4 (c) MEDICAL ORDERS For the clinical records identified as not having a current physician order, KH3P11 : If continuation sheet 5 of 11 ifice of Health Systems Management / Office of Long Term Care Version 09/12/08 TATE FORM PRINTED: 01/22/2009 FORM APPROVED New York State Department of Health 3TATEMENT OF DEFICIENCIES 'ND PLAN OF CORRECTION (X1) PROVIDERISUPPL[ERICLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A BUILDINGCOMPLETED (X3) DATE SURVEY LC0497A 'lAME OF PROVIDER OR SUPPLIER B.WING STREET ADDRESS, CITY. STATE, ZIP CODE 01114/2009 GENTIVA HEALTH SERVICES - BROOKLYN' (X4) ID PREFIX TAG 50 COURT ST. #1204 BROOKLYN, NY 11201. ID PREFIX TAG PROVIDER's PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (XS) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H 512 Continued From page 5 the needs of the patient dictate but no less frequently than every six months, except where an authorized practitioner, as part of an authorization, orders personal care services for up to one year for a Medicaid patient I This Regulation is not met as evidenced by: Based on record reviews and staff interview, the agency failed to ensure that medical orders are reviewed and revised every six months. This was evident for three (3) of four (4) patient care records reviewed. (Patients #1, ,#2 and #3.). H 512 these records have had the orders resent to the physicians, followed up with a phone call to their offices and have all been signed and placed in the clinical records. 100% of all active Licensed Agency clinical records have been reviewed wthcuren clinica copiae for compliance with current clinical orders in the records. This was accomplished by 1/16/09 by the Area Director. In an effort to prevent this practice from reoccurring, the MCP and clerical staff has been re-educated on te o thercesaf papern lin ic o cate froc from SOC to creating the clinical record, including the review of the SOC documents and creating of the Plan of Treatment for the physician to sign. This was completed on 1/16/09. 100% of all Licensed Agency clinical records will be audited for compliance With current physician Plans of Failure of the agency to ensure that medical orders are reviewed and revised every six months places patients at risk for not being under the care of an authorized practitioner. Thefindings are: 1) Patient #1 has diagnoses which include: Total Hip Replacement and Hypertension. The patient care record documents a medical order dated: "11/15/08 to 1/13/09". There is no documented evidence of medical orders datedwihcretpyianPnso Treatment. This information will be after "1/13/09". collected and presented to the PI and PAC Committees quarterly. diagnosed which include: Brain 2) Patient #2 has Responsible party(s): AD; MCP Pain. Injury and Chronic The patient care record documents a medical orderdated: "09/09/08 to 11/07/08". There is no documented evidence of medical orders dated after '11/07/08"[ 3) Patient #3 has diagnoses which include: Leukemia, Pulmonary Embolism, Diabetes Mellitus and Acute Pericarditis. The patient care record documents a medical order dated: "9/11/08 to 11/09/08". There is no documented evidence of medical orders dated after ce of Health Systems Management / Office of Long Term Care ,TE FORM Version 09/12/08 KH3P11 ( If continuation sheet 6 of 11 PRINTED: 01/22/2009 FORM APPROVED New York State Department of,Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (2) MULTIPLE CONSTRUCTION A- WING lB. BUILDING __________ (X3) DATE SURVEY COMPLETED LC0497A NAME OF PROVIDER OR SUPPLIER B STREET ADDRESS, CITY, ST ATE, ZIP CODE 0111412009 GENTIVA HEALTH SERVICES (X4) ID PREFIX TAG - BROOKLYN 50 COURT ST. #1204 BROOKLYN, NY 11201 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H 512 Continued From page 6 H 512 "11/09/08". i On January 14,.2009 at 3:45 PM, the Assistant Director was interviewed and stated: "Those doctors orders are floating around here somewhere. I'm not sure why they were not filed." H 5141 766.4(d) Medical orders 766.4 Medical orders. . : H 514 H514 766.4 (d) MEDICAL 'ORDERS (d) Medical orders shall reference all diagnoses, medications, treatments, prognoses, and other, On the clinical records identified as not having the orders signed in 30 pertinent patient information relevant to the agency plan of care; and days, these records have had the orders re-sent to the physicians, (1) shall be authenticated by an authorized f practitioner within thirty (30) days after admission 'to the agency; and (2) when changes in the patient's medical orders are indicated, orders, including telephone orders, shall be authenticated by the authorized practitioner within thirty,(30) days. This Regulation is not met as evidenced by: Based on record reviews and staff interview, the agency failed to ensure all medical orders are signed by the authorized practitioner within 30 days. This was evident for three (3) of five (5) patient care records reviewed. (Patients #3, #4 and #5.) Failure to ensure all medical orders are signed by the authorized practitioner within 30 days places patients at risk for receiving unauthorized care. The findings are: 1) Patient #3 has diagnoses Which include: 'ffice of Health.Systems Management / Office of Long Term Care Version 09/12/08 TATE FORM . followed upwill all be signed and their offices and with a phone call to placed'in the clinical records. The clerical and clinical staff will be re-educated at a mandatory staff meeting on 1/29/09 regarding this regulation and compliance.For r reuionand copine . o after multiple calls by the clerical support staff, and the AD,a copy of the order will be brought to the office by the Account Executive (AE) for signature in person. This will be ongoing until all competed and signed. Going forward, 100% of all Licensed Agency clinical records will be reviewed for compliance with orders signed, and dated in 30 days of the order. Staff will-have been reKH3Pt1 Iicontinuation sheet 7 of 11 PRINTED: 01/22/2009 FORM APPROVED New York State Department of Health OF DEFICIENCIES ND PLAN OF CORRECTION (TATEMENT (Xl) PROVIDERJSUPPLIER/CLIA IDENTIFICATION NUMBER' (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED NUMBlENRF;CRRECONA.BUILDING WING STREET ADDRESS, CITY, STATE, ZIP CODE LC0497A 4AMt OF PROVIDER OR SUPPLIER 0114/2009 /B. 50 COURT ST. #1204 GENTIVA HEALTH SERVICES - BROOKLYN (X4) ID PREFIX TAG BROOKLYN, NY 11201 IO PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCEDTO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H 514 Continued From page 7 Leukemia, Pulmonary Embolism, Diabetes Mellitus and Acute Pericarditis. ,The patient care record documents medical orders for occupational therapy dated "12/15/08" and "11/12/08' by the dccupational therapist, which do not include documented evidence of a physician's signature. The patient care record documents telephone orders dated "12/12/08", "11/24/08", "1108/08" and "11/6/08" by the nurse. The orders do not include documented evidence of a physician signature. 2) Patient #4 has diagnoses which include: Revised Hip Replacement, Hyperlipidemia and 0steoarthritis. The patient care record'includes a medical order dated "02/05/08 to 04/04/08" which documents a physician's signature. There is no documented evidence of when the physician signed the order. 3) Patient #5 has diagnoses which include: Non-Healing Surgical Wound. The patient care record includes a medical order dated "02/01/08 to 03/31/08" which documents the nurse received a Verbal order dated "2/1/08" for the start of care. The physician signature is documented on "4/14/08". On January 14, 2009 at 1:35 PM, the Assistant Director was interviewed and did not provide an explanation. H10361 766.9(l) Governing authority Section 766.9 Governing authority. :e of Health Systems Management / Office of Long Term Care . Version 09/12/08 ,TE FORM m H 514 educated on the timeliness of the orders to be sent to the office for ability to obtain signatures dated timely at 1/29/09 staff meeting. The clerical staff members responsible for timely orders has been educated in the steps to take to obtain signatures timely, and to notify the AD if a signature is not obtained by day 21. 100% of all Licensed Agency clinical records will be audited for compliance with signed and dated physician orders. Results of the 100% audit will be tracked and reported to the PI and . PAC Committees quarterly. Responsible party(s): AD, AE, clerical support staff; clinical field staff H1036 KH3P11 If continuation sheet 8 of 11 PRINTED: 01/22/2009 FORM APPROVED - New York State Department of Health (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING _____ _____ STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X3) DATE SURVEY COMPLETED LC0497A NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 01/1412009 50 COURT ST. #1204 GENTIVA HEALTH SERVICES - BROOKLYN (X4) ID PREFIX TAG BROOKLYN, NY 11201 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY. MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H10361 Continued From page 8 The governing authority or operator, as defined in" Part 700 of this Title, of a licensed home care services agency shall: ...... (I)appoint a quality improvement committee to establish and oversee standards of care. The quality improvement committee shall consist of a consumer and appropriate health professional persons including a physician if professional health care services are provided.The committee shall meet at least four times a year to: * (1) review policies pertaining to the delivery of the * health care services provided by the agency and recommend changes in such policies to the governing authority for adoption; (2) conduct a clinical record review of the safety, adequacy, type and quality of services provided which includes: (i) random selection of records of patients currently receiving services and patients discharged from the agency within the past three months; and H1036 H1036 766.9 (1) GOVERNING AUTHORITY The QI membership will include two (2) consumer members to ensure the presence of one at each QI meeting going forward. The consumer will be notified in advance of the scheduled meeting for ability to accept the position on the committee. This Agency understands the importance of compliance with regulatory guidelines and the importance of maintaining quality services and adequate care. The QI committee will be complete with all members as dictated by the regulation. adaetoThoou erolaebofecnsueiford Two consumers have been identified and agreed to the role of consumer for the Q1 meetings with one to attend and one to be available.on a coverage basis. The AD will be responsible to give ample time to notify all members of the QI Committee of the scheduled date and time of the meetings for (ii) all cases with identified patient complaints as specified in subdivision 0) of this section;-attendancenofsalldmembers Completed and signed attendance sheets will be presented to the PAC (3) prepare and submit a written summary of committee quarterly. l review findings to the governing authority for Responsible party(s): AD necessary action; and (4) assist the agency in maintaining liaison with other health care providers in the community. This Regulation is not met as evidenced by: Based on record review and staff interview, the agency failed to ensure a consumer was present at the Quality Improvement (QI) Committee ffice of Health Systems Management / Office of Long Term Care Version 09/12/08 TATE FORM 6895 KH3PI1 If continuation sheet 9of 11 PRINTED: 01/22/2009 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES ,ND PLAN OF CORRECTION (X1)- PROVIDER/SUPPLIERCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING(X3) DATE SURVEY COMPLETED LC0497A 'lAME OF PROVIDER OR SUPPLIER 1B. WING ____________ 01/14/2009 STREET ADDRESS, CITY, STATE, ZIP CODE GENTIVA HEALTH SERVICES - BROOKLYN BROOKLYN, NY 11201 (X4) Io PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE H1036 Continued From page 9 meetings. Failure to ensure the Quality Improvement 1,Committee performs the required functions places patients at risk for receiving poor quality services, unsafe and inadequate care. The finding is: The QI minutes from meetings dated "5/16/08, 7/31/08 and 1/25/08" do not have documented evidence of consumer attendance. On January 14, 2009 at 2:00 PM, the Assistant Director was interviewed and stated: "We're actually getting two new consumers for that lreason. So, we don't have that problem.' H1302 766,11(a) Personnel 766.11 Personnel. sThe e The governing authority or operator shall ensure for all health care personnel: (a) the development and implementation of written personnel policies and procedures, which are reviewed at least annually and revised as necessary. This Regulation is not met as evidenced by: Based on record review and staff interview, the agency failed to revise the Criminal History Background Check Policy and Procedure. Failure to revise the Criminal History Background Check Policy and Procedure fails to inform the agency authorized person of the procedure for background checks. The finding is: -e of Health Systems Management / Office of Long Term Care 1E FORM Version 09/12/08 H1036 H1302 H1302 766.11 (a) PERSONNEL agency has reviewed and revised it's CHRC policy (See attachment #1) to include all the recentupdates, including the statement of the temporary employee will be supervised weekly pending the results of the criminal history background check. This office has not hired any paraprofessional personnel since 2005, so there are no personnel issues with the CHRC process since 2005. The policy has been updated as well as a process put in place for theoccasion of a newly hired T paraprofessional person. (See .attachment #2) 6899 KH3P11 - If continuation sheet 10 of 11 PRINTED: 01/22/009 New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTI PLE CONSTRUCTION A. BUILDING FORM APPROVED (X3) DATE SURVEY COMPLETED B. WING LC0497A NAME OF PROVIDER OR SUPPLIER STREET ADDRESS: CITY, STATE; ZIP CODE 01114/2009 50 COURT ST. #1204 BROOKLYN, NY 11201 ID PREFIX TAG SGENTIVA HEALTH SERVICES -BROOKLYN (X4 ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE H1302 Continued From page 10 The agency: "Background Investigations" does not include documented evidence of informing personnel that temporary employees are to be supervised weekly pending, the results of the H1302 All staff directly involved in the hiring and supervision of the temporary employees will be educated on the policy updates at the mandatory staff meeting on 1/29/09. criminal history background check. On January 14, 2009 at 3:26 PM, the Assistant Director was interviewed and did not provide an explanation- Quarterly reports to the.PI and PAC Committee regarding the status of any temporary employee and the compliance with the supervision process until the background check is complete will be documented. fice of Health Systems Management/.Office of Long Term Care "ATE FORM Version 09/12/08 689 KH3P1 1 If.continuation sheet 11 of 11 SUSTATE OF NEW YORK DEPARTMENT OF HEALTH Metropolitan Area Regional Office New York, NY 10007 90 Church Street Wendy E. Saunders Executive Deputy Commissioner Richard F. Daines, M.D. Commissioner June 16, 2009 Gentiva Health Services Attn: Michele D. Rosenblum, Administrator 50 Court Street, #1202 Brooklyn, NY 11201 Re: Response to Plan of Correction Survey Date: May 26, 2009 License: #33-7425 Dear Ms. Rosenblum: Please be advised that the Plan of Correction relating to the recent Recertification Survey of your agency have been reviewed by this office. All items were found to be acceptable and it is expected that.you will implement this plan within the time. frames that were submitted. A post approval review will be conducted to verify the correction of deficiencies. If.you have any questions regarding this matter, please contact (212) 417-5888. Sincerely, Cheryl Phoenix-Tannis,- RN,- MSN, CS Program Manager Home Health and Hospices Services Metropolitan Area Regional Offices /jt SGENTIVA7 June 9, 2009 /IfI. Ms..Cheryl Phoenix-Tannis. Program Manager, Home Health and Hospice Services State of New York Department of Health Metropolitan Area Regional Office 90 Church Street New York, NY 10007 Plan of Correction in Response to Re-Certification Survey RE: 33-7425 License: Survey Date: May 26, 2009 Dear Ms. Phoenix-Tannis, Please find enclosed the detailed Plan of Correction in response to the survey by the Department of Health on May 26, 2009 for Gentiva Health Service, Brooklyn, NY. If you have questions or require additional information, please contact me at 718237-2389. We look forward to hearing from you. Sincerely, Michele D. Rosenblum, R.N. Administrator Gentiva Health Services 50 court st. * #1202 * brooklyn, ny 11201 t 718.237.2389.? f 718.237.0632 www.gentiva.com :PARTMENT OF HEALTH AND HUMAN SERVICES :NTERS FOR MEDICARE & MEDICAID SERVICES -EMENT OF DEFICIENCIES PLAN OF CORRECTION (Xl) PROVIDER!SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING ___________ PRINTED: 06/02/2009 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED 337425 4E OF PROVIDER OR SUPPLIER B.WING STREET ADDRESS, CITY, STATE, ZIP CODE 05/2612009 50 COURT STREET SUITE 1202 ;NTIMA HEALTH SERVICES BROOKLYN I (4) ID 3EFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY. FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG BROOKLYN, NY 11201 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE 000 INITIAL COMMENTS G 000 G337 Corrective action for those patients found to have been affected by the deficient practice: A Recertification Survey was conducted at Gentiva Health Services on May 20 through May 26,2009. reviewed and Eleven (11) clinical records were #11. identified as Patients #1 through - 1. Imedication o RN case managers will reconcile medications to all medications in the home,and the list for patients 4, 6, and 7. RN case manager'will call MD and verify all medications. RN case manager will prepare I Four (4) home visits were made to Patients #, #5, #6 and #7. - .revised 2. and current medication list and forward to the MD for signature. RN case manager will provide patient education on medication management, when' to call the RN with changes and/or questions Seven (7) as Employees #1 throughreviewed and identified personnel records were #7. 337 484.55(c) DRUG REGIMEN REVIEW . G 337 and document education and patient response ' The comprehensive assessment must include 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. '3. Manager of Clinical Practice will case wics rie Monaeronca to education in the clinical record. conference and review visit notes with RN manger tomonitor that I Clinical case mplemented. Manager of and 2 above are Practice will provide interventions and additional training if I and 2 above are incomplete. 4. Manager of Clinical Practice will review all visit notes for patients 4, 6,and 7 and will manager during weekly case conference. review medication changes with RN case ely ase cnfeRence Manager durin This STANDARD is not. met as evidenced by: record Based on observation,faledto review and staff intrviw te aencocuent:I medications in the plan of care and maintain documentation of the medication dosage. This was evident for three (3) patients(home visits) of 4 (11) eleven clinical records reviewed. ( Patients ,6 and 7) 5. Manager of Clinical Practice and RN case manager will reconcile medication changes to current medication list and physician orders. RN case manager will call MD with any discrepancies to verify current medications send,current mmdication list to MD. n ieand c Manager of Clinical Praciice will present medication data of patients 4, 6, and 7 to the Failure to keep accurate patient medication dosage and document medications places patients at risk for medication errors and poor - Performance Improvement Committee for review and recommendations. Individual Responsible: Director of PatientServices Completion Date: quality of care. The findings are: 6/30/2009 IORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6)DATE is correcting providing it determined that () denotes i deficiency statement ending with an asteriskthe patients. a deficiency which the institution may be excused from (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days eguards provide sufficient protection to plans of correction are disclosable 14 the c, _4 date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued Is following the date these documents gram participation. RM CMS-2567(02-99) Previous Versions Obsolete Event ID: LUF111 Facility ID: NY2121F If continuation sheet Page 1 of 3 DEPARTMENT Of IIEALJH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES TATEMENT OF DEFICIENCIES ,ND PLAN OF CORRECTION (X1) PROVIDERISUPPLIERCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING __________ PRINTED: 06/02/2009 FORM APPROVED OMB NO. 0938-0391 C(X3) SURVEY DATE COMPLETED 337425 NAME OF PROVIDER OR SUPPLIER 8. WING___________ STREET ADDRESS, CITY, STATE, ZIP CODE 50 COURT STREET SUITE 1202 05/2612009 GENTIVA HEALTH SERVICES BROOKLYN (X4) ID PREFIX TAG , BROOKLYN, NY 11201 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG 33 rmpae1G oniud 337" PROVIDER'S PLAN OF CORRECTION ACTION SHOULD BE (EACH CORRECTIVE TO THE APPROPRIATE CROSS-REFERENCED DEFICIENCY) (x5) COMPLETION DATE G 337 Continued From page 1 1) Patient #4 (Home Visit) with a start of care date of 4/30/09 with a diagnoses of Fractured Femur, Abnormal Gait, Urinary Incontinence, and How will agency identify other patients having the potential to be affected by the same deficient practice and corrective .actions to be taken? 1. Manager of Clinical Practice will review all current patients and new admissions for the Glaucoma. During a home visit on May 21,2009 the following medications were observed in the patient's home: "Nasacort (Triamcinolone Acetonide) 6.5mg two (2) sprays in each nostril at night". the clinical record dated "4/4/09 to 7/2/09 does not document the medication observed in the clinicians identified in the care of patients 4, on the medication lists, physician focusing 6, and 7 during a case conference, order and rnithe medications physciaoe aN case manager and PT. 2. Manager of Clinical Practice will document case conference and results. 3. Manager of Clinical Practice will review visit notes and focus on documentation of medication changes. review of medications in the home by the RN patient's home. . On May 22, 2009 the Director of Patient Services 4. Manager of Clinical Practice will Irandomly , ~~~~patient was interviewed and stated: "the patient's wife did not mention this medication to the nurse." I 2) Patient #6 (Home Visit) with a start of care date of 2/1/09 with a diagnoses of Pressure Ulcer Heart Failure, call patients andclinicians identified in care of 4, 6, of 7 to review micainn ent 4,an o eiwedications and verify accuracy of medication documentation. 5. Manager of Clinical Practice will present Heel, Diabetes; Congestive Hypertension, and Hyperlipidemia. medication data of current and new care of patients 4, 6,and 7to the admissions for clinicians identified in the Performance Improvement Committee for During a home visit on May 22, 2009 the following medication was observed in the patient's home. "Augmentin 875mg one tab P.O twice a day". " The plan of care dated "4/11/09 to 6/9/09 review and recommendations.. Individual Responsible: Director of Patient Services Completion Date: What measures will be put in place and/or 7/30/2009 documents: "Augmentin 500mag P0 BID". On May 22, 2009 the Director of Patient Services was interviewed and stated: " There is what systemic changes will be made to ensure that deficient practice does not recu r: ' . ' 1. Director of Patient Services will train all clinical staff on medication assessment, 2. I review, coordination and documentation at the regularly scheduled staff meeting. documentation in the patient's chart that the wife is noncompliant with the medication, we still have to check with the nurse." 3) Patient #7 (Home Visit) with a start of care date of 4/9/09 with a diagnoses of Cancer of the Esophagus, Hypertension, Abnormal Gait, and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LUF111 Medication review and documentation and the progress towards improvement will be staff meetings through the next quarter, - standard agenda item at regularly scheduled eeting e thr tenxqurr NY2121F Facility ID: If continuation sheet Page 2 of 3 EPARTMENT OF, HEALTH AND HUMAN SERVICES ENTERS FOR MEDICARE & MEDICAID SERVICES rEMENT OF DEFICIENCIES PLAN OF CORRECTION (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION A. BUILDING __________ PRINTED: 06/02/2009 FORM APPROVED OMBNO,0938-0391 (X3) DATE SURVEY IDENTIFICATION NUMBER: COMPLETED 337425 OF O1E PROVIDER OR SUPPLIER B WING STREET ADDRESS, CITY, STATE, ZIP CODE 50 COURT STREET SUITE 1202 05/2612009 =NTIVA HEALTH SERVICES BROOKLYN X4) ID REFIX TAG " ID PREFIX TAG BROOKLYN, NY 11201 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (x5) COMPLETION DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 3 337 Continued From page 2 G 337 1 3. 4. Hyperlipidemia. During a home visit on May 22, 2009, the D a2 tby i following medications were observed in the patient's home: "Combigan 5ml ( Brimonidine drop in Ointmeent 50wni a Tartrate) one Ophalm both eyes twice a day, ly Tatra)ne Bacitracin Ophthalmic Ointment 500 units apply, 1/4 inch in both eyes pm when become red". The plan of care dated: "4/9/09 to 6/7/09 does rot document the medications observed in the patient's home. I Evidence of training will be maintained in staff personnel files. All PT only cases, unless otherwise ordered the physician, will be initially assessed by and RN case manager. 5.All PT only patients' medications will be I reviewed by PT and Manager of Clinical Practice and patients will be called to verify medications. If indicated, MD will be notified and sent revised medication list. Individual Responsible: Director of Patient "Services Completion Date: 9/30/2009 How the corrective action will be. monitored to ensure that the deficient 'On May 22, 2009 the Director of Patient Services was interviewed and stated: "We have to check ~cited with the nurse. The aide accompanies the patient [1 to his Doctors appointments and forgets to mention the additional medication to the nurse." * practice will not recur; i.e., what quality assurance program will be put in place? . Administrator will report on the deficiencies during the recertification survey and the the at cied ringothe aerone a t thmlyt20 2. 2. i 3. Performance Improvement Committee meeting. Administrator will incorporate Effective Drug Regimen Review as a standard indicator into the Performance Improvement Plan. Director of Patient Services will collect Drug Regimen Review data as part of the clinical record review process and data will be presented to the Performance Improvement Committee. p Review and recommendations by the Performance Improvement Committee will be recorded in the minutes and presented lt 4. o , the staff meeting following the Performance Improvement Committee meeting in July, 2009. Individual Responsible: Administrator Completion Date: 7/30/2009 RM CMS-2567(02-99) Previous Versions Obsolete Event ID: LUF111 Facility ID NY2121F If continuation sheet Page 3 Xf 3 PRINTED: 10/07/2009 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION. (Xl) PROVIOER.SUPPLIERICLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A BUILDING __________ (X3) DATE suRVEY COMPLETED LCO806C NAME OF PROVIDER OR SUPPLIER BWIG10101/2009 STREET ADDRESS, CITY, STATE, ZIP CODE GENTIVA HEALTH SERVICES - WHITE PLAINS (X4) ID PREFIX TAG 7-11 S BROADWAY #104 WHITE PLAINS, NY 10601 ID PREFIX TAG q / 031 " SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (XE) COMPLETE DATE H 000 Initial Comments A State Re-Licensure survey was conducted at I the agency on 9/29/09 and 10/1/09. Four (4). patient care records were reviewed and are identified as Patients #1 through #4. Eight (8) personnel records were reviewed and are identified as Employee #1 through #8. H1036 766.9(l) Governing authority Section 766.9 Governing authority. The governing authority or operator, as defined in Part 700 of this Tit!e, of a licensed home care services agency shall: H 000 H1036 Corrective Action Effective immediately a calendar has been established for future meetings 10/23/09 () appoint a quality improvement committee to establish and oversee standards of care. The quality improvement committee shall Consist of a consumer and appropriate health professional persons including a physician if professional shal met a ties yer to health care services are provided.The committee shall meet at least four times a year to:or084/9adtte (1) review policies pertaining to the delivery of the health care services provided by the agency and recommend changes in such policies to the governing authority for adoption; (2) conduct a clinical record review of the safety, adequacy, type and quality of services provided which includes: (i) random selection of records of patients I currently receiving services and patients I discharged from the agency within the past three months; and Office of a1tl F ystemsMran eW Offig of Long Term Care o Y/~/ ,TITLE "1 on08/4/0 an atthe10/23/09 A meeting took place time of the survey the minutes had not been typed and are now attached. j Effective immediately a consumer has been identified and will attend all future meetings effective with the 11 /18/2009 meeting, , (X6) DATE 11/18/09 LABOF&Ag6P_? tIRECTOIAS STATE FORM P 6 Vers'y ER/ UPPLIER REPRESENTATIVE'S SIGNATURE . 9/12/08 f PG3N11 //4 If continuation sheet I of 5 PRINTED: 10/07/2009 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDEPJSUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION ______ A. BUILDING B. WING ____________ _____ (X3) DATE SURVEY COMPLETED LCO806C NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10101/2009 7-11 S BROADWAY #104 WHITE PLAINS, NY 10601 ID PREFIX TAG . GENTIVA HEALTH SERVICES -WHITE PLAINS (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (Xs) COMPLETE DATE H10361 Continued From page 1 (ii) all cases with identified patient complaints as specified in subdivision (j) of this section;. (3) prepare and submit a written summary of review findings to the governing authority for necessary action; and (4) assist the agency in maintaining liaison with other health care providers in the community. This Regulation. is not met as evidenced by: H1036 The meeting of 1/29/2008 was . 10/23/09 pyin pw wh fe l Based on record review and interview, the Governing Authority(GA) failed to ensure that the QI committee meets four (4) times ayear; is to sign the attendance sheet. Effective immediately all future attended by the required members and the committee review active patient care records, discharged patient records, and policies and procedures. Failure to ensure that the QI committee meets four (4) times a year, consists of the required membersand performs the required tasks places patients at risk for receiving poor quality care.. The findings are: The QI meeting minutes document the QI in 2009 and one (1) committee met two (2) times time in 2008. The QI meeting minutes document meetings on "1/29/08, 2/13/09, and 4/28/09". and 4/28/09" lack documentation of othe ' o consumer attedy a ll audited for physician signature. 1-1036 Patients discharged from the agency are identified by printing a discharge report and a clinical record The QI meeting minutes dated "1/29/08, 2/13/09, review is conducted and the outcomes of the eview are 1/18/09 review are attendance. atdc The 01 meeting minutes dated"1/29/08" lacks documentation of physician attendance. o The QI meeting minutes dated "1/29/08, 2/13/09, and 4/28/09" lack documentation of patients discharged from the agency and review of ___ reported to the committee. Additionally a random selection of active patients shall be made prior to each meeting and the PG3N11 If continuation sheet 2 of 5 Office of Health Systems Management / Office of Long Term Care .899 Version 09/12J08 STATE FORM PRINTED 10/07/2009 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIERCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING __ _ _ _ _ _ _ _ (X3) DATE SURVEY COMPLETED LCO806C NAME OF PROVIDER OR SUPPLIER B.WING___________ STREET ADDRESS, CITY, STATE, ZIP CODE 10/01/2009 GENTIVA HEALTH SERVICES (X4) ID PREFIX TAG - WHITE PLAINS 7-11 S BROADWAY #104 WHITE PLAINS, NY 10601 ID PREFIX TAG I SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) : PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (x5) COMPLETE DATE H10361 Continued From page 2 policies and procedures. H1036 record audited for During interview with the Area Vice President (AVP) 10/1/09, the AVP did not provide the . compliance. The results of these audits ' documented information and stated "the Director of Clinical Services (DCS) was working on the will be reported to the committee H1142.. 6" '1/18/09 .' QA minutes ...... the DOS is away on vacation". H11421 766.9(o) Governing Authority !VSection 766.9 Governing authority i , Policies and procedures are reviewed every 10/23/09 (o) Health Provider Network Access and Reporting Requirements. The governing authority or operator of an agency shall obtain from the o Department' s Health Provider Network (HPN), HPN accounts for each agency that it operates and ensure that sufficient, knowledgeable staff \;Will be available to and shall maintain and keep current such accounts. At a minimum, twenty-four hour, seven-day a week contacts for emergency 1 communication and alerts, must be designated by each agency in the HPN Communications Directory. A policy defining the agency's s HPNof coverage consistent with the agency' hours operation shall be created and reviewed by the agency no less than annually. Maintenance of each agency' s HPN accounts shall consist of, but not be limited to, the following: '(1) sufficient designation of the agency' s HPN coordinator(s) to allow for .HPN individual user application; qrte quarter and have been added to the agenda as an ongoing agenda item aed to assure compliance with the standard I On a quarterly basis the activities of the o quality improvement committee will be monitored to assure compliance with: Consumer attendance Physician attendance as evidenced by (2) designation by the governing authority or operator of an agency of.sufficient staff users of the HPN accounts to ensure rapid response to requests for information by the State and/or local i Department of Health; Office of Health Systems Management / Office of Long Term Care .Pc Version 09/12108 STATE FORM signature on the attendance sheet A review of clinical record review for both discharged and active patients. A review of policies presented to review a nd discuss. Ifcontinuation sheet 3 of 5 PRINTED: 10/07/2009 FORM APPROVED New 'ork State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X) PROVIDERJSUPPLIERJCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION _______ A BUILDING B. WING __o_o___/0_/2009 ____ (X3) DATE SURVEY COMPLETED LC0806C NAME OF PROVIDER OR SUPPLIER 10/0112009 STREET ADDRESS, CITY, STATE, ZIP CODE GENTIVA HEALTH SERVICES -WHITE PLAINS (X4) ID PREFIX TAG SUMMARY-STATEMENT OF DEFICIENCIES 7-11 S BROADWAY #104 WHITE PLAINS, NY 10601 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY). (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) COMPLETE DATE. H1142 Continued From page 3. user contract; and (3) adherence to the requirements of the HPN (4) current and complete updates of the Communications Directory reflecting changes that include, but are not limited to , general information and personnel role changes as soon as they occur, and at a minimum, on a monthly basis. H1142 This jThis Regulation is not met as evidenced by: Based on record review and staff interview, the' Governing Authority (GA) failed develop a complete Health Provider Network (HPN) policy. Failure to ensure daily access to the HPN places the agency at risk for not being aware of information necessary to provide quality care. The findings are:. H142 immiediately Em An addendumn.to the 1/30 ., .Effective The agency HPN policy failed to identify the following:-An updated directory on HPN; A HPN policy specifying contact frequency. The agency HPN policy lacks documentation of the specific frequency of accessing the HPN by the designated agency staff. During an interview with the back up HPN Coordinator on 10/1/09, the Coordinator stated she was logging on to the HPN once a week. During the pre-survey preparation on 9/28/09, the HPN Communication Directory was accessed for the names of designated HPN Coordinator contact persons. disaster policy is attached for review and addresses the issues of verifying contact information and also that daily contact is made with the HPN site., 10/23/09 I Information obtained onsite contradicted the Office of Health Systems Management / Office of Long Term Care Version 09/12/08 STATE FORM 6899 PG3N11 If continuation sheet 4 of 5 PRINTED: 10/07/2009 FORM APP ROVED New-York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION. (X1) PROV1DER/SUPPLIERCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION BUILDINGED B. WING (X3) DATE SURVEY TA. LCO806C NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 10/01/2009 GENTIVA HEALTH SERVICES - WHITE PLAINS (X4) ID PREFIX TAG 7-11 S BROADWAY #104 WHITE PLAINS, NY 10601 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE I SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H1142 iContinued From page 4 information from the HPN Directory. During an interview with the Area Vice President (AVP) on 10/1/09, the AVP did not provide an explanation for the finding. H1142 a log has been developed and each day the designated/10/23/09 person will sign onto HPN and sign the log indicating the same. This log is attached. .0/23/09 1 Every month the HPN coordinator will sign on to the site and confirm the contact information is correct and submit this to the This process DOH. a log which is attached. will be documented in To assure there is no recurrence the logs will be reviewed 1 3 monthly for compliance with the , j,- policy. Office of Health Systems Management /Office of Long Term Care Version 09/12/08 . STATE FORM PG3N11 Ifcontinuation sheet 5 of 5 PRINTED: 08/17/2009 New York State Deartment of Health STATEMENT OF DEFICIENCIES AND PLAN" CORRECTION OF (X1I) PROVIDER/SUPPLIERPCLIA IDENTIFICATION NUMBER X2 MULTIPLE CONSTRUCTION ".COMPLETED A. BUILDING ____________ FORM APPROVED (X3) DATE SURVEY LC3536C NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 0711012009 50 CLINTON STE 606 STREET - PREMIER HOME HEALTH CARE SERVICES IN, (X4) ID PREFIX TAGi 5 LNM TENY1 HEMPSTEAD, S 11550 5 NY ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION). j PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) I (X5) COMPLETE DATE H 000! Initial Comments A.Re-Licensure Survey and Home Health Aide Training Program (HHATP) Survey were. conducted at Premier Home Health Care Services on 07/09/09 and 07/10/09. H 000 o Eleven (11) Patient Care Records reviewed and 1 identified as Patients #1 to #11. Two (2) Home Visits were made to Patients #1 and #4. Ten (10) Personnel Records reviewed and .identified as Employees #1 to #10. One (1) HHATP record reviewed and identified as Trainee #1.H 404:.766.3(b) Plan of care 76 H 404 766.3 Plan of care. Pfound 1. Corrective action for those patients to be affected by the deficient Patient #1 has been discharged; last day of service was 7/17/09. The governing authority or operator shall ensure that: (b) plan. of care is established for each patient a based on a professional assessment of the Patient #4 - Interim orders were sent to physician on identifying paraprofessional patient's needs and includes pertinent diagnosis, prognosis, mental status, frequency of each level of care as HIiA. the physician on for signature identifying Patient #10 - Interim orders were sent to service to be-provided, medications, treatments, diet reiesIucina functional limitations and iiain n ditregimens, rehabilitatioh potential the paraprofessional level of care as PCA. This Regulation is not met as evidenced by" Based on record reviews, home visits (HV) and staff interview, the home care agency failed to develop plans of care which specified the type of services home health aide (hha) or personal care aide (PCA)) to be provided to the patient. This was evident in seven (7) of eleven (1 tyfient care records reviewed (Patients , # 3,/ fi~e of Health SySte Ma nieent Ice ofLong Term Cafre .I e Patient #2-Interim orders weresent to the physician for signature identifying the paraprofessional level of care as PCA. Patient #3 - Interim orders were sent to the physician for signature identifying the paraprofe.sional level of care as PCA. . "-[ DATE '~8ORATOYDtjT4 8ORATRY ITOR'S 0 OVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE ;TATE FORM Version 09/12108 -i QGGV1 1 If continuation Sleet Iof 20 PRINTED: 08/17/2009 oFORM APPROVED New York State Denartment of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDERISUPPLIERCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X) DATE SURVEY CMPLETED COMP__TED LC3536C NAME OF PROVIDER OR SUPPLIER B.WING STREET ADDRESS, CITY, STATE, ZIP CODE, 07110/2009 PREMIER HOME HEALTH CARE SERVICES INI (X4) ID PREFIX TAG 50 CLINTON STREET STE 608 HEMPSTEAD, NY 11550 ID PREFIX 1 I TAG. SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDEDBY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) o__DEFICIENCY) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE (XCI COMPLETE DATE H . 40, From 1.H404 *H404. Patient#11 -L Interim orders were sent to the physician for signature identifying the paraprofessional level of care as PCA. Failure to ensure that the nursing staff develop the Plan ofCare.which specifies the type of services (hha or PCA) to be provided, places the patients at risk for unmet patient Care needs. The findings are: 1) Patient #1 (HV) has an admission date of "5/30/09" with diagnoses of CAD (Coronary Artery Patient #6- Ioterim orders were sent to the physician for signature identifying the paraprofessional level of care as PCA. All interim orders were sent to MD on 7122109. TheFieldNorseSupervisorandOffice Adminisrator will audit all applicable physician orders for compliancewith correct identification of paraprofessional level of service and completion of the Plan of Treatment. An amendment to the POT Disease) and Renal Failure. The "Plan of Treatment" (the agency Plan of Care) dated "5/30/09 - 11130/09" documents orders for: "HHAIPCA" (home health . aide/Personal Care Aide) frequency: 5 - 7 days ' per week x 4 - 9 hours a day. r e " o h. There is no documentation to identify the level of will be sent to the physician with any items identified as missing on the POT. theIdentificationbe affectedpatients having potential to of other by the tefpoential what corrective action will t deficiency and t afecte be taken: case managed patients are affected by paraprofessional services that the patient is receiving from the agency. oIoAll I During home visit on 7109/09, the aide was interviewed and stated that he is working in the capacity as a home health aide on the case." I this regulation. .L 1. As of 8/28/09, there are a total of 129 case managed cases. The agency will i/o I ol Pta aperform 2 - Patient #4 (HV) has an admission date Of. "05/31/07" with the diagnoses including Olivo INext Ponto Cerebellar.Atrophy and Non-Insulin Dependent Diabetes Mellitus. The "Plan of Treatment" (the agency's Plan of Care) dated "05/31/09 - 11130/09" documents. orders for : "HHAIPCA" seven (7) days, six (6) to Stwelve.(12) hours a day." 100% audit case balance the current population ofof the managed ofases. cet uati oc, em agenc quarter (Oct/NovDec), the agency will audit all new case managed cases going out. 2. Based on the audit findings, if 100%. are found to be complete then-the aldit % will be reduced to 10% quarerly. 3. Clinical Record audit tool will be revised to reflect level of paraprofessional service indicated HHA/PCA. There is no documentaition to identify the specific level of paraprofessional services ( hha or PCA) ; that the patient is receiving from the agency. )fdice of Health Systems Management / Office of Long Term Care 'TATE FORM Version 09112/08 QGGV1 1 it oninUaln sheet 2 o 20 PRINTED: 08/17/2009 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER' (X2) MULTIPLE CONSTRUCTION A. BILDLING ___________ (X3) DATE SURVEY COMPLETED LC3536C NAME OF PROVIDER OR SUPPLIER '-. B.WING STREET ADDRESS. CITY, STATE, ZIP CODE 07/10/2009 PREMIER HOME HEALTH CARE SERVICES IN, ,iX4) ID PREFIX TAG 50 CLINTON STREET STE 608 HEMPSTEAD, NY 11550 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED.TO THE APPROPRIATE' DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST,BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) I H 4041 Continued From page 2 During home visit on 7/10109, the aide was interviewed and stated that she was working in the capacity of a .PCA.. H 404 Ill. Measures that will be put in place to ensure that the deficient practice will not reoccur: 1. The Director of Clinical Services will be responsible for overseeing the audit process and then the Office Administrator moving forward. 3) Patient #10 has an admission date of "1/19109" with diagnoses including Hypertension, I Depression, Psychosis, and Chronic Obstructive Pulmonary Disease. The "Plan of Treatment"(the agency's Plan of Care) dated "4/27/09 - 6126109" includes orders 2. The 485 Plan of Treatment indicating the paraprofessional level of services is aincluded in the agency all new hires. N orientation for for disciplines and treatment for "HHA/PCA" seven (7) days'live-in services. There is no documentation to identify the specific level of paraprofessional services ( hha or PCA) that the patient is receiving from the agency. 4) Patient #2 has an admission date of 3. Current FNS's were reoriented on the 485/Plan of Treatment form and level of appropriate completion thereof. IV. Row will the corrective action be monitored to ensure the deficient practice will not reoccur? "12/2/0" wih f Breast Cancer. "12/12108" with.the dagnois teBeastCaner.As diagnosis.of SThe "Plan of Treatment" (the* agency's Plan of is company practice, all new R.N's will continue to be oriented to the 485/Plan of during the new hire orientation process prior to beginning a TTreatment "Care) dated "06/12/09 = 12/12/09" includes orders for disciplines and treatment for "HHA/PCA" Five (5) to seven (7) days, two (2) to four (4) hours a day. field wor. I. As of 8/28/09, there are a total of 129 case managed cases. The agency will perform 100% audit of the balance of the current population of case managed eases. quarter (Oct/Nov/Dec), the agency will audit all new case managed cases There is no documentation to identify the specific level of paraprofessional services ( hha or PCA)Next that the patient is receiving from the agency. 5) Patient #3 has an admission date of "1/02/07" with the diagnoses including Cerebral Vascular Accident and Hypertension. The "Plan of Treatment" ( the agency'S Plan of Care) dated "07/02109 - 01/02/09" documents orders for: '"HHA/PCA" seven,(7) days live-in services. fice of Health Systems Management / Office of Long Term Care Version 0/1 2/08 -ATE FORM - going out.. 2. Based on the audit findings, if 100% are found to be complete then the audit % will be reduced to 10%. iQGGV11 II cuntinualion sheet 3 of 20 PRINTED: 08/17/2009 . ' FORM APPROVED New-York State Department of Health 7 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xi) PROVIDERISUPPLIERICLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED LC3536C NAME OF PROVIDER OR SUPPLIER B. ING STREET ADDRESS, CITY, STATE, ZIP CODE 07/1012009 PREMIER HOME HEALTH CARE SERVICES IN, (X4) ID PREFIX TAG HEMPSTEAD, NY 11550 ' i ID PREFIX TAG 50 CLINTON STREET STE 608 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE* CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (XS) COMPLETE DATE H 404 Continued From page 3 There is no documentation to identify the specific level of paraprofessional services ( hha or PCA) that the patient is receiving from the agency. 6) Patient #11 has an admission date of "12/12/08" with the diagnoses including Cerebral H404 Based on the structure established by the governing authority, audit results will be documentedQ]1 Summary Forms. Results Corporate on the Branch, Regional and Corporte iwummby eOrm.ces will lie reviewed by the Office Administrator and Director of Clinical Services. Findings will be reported at the Anoxia and Depression. The "Plan of Treatment" ( the agency's Plan of Care) dated "06/12/09 - 12/12/09" documents includes orders for. "HHAJPCA" four (4) toseven (7) days, four (4) to eight (8) hours a day. There is no documentation to identify the specific level of paraprofessional services ( hha or PCA) Branch, Regional and governing authority Corporate QI Committee meetings and reflected in the minutes. The VP of Operations, Office Administrator and Director of Clinical Services, based on the findings will determine if the system iseffective and make any revisions as necessary. that the patient is receiving from the agency. 7) Patient #6 has an admission date of Persons responsible for the corrections and ongoing compliance are: Field Nurse Supervisors Regional.OfficeAdinnistrator "04113/09" with the diagnoses including Dementia Director of Clinical Services and Hypertension. The "Plan of Treatment" ( the agency's Plan of Care) dated "04/13109 - 10/13/09" documents I orders for: "HHA/PCA" five (5) to seven (7) days, six (6) to eight (8).hours a day..A There is no documentation to identify the PCA) Slevel of paraprofessional services ( hha orspecific that the patient is receiving from the agency. During interview with the Director of Clinical Services.(DCS) and Regional Area Manager on 7/09/09 at 2:15PM, the survey findings were I reviewed for Patients #2, #3, #4, #6 and #11. The DCS stated that the nurses should be identifying the level of aide'service whether it's a hha or VP of Operations Completion date: 9/30/09 f .," . -> " PCA. The DCS further stated that the agency revised the Plan of Treatment forms back in March of this year to reflect "HHA/PCA": Jffice of Health Systems Management / Office of Long Term Care ?TATE FORM Version 09112108 . A QGGV1 1 If continuation sheet 4 0120 PRINTED:-08/1712009 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES ANDPLAN OF CORRECTION (XI) PROMlDERPSUPPLIERCLA IDENTIFICATION NUMBER: LC536C FOMPRVED (X2) MULTIPLE CONSTRUCTION A, BUILDING " (X3) DATE SURVEY COMPLETED " NAME OF PROVIDER OR SUPPLIER B. WING B W __________ LC3536C .. 07/1 0/2009 STREET ADDRESS, CITY, STATE, ZIP CODE PREMIER HOME HEALTH CARE SERVICES INi (X4) IO PREFIX TAG HEMLITAN 11550 HEMPSTEAD, NY 11550 I ID PREFIX TAG 50 CLINTON STREET STE 608 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSCIDENTIFY1NG INFORMATION) Ix). COMPLETE DATE H.618 766.5(b)(3) Clinical supervision 76" Cfound 766,5 Clinical supervision. The governing . 'authority shall ensure for all health care services that: ...... H 618 . 1. Corrective action for thosep adents to be affected by the deficient practice: 1. Office Administrator (OA) was counseled on 7/22/09 regarding (b) all staff delivering care in patient homes are adequately supervised. The department shall consider the-following factors as evidence of adequate supervision: (3) clinical records are kept complete and changes in patient condition, adverse reactions, and problems with informal supports or home environment are charted promptly and reported to supervisory staff. This Regulation is not met as evidenced by: Based on record reviews and staff interview, the ....... appropriate branch oversight of patient records. 2. Field Nurse Supervisors were counseled by Office Administrator on 7/22/09 regarding appropriate review of time sheets. ... 3. Patient #1 was discharged on 7117/09. iHHA was reoriented regarding appropriate documentation on duty 1 " to reflect plan of care. " Patient #8-- ]HA was reoriented regarding appropriate documentation on duty sheets to reflect-plan of care agency failed to maintain complete patient care recordsand ensure that4he home health aide (hha) and the personal care aide (PCA). - document according to the aide's "Plan of Care" 1 (written instructions). This was evident in four (4) of eleven (11)patientcare records reviewed. S( atie nts,#Ir" --V ka ncdp r -' p , .. (Pa.ients #~ " and .. Failure to ensure that the home health aides and personal-care bides document the tasks performed according to written instructions places the patients at risk for poor patient outcomes. The findings are: " - Patient #5 - PCA was reoriented regarding appropriate documentation on duty sheets to reflect plan of care o Patient #9 - TIHA was reoriented regarding appropriate documentation on duty aettorlt pocae. d s AD counseling and re-orietation wM completed by Office Administrator on 7/22/09. 11. Identification of other.patients having 1) Patient #1 - admitted to the agency on "5/30/09" with diagnoses of CAD (Coronary Artery Disease) and Renal Failure. The Plan of Care signed by the physician on "5/11/09" documents orders for: "HHA/PCA" (home health aide/Personal Care Aide) "frequency: Days per week 5 to 7 Hours per day 4 )ffice of-Health Systems Management / Office of Long Term Care 'rATE FORM Version D9112108 o the potential to be affected by the deficiency and what corrective action will he taken: - All case managed patients are affected by this regulation. QGGV11 .If continuation sheI t5120 PRINTED: 08/17/2009 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X) PROVIDER/SUPPLIERJCLIA IDENTIFICATION NUMBER (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED B. WING LC3536IC NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE 07/10/2009 PREMIER HOME HEALTH CARE SERVICES IN' (X4) ID [. PREFIX TAG 50 CLINTON STREET STE 608 HEMPSTEAD, NY 11550 iD PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY.FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO T-C APPROPRIATE ."oDEFICIENCY) (X5) COMPLETE BATE H 618! Continued From page 5 to 9 Hours and days may vary upon patient preference." The aide is to assist with ADLS (activities of daily living), and other duties as directed by the Plan of Care. 1 618 Theclinical record audit tool will be revised to reflect HAPCA duty at toolhe sheets match HIIAPCA plan of care. The aide Plan of Care dated "5/30/09" documents instructions to "assist with personal care, prepare low salt meals as needed, encourage fluid intake and remind to take medicationdaily." The aide.activity sheets dated "6/02/09, 6/03/09, 6/05/09, 6/08/09 - 6/10/09 and 6/12/09" lack documentation that the aide reminded the patient oThe Branch Field Nurse Supervisors will audit 100% of the lHA duty sheets and compare them to the BRA plan of care for private pay and case managed cases and initial that they were reviewed. JIM Measures that will be put in place to ensure that the deficient practice will not reoccur: " I I Field Nurse Supervisors will review HIIA/PCA duty sheets against the HHA/PCA plan of care, circle to take medications. On 7/10/09 at 9:00 AM, the Director of Clinical Services (DCS) and Regiona 'Area Manager (RAM) were informed of the Survey findings. The DCS and the RAM did not provide anmacth explanation. " .2) Patient #8 - admitted to the agency on "1/24/09" with diagnosis of Compression Fracture of Back discrepancies and notify the Hl]A/PCA of the discrepancies. The HHAIPCA was reoriented regarding accurate documentation on duty sheets to match the HMA/PCA plan of care and .AICApnofarad following the HHA/PCA plan of care. " IV. How will the corrective action be monitored to ensure the deficient practice will not reoccur? Agency auditors will be educated on the The aide Plan of Care-dated "3/27/09"and updated on 5/27/09 documents instructions: "Personal Care, household tasks, prepare and serve low fat and low salt diet, and remind to take medication." o oo I, 51 . change in the audit tool. T"he Branch will audit 10 clinical reor 8 quarterly for the presence and accurate completion of the IIIIAIPCA duty sheets. " The aide activity sheets dated 5/18/09 - 5/22/09 lacks documentation that the aide reminded the patient to take medications. On 7/1 0/09 at 9:00 AM, the agency's DCS and RAM were informed of the findings. The DCS stated that "the nurses do review the aide activity sheets." No further explanation was provided. ftice of Health Systems Management / Office of Long Term Care "TE FORM Version 09/12/08 I - O GGV11 Ifcontinuation sheet 6of 20 PRINTED: 08/17/2009 FORM APPROVED New York.State Department of Health AND PLAN OFOF DEFICIENCIES STATEMENT CORRECTION ( PROVIDERPSUPPLiERICLIA . IDENTIFICATION NUMBER: ((1X2)A UIPLCN STGTO (X2)MULTIPLE CONSTRUCTION A. BUILDING __________ 13. WING__________ . X) AESRE (X3)DATE SURVEY COMPLETED LC3536C NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE. ZIP CODE 07/1012009 50 CLINTON STREET STE 608 HEMPSTEAD, NY 11550 ID PREFIX TAG . PREMIER HOME HEALTH CARE SERVICES IN, (X4) ID . PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES . (EACH DEFICIENCY MOST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) . . PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD RE ( CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Based on the structure established by the 0(5) COMPLETE DATE H 618~Continued From page 6 3) Patient #5 7 admitted to the agency on . [."1/30/09" with diagnosis of Hypertension. The Plan of Care dated "01130/09 --07/30/09"' documents orders for: "HHA" (home health aide) frequency: Days per week three (3) to four (4) days three (3) to four (4) Hours a day. Aide to assIst with ADLS and Pesonal care". o.meetings H 618. governing authority, audit r-esults will be o documented on the Branch, Regional and Corporate Q1 Summary Forms. Results will be reviewed by the Officeo Administrator and Diredor of Clinical Services. Findings will be reported at the Branch, Regionl and governingo authority Corporate QI and reflected inCommittee the minutes. The VP of Operatiois, Office *The aide'sPlan of Care dated "3/30/09 and 5/20/09" documents instructions to complete the task of "remind to take medication daily", The aide activity sheets dated "2/16/09 to 2/27/09, 3/23/09 to 4/24/09, 5/25/09 to 5/29/09 and 6/08/09 to 6/12/09" lacks'documentation that the hha reminded the patient to take medications. On 7/09109 at 2:15PM, the agency DCS and RAM were informed of the findings. The DCS stated that "the nurses do review the aide activity sheets." No-further explanation was provided. 4) Patient #9 - admitted to the agency on "2/28/08" with diagnoses of Brain Tumor and Administrator and Director of Clinical Services, based on the findings will determine if the system iseffective and make any revisions as necessary. Persons Responsible for the corrections and Ongoing compliance are: Field Nurse Supervisors Regional OfficeAdministrator Director of Clinical Services VP of Operations Completion date: 9/30/09 Breast Cancer. The Plan of Care dated "2/28/09 -8/28109" documents Days for: "HHA" (home seven. (7) "frequency: ordersper week five (5) to health aide) days three, four (4) to eight (8) Hours a day. Aide to assist with ADLS, 3nd personal care". The aide's Plan, of Care dated "4/28/09 and 6/18//09" documents instructions to complete the tasks of "ROM (Range of Motion) exercises daily, remind patient to take medication daily and incontinence care every visit". ' The aide activity sheets dated "5/4/09 to 5/15/09, )ftice of Health Systems Management / Office of Long Term Care TE FORM Version 09/12/08 OGGV11 If continuation sheet 7 of 20 PRINTED: 08/1712009 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION I' (XI PRO\.IOERISUPPLIEPJCLIA IDENTIFICATION NUMBER* (X2) MULTIPLE CONSTR ucrIoN . (X3) DATE SURVEY COMPLETED ~~~~ LC3536C ~B A. BUILDING WING _________ __________ 07/10.2009 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS:CITY, STATE, ZIP CODE 50 CLINTON STREET STE 668 EM0SCEANTONYTET56D PREMIER HOME HEALTH CARE SERVICES IN, " HEMPSTEAD, NY -11550 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL ' REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX RFX TAG PROVIDER'S PLAN OF CORRECTION ACTION SHOULD BE G O HUDB CROSS-REFERENCED TO THE APPROPRIATE (EACH GORRECTIVE (AHCRETV DEFICIENCY) . ' i COMPLETE C(x5) DATE o H 618: Continued From page 7 . 5/24/09 to 5/28/09, 6/01/09 to 6/05/09 and 6/08/09 to 6/12/09" lack documentation that the H 618 ' ihha performed thetasks of ROM exercises and incontinence care. "The aide activity sheets dated "5/16109 and 5/18/09 to 5/22/09" lacks documentation that the hha performed the task of incontinence care. The aide activity sheet dated "6/11/09" lacks documentation that the hha reminded patient to .take medications. The aide activity sheet dated "6/07/09, 8 :00 AM to 12:00 PM four (4) hours" was found to be blank and was signed and dated "6107109" by the hha and the registered nurse. On 7/09/09 at 2:15PM, the agency DCS and RAM were informed of the findings. The DCS stated that "the nurses do review the aide activity sheets." No further explanation was provided. H1002: 766.9(a) Governing authority Section 766.9 Governing authority. The governing authority or operator, as defined in Part 700 of this Title, of a licensed home care services agency shall: (a) be responsible for the management.and operation of the agency; (b) ensure compliance of the home care services agency with all applicable Federal, State and local statutes, rules and regulations. This Regulation is not met as evidenced by: Based on reviewed records and staff interview, the Governing Authority (GA) failed to ensure )ffice of HealthoSystems Managemenl /Office of Long.Term Care "TE FORM Version 09/12108 . Hi002 " i QGGV1 1 If continuation8o 20 sheet PRINTED: 08/17/2009 New York State Department of Health SrATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDERSUPPLIER/CLIA IDENTIFICATION NUMBER (X2) MULTIPLE CONSTRUCTION A BUILDING B.WING _ __________ FORM APPROVED (X3) DATE SURVEY COMPLETED LC3536C NAME OF PROVIDER OR SUPPLIER 07/1012009 STREET ADDRESS, CITY, STATE, ZIP CODE PREMIER HOME HEALTH CARE SERVICES IN' (X4) ID PREFIX TAG 50 CLINTON STREET STE 608 HEMPSTEAD, NY 11550 I PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE "DEFICIENCY)(XSI COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY-FULL REGULATORY OR LSC IDENTIFYING INFORMATION) : " H1002: Continued From page 9H1002 issue the certificate to the aide and the I certificates are issued from the corporate office." The RAM further stated that "the agency will : make all necessary changes to the Competency Evaluation Forms to reflect changes." " 111008 i. Corrective action for those patients found to be affected by the deficient practice: H10.8; 766.9(d) Governing authority Section 766.9 Governing authority. The governing authority or operator, as defined in Part 700 of this Title, of a licensed home care services agency shall: H1008 Agency policy and procedure was revised to reflect "Professional staff receives an evaluation after 90 - day probationary i zzjo? period and annually thereafter". 11. Identification of other patients having the potential to he affected by the deficiency and what corrective action will be taken: - (d) adopt and approve amendments to written policies regarding the management and operation (of the home care services agency and the . provision of health care services. This Regulation is not met as evidenced by: Based on record review and staff interview, the Governing Authority failed to ensure that the policy and procedure was complete to include theensure required annual supervision of all agency staff that are responsible for the provision of patient health care services. Failure to ensure that the agency's policy and procedures are complete to ensure the safety of patient health care services, places the patients at risk for poor quality of care, I The finding is: I The agency policy and procedure for"... Clinical Supervision of Professional Staff" documents : o "...Vice President of Clinical Services or Regional Director of'Clinical Services is responsible for the All thi case managed patients are affected by 100% of FNS Personnel Records will be audited to ensure compliance with the required probationary and annual evaluations. o Ill. Measures that will be put in place to that the deficient practice will not reoccur: As per agency policy, the Office Administrator will ensure that all new hires will have an evaluation at the 90-day probationary period and then annually 1, ic thereafter. In accordance with agency policy, all current staff wilt have annual evaluations completed by the Regional Director of Patient Services. IV. How will the corrective action be monitored to ensure the deficient practice will not reoccur? Annual evaluations will be completed on all professional staff by the Regional Director of Patient Services. supervision of all Field Nurse Supervisors...the Field RN (Registered Nurse) Supervisor is Office ofHealth Systems Management / Office oi.Lorig Term Care STATE FORM Version 09/12/08 - responsible for the supervision of all. professional , 100% of applicable personnel records of professional staff will be audited by the Branch quarterly to ensure compliance with annual evaluations. Ifcontinuation sheel 10of20 - son 0 G~v1l PRINTED: 08/17/2009. FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING __________ (X3)DATE SURVEY COMPLETED LC3536C NAME OF PROVIDER OR SUPPLIER B. STREET ADDRESS, CITY, STATE, ZIP CODE 071 0/2009 PREMIER HOME HEALTH CARE SERVICES IN' (X4) ID PREFIX TAG 50 CLINTON STREET STE 6008 HEMPSTEAD, NY 11550 I ID PREFIX. TAG I PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BEPRECEDED BY FUEL REGULATORY OR LSC IDENTIFYING INFORMATION) (X5) COMPLETE, DATE H1008. Continued From page 10 staff.....7. Supervision should occur at frequent intervals during the probationary period in order to ensure safe patient care and staff familiarity H1008 Based on the Structure established by the with agency procedures ....8. Ongoing suprvisory activities may be adjusted by the Director of Clinical Services in order to meet the specific needs of staff members". : governing authority, audit results will be documented on the Branch, Regional and Corporate QI Summary Forms. Results will be reviewed by the Regional Office Administrator and Director of Clinical Services. Findings will be reported at the Branch, Regional and governing authority Corporate QI Committee meetings and reflected in the minutes. There is no documentation in the agency's policy and procedure of the required annual . supervision of all professional staff that are responsible for the delivery of patient care services. - make revisions as necessary. Persons responsible for the correction The VP of Operations,Office Administrator and Director of Clinical Services, based on the findings will determine if the system is effective and During interview on 7/09/09 at 2PM with the Regional Area Manager and the Regional Director of Clinical Services, the agency's staff did not provide an explanation for finding . H1010 766.9(e) Governing authority Section 766.9 Governing authority. The governing authority or operator, as defined in Part 700 of this Title, of a licensed home care services agency shall: (e) make available to the public information conceming the services which it offers, the geographic area in which these services are made available, the charges for the various types of service and the payment mechanisms which may be available for such services. . ,This Regulation is not met as evidenced by: Based on observation record review, home visit (HV), and staff interview, the Governing Authority failed to ensure that the agency accurately advertise services which are approved by the New York State Department of Health S(NYSDOH). )ffice of Health Systems Management I Office ol Long Term Care 6,TE FORM Version 09112/08 ,and on-going complianec are, Administrator Director Of Clinical Services VP of Operations Completion date: 9/30/09 //-L' , I. H1010mt I. Corrective action for those patients found to be affected by the deficient practice: . The Office Administrator to reorient FNS's regarding services offered by. agency and provision of appropriate documentation to patient. . Patient #1-INS to review services provided by home health agency, cross Out services not provided and have patient sign, place in clinical record. Identification of other patients having the potential to be affected by the deficiency and what corrective action wil be taken: All case managed patients are affected by this regulation. 1.All case managed records will be audited to ensure only services provided by agency are identified. QGGV11 'z'c5 . ?2 If continuation sheet 11 of 20 PRINTED: 08/17/2009 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES ,[AND PLAN OF CORRECTION (XI) PROVIDERISUPPLIERCLIA IDENTIFICATION NUMBER. (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING ________ " (X3) DATE SURVEY COMPLETED LC3536C NAME OF PROVIDER OR SUPPLIER WN07/10/2009 STREET ADDRESS, CITY. STATE. ZIP CODE PREMIER HOME HEALTH CARE SERVICES INI (X4) o PREFIX TAG 50 CLINTON STREET STE 608 HEMPSTEAD, NY 11550 o ID PREFIX TAG PROV1DER'S PLAN OF CORRECTION (EACHCORRECTIVE ACTION SHOULD BE CROSS-REFERENCEB TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H1010 Continued From page 1. H1010 2. Results of audit will be reviewed with FNS. FNS will cross out services not provided, and have patient sign new consent on next visit. At the time of the Advertising services which the agency is not licensed to provide has the potential for patients to receive agency services without Department of Health oversight, SThe findings include: The agency "Admission Package" that includes visit, the FNS will explain services offered by the Hempstead Branch Office. 3. All new admissions will be reviewed by the branch and ensure that physical therapy is crossed out and other services as c d a h e LU. Measures that will be put hi place to ensure that the deficient practice will not reoccur: Office Administrator will reorient FNS's regarding appropriate completion of the consent form. Cross out services not indicated Or offered in the branch. (Consent form is utilized for all branches 32 in 7 states which are why physical and other services are (in there). The Branch will audit 10% of case managed records quarterly for accurate completion of the "Consent for Treatment" Form: the "Consent for Treatment" documents: "physical therapists and/or other health professionals" as a service the agency is able to provide." I The agency license observed posted on the wall documents Nursing, home health aide (hha) and Personal Care Aide (PCA) as the approved services and documents: "Nassau, Suffolk and Queens" counties as the:agency's service area, o . [ . . .therapy During a home visit to Patient #1 on 7/09/09, .the "Consent for Treatment" form in the "Admission Package" was reviewed and documents "physical theral~ist" and/or otffer health professionals". The agency is not authorized to provide Physical Therapy in the state of New York. Services (DCS) and Regional Area Manager. During an interview with the Director of Clinical (RAM) on 7/09109 at 10:30 AM, the RAM stated that "in the State of New York we do not provide Physical Therapist or any other services." The RAM confirmed that "the nurses should be crossing out when the case is opened.". H1036. 766.9(I) Governing authority Section 766.9 Governing authority. The governing authority or operator, as defined in' Dffice of Health Systems Management / Office of Long Term Care , - TE FORM Version 09/12/08 H1036 QGGV11 o - If continuation sheet 12of20 %t PRINTED: 08/1712009 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTIO N (X1) PROM DERISUPPLIERCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING B.WING __________ (X3) DATE SURVEY COMPLETED LC3536C NAME OF PROVIDER OR SUPPLIER 0711012009 STREET ADDRESS, CITY, STATE, ZIP CODE PREMIER HOME HEALTH CARE SERVICES IN (X4) ID PREFIX TAG 50 CLINTON STREET STE 608 HEMPSTEAD, NY 11550 ID PREFIX TAG ' PROVIDER'S PLAN OF CORRECTION (EACH'CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) _____DEFICIENCY) H1010, Continued From page 11 Advertising services which the agency is not to receive agency services without Department of Health oversight H1010&: " 4-rn- dLJr L " H IO] . licensed to provide has the potential for patients IV. How will the corrective action be monitored to ensure the deficient practice. will not reoccur? Based on the structure established by the governing authority, audit results will be The findings include: The "Consent"Admission Package" that includes the agency for Treatment" documents: " the raConsents Treatmndo cum henlts: physical therapists and/or other health professionals" as a service'the agency is able to provide." o documented on the Branch, Regional and Corporate QI Summary Forms. Results will be reviewed by the Office Administrator and Director of Clinical Services. Findings will be reported at the Branch, Regional and governing I The agency license observed posted on the wall documents Nursing, home health aide (hha) and Personal Care Aide (PCA) asthe approved services and documents: "Nassau, Suffolk and Queens" counties as the'agency's service area. During a home visit to Patient #1 on 7/09/09, the ' "Consent for Treatment" form in the "Admission Package" was reviewed and documents "physical authority Corporate QI Committee meetings and reflected in the minutes. The VP of Operations, Office , Administrator and Director of Clinical Services, based on the findings will determine if the system is effective and make revisions as necessary. Persons responsible for the correction theraoist" and/or other health professionals". The agency is not authorized to provide Physical Therapy in the state of New York. and on-going compliance are: Field Nurse Supervisors RegionalOffice Administrator Director of Clinical Services VP of Operations Completion date: 9130(09 During an interview with the Director of Clinical Services (DCS) and Regional Area Manager (RAM) on 7,09109 at 10:30 AM, the RAM stated that "in the State of New York we do not provide Physical Therapist or any other services." The RAM confirmed that "the nurses should be crossing out when the case is opened." H1036; .I 766.9(l) Governing authority Section 766.9 Governing authority. H1036 The governing authority oroperator, as defined in Dffice of Health Systems Management / Office of Long Term Care STATE FORM ' Version 09112108 . . - QGGV1 1 , I continuaton sheet 12 Df20 PRINTED: 0817/2009 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDFRISUPPLIEFCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING . - (X3) DATE SURVEY COMPLETED LC3536C NAME OF PROVIDER OR SUPPLIER 07/10/2009 STREET ADDRESS, CITY, STATE, ZIP CODE PREMIER HOME HEALTH CARE SERVICES IN( (X4) ID PREFIX TAG 50 CLINTON STREET STE 608 HEMPSTEAD, NY 11550 I 0 PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE _DEFICIENCY) SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) . _ (x5) COMPLETE DATE H13041 Continued From page 14 H1 304 766.11 (b) Persbnnel H1304 H1304 76.11Personne. The governing authority or operator shall ensure for all health care personnel: I 1.Corrective action for those patients found to be affected by the deficient practice: . No specific patients were identified in the citation. o "the I. Identification of other patients having potential to be affected by the deficiency and what corrective action will I personal (b) that qualifications for home health aide and care aide as specified in section 700.2 - be taken: All case managed patients are affected by of this Title are met. This Regulation. is not met as evidenced by:. Based on record review and staff interview, th.e agency failed to ensure the an employee has " home health aide (hha)qualifications. This was evident.for one (1),of one (1) Trainee (Nurses. " this regulation. 1. All active lIIAIPCA employee records will be audited to ensure applicable certificate document is in the file. In the event that appropriatedocument is not located in the record, employee will be removed from theobtained. appropriate documentation is case until Aide Transitioning) record reviewed. (Employee #1/Trainee #1). Failure to ensure that all hha employees have their certificate from qualifying training programs prior to employment places the patients at risk for receiving poor quality-care by unqualified staff. The finding is: ' records per quarter for certificate p 111. Measures that will be put in place to 'rhe Office Administrator/Compliance Coordinator will review all new hire personnel files to ensure all appropriate documentation is present. ensure that the deficient practice will not reoccur: . The personnel record of Employee #1/Trainee #1 lacks documentation that the aide received the Home Health Aide Certificate of Completion. The employee was hired on "2/19/09"and serviced clients from 3/06/09 to the present. The employee/trainee record documents completion of "Nurses Aide Transitionirig" on 4/30/09. I IV. How will the corrective action be monitored to ensure the deficient practice will not reoccur? Based on th structure established by the authority, audit results will be documented on the Branch, Regional and Corporate QI Summary Forms. Results uringan itriw ihteigoverning During an interview with the Director of Clinical Services (DCS) and Regional Area Manager (RAM) on 7/10/09 at 9:35 AM, the RAM stated that "the agency had 90 days to issue the will be reviewed by the Office Administrator and Director of Clinical certificate and the certificates are issued from the corporate office". The RAM could not verify if the _______________-________- Services. Findings will be reported at the Branch, Regional and governing authority Corporate QI Committee \r,-- ..-QGGVI1 Dbffice of Health Systems Management / Office of Long Term Care TE FORM /ersion 09/12108 ., I contiouativA sheet i5 of 20 PRINTED: 08/17/2009 New York State DeDartment of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIERJCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING FORM APPROVED (X3) DATE SURVEY COMPLETED " LC3536C NAME OF PROVIDER OR SUPPLIER 8. WING___________ 07/10/2009 STREET ADDRESS, CITY, STATE, ZIP CODE I H50 PREMIER HOME HEALTH CARE SERVICES IN' (X4) ID PREFIX TAG CLINTON STREET STE.608 HEMPSTEAD, NY 11550 1D PREFIX - TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5). COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H1304 Continued From page 15 H1304 meetings and reflected inthe minu es- Trainee #1/Employee #t had received .the hha certificate. During.telephone interview on 7/14/09 at 9:20AM The VP of Operations, Office Administrator and Director of Clinical Services, based on the findings will determine if the system is effective and with the RAM to clarify the Employee's "position title", the RAM faxed the requested information on 7/14109 at 11:50AM. The fax documents that ,the Employee was hired as a "HHA (home health aide)". The agency's staff did not provide an explanation for the agency hiring the employee as a hha prior tothe completion of the Nurses Aide Transition on 04/30/09. "". make any revisions as necessary. Persons responsible for the correction and on-going compliance are: Regional Office Administrator Director of Clinical Services VP of Clinical Services Compliance Coordinator Completion date: 930/09 . , Hi1337. 766.11 (f)(ii)Perso.nnel Section 766.11 Personnel H1337 I. Corrective action for those patients found to be affected by the deficient ; practice: No specific patients were identified in the 1. Identification of other patients having The governing authority or operator shall ensure for all health care personnel: o.deficiency: (f)(ii) a criminal history record check to the extent required by section 400.23 of this Title : the potential to be affected by the deficiency and what corrective action will be taken: All case managed patients are affected by this regulation. 'I I This Regulation is not met as evidenced by: Based on record review and staff interview, the agency failed to complete the required " supervision for the temporary employees awaiting the Criminal History Record Check (CHRC) report results. This was evident in three (3) of four (4) employees requiring CHRC supervision. (Employees #1, #3 and #8). Failure to supervise the temporary employees, The compliance coordinator will run weekly reports from the Arrow system to determine HHA's/PCA's with outstanding CHRC's and the need for provisional visits. i initial will be Timely supervision weeks. provided with an onsite visit followed by telephone supervision in alternating places the patients at risk for poor quality care. The findings are: Dffice of Health Systems Management / Office of Long Term Care 4-,TE FORM . 1 . Version 09112108 QGGV11 Ifconfinuaon sheet 160120 PRINTED: 08/17/2009 New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (I) PROVIDERISUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER: "UILlIG B.WING __________ FORM APPROVED (X3) DATE SURVEY COMPLETED LC3536C NAME OF PROVIDER OR SUPPLIER STREET ADDRESS CITY, STATE, ZIP CODE 07/10/2009 HEM PSTEAD, NY 11550 i _ PREMIER HOME HEALTH CARE SERVICES IN( . (X4) IO PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG _ _ o PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE (XSI COMPLETE DATE __ ,DEFICIENCY) H1337 Continued From page 16 1) Employee #1 was hired by the agency as a H1337 1U. Measures that will be put in place to ensure that the deficient practice will not reoccur: - home health aide (hha) on "2/21/09" and was assigned to first case on "3/06/09". The personnel record documents alternate Field Nurse Supervisors, coordinator and on-site/telephone supervision weekly until "5/01/09". .The record lacks documentation of telephone supervision for the weeks of 5/09/09, compliance coordinator were in-serviced on 7/22109 regarding the CHRC policy and procedure, supervision of LIHA's/PCA's and schedule for provisional visits. 5/16/09 and the week of 6/27/09. On 7/10/09 at 11:30 AM, the findings and requirements for temporary supervision were reviewed with the agency's Director of Clinical Services (DCS) and Regional Area Manager IV. How will the corrective action be monitored to ensure the deficient practice will not reoccur? The compliance coordinator will review (RAM). The RAM and/or DCS did not provide an explanation for the survey findings. the logs in the Arrow System weekly to ensure scheduled compliance activities. The Office Administrator will monitor 2) Employee 93 was hired by.the agency as a PCA (personal care aide) on "2/17/09" and was this process. The Branch will audit 10 records quarterly to ensure to ensure compliance assigned to the first patient on 3/09/09. The personnel record documents an alternate on-site/telephone supervision until 4/10109. There o is no documentation of on-site supervision for the weeks of 4111/09 and 4/25/09. The next on-site supervision was conducted on "4/21/09". The personnel record lacks supervision after 6/22/09. On 7/10/09 at .11:30 AM, -the findings and requirements for temporary supervision were requremets .authority reviewed with the agency's DCS and RAM. The RAM/DCS. did not provide an explanation for the survey findings. with CHRC and provisional visits. Based on the structure established by the governing authority, Audit results will be' documented on the Branch, Regional and Corporate.Q1 Summary Forms. Results will be reviewed by the Regional Office Administrator and Director ofClinical Services. Findings will be reported at the Branch, Regional and governing Corporate meetings and reorete Q1 Committee reflected i the 11111nutes. in toeminte. aetia The VP of Operations Office Administrator and 1)jrector of Clinical Services, based on the findings will 3) Employee # 8 was hired by the agency on '"2/17/09" as a PCA and was assigned to the first patient on 3/16/09. The personnel record lacks documentation of the determine if the system is effective and. make any revisions as necessary. initial onsite supervision' by the registered and/or Difice of Health Systems Management / Office of Long Term Care "4.TE FORM Version 09112/05 ,, QGGV11 if continuation sheet 17 of 20 PRINTED: 08/17/2009 New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X PROVIDERtSUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A, BUILDING FORM APPROVED (X3) DATE SURVEY COMPLETED LC3536C NAME OF PROVIDER OR SUPPLIER 8. WING 07/10/2009 STREET ADDRESS, CITY. STATE, ZIP CODE PREMIER HOME HEALTH CARE SERVICES IN( IX4) ID PREFIX TAG 50 CLINTON STREET STE 608 HEMPSTEAD, NY 11550 ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD 3E CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) IXSI COMPLETE DATE H1337 Continued From page 17 licensed nurse. The personnel record documents that the onsite/offsite supervision was performed every two (2) weeks and not the required alternating weekly onsite/offsite supervision. There is rio documentation of on-site supervision for the weeks of 3/23 /09, 4/14/09 and 5/25/09. The personnel record lacks supervision after 6/29/09. There is no off-site supervision performed on the weeks of 4/07/09, 4/21109, 5/04/09, 5/18/09and 6121/09.,,. During interview on 7/10/09 at 1:15PM, the findings and requirements for temporary. supervision were reviewed with the agencys DCS and RAM%The RAM stated that the "CHRC report results have not been received'yet by the agency". The RAM/DCS did not provide an explanation for I the survey findings. The agency Policy and ProceduRe for "9.20 1Criminal B38ckground. Checks (CHRC) supervision as: . H1337 Persons responsible for the correction and on-going compliance are: Regional Offic Administrator Field Nurse Supervisors Coordinator Compliance Coordinator Regional I)irector of Clinical Services VP of Clinical Operations Completion date: 9/30/09 -1 4, - jo $ . ,m5,1 " t.... . "3 -. - Fingerprinting" documents the procedur -- ivor i i;, y3~ -,g q ,j " ..... All newly hired fingerprinted employees.will 1 be supervised in accordance with the Department of Health regulations. Supervision must start with a field visit by an RN or LPN (Registered Nurse/Licensed Practical Nurse). The following week's supervision will be conducted by, telephone. Employees will then be supervised * .r " ' . - i -c , , 41- through field -visits and telephone Galls on alternate weeks ..... H1454i 766. 12(c) Records and reports 766.12 Records and reports. H1454 54 " / , Dffico of Health Systems Management / Office of Long Term Care "'7TE FORM Version 09112108 oG GVii /) / II co iua tion sheaq"l J + '1 . V t " /, / .> vl 9 PRINTED: 0817/2009 FORM APPROVED New York State Department of Health STATEMENT OF DEFiCIENCIES AND PLAN OF CORRECTION (XI) PROV)DERISUPPLIER/CLIA IDENTIFICATION NUMBER (X2) MULTIPLE CONSTRUCTION A. BU.LDING B. WING___________ (X3) DATE SURVEY COMPLETED LC3536C NAME OF PROVIDER OR SUPPLIER 07/10/2009 STREET ADDRESS, CITY, STATE, ZIP CODE PREMIER HOME HEALTH CARE SERVICES IN' (X4) ID PREFIX TAG 50 CLINTON STREET STE 60B HEMPSTEAD, NY 11550 ID PREFIX TAG " -I PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTON SHOULD E CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) I. Corrective action for those patients found to be affected by the deficient practice: (XS) CMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES. (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY DR LSC IDENTIFYING INFORMATION) H1454i Continued From page 18 .* (c) The home care services agency shall furnish H1454 annually to the department a copy of. (1) statistical summaries of all health care services delivered on forms provided by the department; , (2) if a for-profit corporation, a list of the principal o No specific patients were identified in the deficiency, I. Identification of other patients having the potential to be affected by te deficiency nd what corrective action will This regulation would not affect patient I stockholders and the number and percent of the total issued and outstanding shares Of the corporation held by each, duly certified by the secretary of the corporation as to completeness and accuracy; (3) if a not-for-profit corporation, a list of directors, officers and corporate members, if such .members number 10 or fewer; and i , (4) other such records and reports as may be outcomes. [I. Measures that will be put in place to ensure that the deficient practice will not reoccur: 2006 and 2007 statistical reports will he ruid resubmitted. IV. How will the corrective action be monitored to ensure the deficient practice will not reoccur? I. A process has been put in place for the Information Technology and Operations Departments to complete process on a legally required by the department (d) The agency shall furnish simultaneously to the department copies of.all notices and documents required to be filed with the Securities and j Exchange Commission. This Regulation is not met as evidehced by: * Ba.sed on interview, the agency failed to provide the required statistical reports for the survey. tmely basis. 2. Statistical reports will be coileted and submitted annually. This will be monitored by the governing body annually. Persons responsible for the correction I Failure to ensure that the agency has submitted the required annual statistical reports to the New York State Department of Health (NYSDOH) Splaces the patients at risk for poor quality of care. e tand The finding is: On 7/9/09, the agency's annual statistical reports for the years 2006 and 2007 were requested. The requested reports were not provided by the home Office of Health Systems Managoment / Office of Long Term Care c"rATE FORM Version 09/12/08 on-going compliance are: Chief Operating Officer Chief Financial Officer VP of Information Technology Completion date: 9/30/09 oW I (1 . Itconinuationsheet 190f20 . . QGGV11 " PRINTED: 08/17/2009 .FORM APPROVED (X2) MULTIPLE CONSTRUCTION BNOLORCGNIDENTIFICATION A. WUING __________ .'07/10/2009 New York State Department of Health ADEMNTOF DEFICIOERCES (X1.) PROVIDER/SUPPL!ER/CLIA AN NU MBER (X3) DATE SURVEY COMPLETED LC3536C NAME OF PROVIDER OR SUPPLIER PREMIER HOME HEALTH CARE SERVICES (X4) ID PREFIX i TAG IN B.WING STREET ADDRESS, CITY, STATE, ZIP CODE 50 CLINTON STREET STE 608 HEMPSTEAD, NY 11550 ID I PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) {X5) COMPLETE DATE H1454 Continued From page 19 care agency. During interview on 7/09/09 at 2:00PM with the Regional Area Manager (RAM), the RAM stated that "the agency's corporate office is responsible to submit the reports": The agency Was provided time to locate/provide H1454 the required reports. During interview on 7/10/09 at 11:30AM with the agency's RAM, the RAM I stated that "the corporate office is still looking for them". - I.. I - I.I Office of Health Systems Management / Office of Long Term Care r''-,TE FORM Version 09/1 2/08 " OGGV11 "I conlinuation sheel 20 of 20 New York State Department of Health STANEMENT OF DEFICIENCIES AND pLAN OF CORRECTION (x12 PR;OVIDE R/UFPLIEPCLLA IDENTIFICATION NUMBER; PRINTEU: 10/06/2009 FORM APPROVED ((2) MULTIPLE CONSTRUCTION A, BUILDING S. VV qNG I(X) DATE SURVEY COMPLETED "C LC0411D NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATEC, CODE ZIP 0913012009 ALL METRO HEALTH CARE - 8A'YLON (X4) I0 PREFIX TAG j -I 181 WEST STREET BABYLON, MAIN11702 NY ID PREFIX TAG 1 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE OtFICIENCY) COWI.ETE DATE " SUMMARY STATEIVNT OF DEFICIENCIES (EACH DEFICIENCY MUST LE PRECEDED BY FULL REGULATORY OR LSC tI)ENrIFYING INFORMATION) H YQ0U Initial Comments H 000 Surveyor: i 0733 A Complaint Survey was conducted on September 30, 2009. Complaint # NY00077121 Three(3) patient care records were reviewed and identified as Patients #1 - #3. One (1) personnel record was reviewed and identified as Employee #1. H 614 766.5(b)(1) Clinical supenision "H 766.5 Clinical supervision. The governing authority shall ensure for all health care services that: (b) all staff delivering care in patient homes are adequately supervised The department shall consider the follcwing factors as evidence of adequate supervision: I 614 (1) staff regulaily prvideservices at the times and frequencies specified in the patients of plan care and in accordance with the policies and procedures of their respecive services ] his Regulaon is rot met as evidenced by: Surveyor 10733 n Based n record roview and staff interview, the agency failed to ensure that the patient received the the Personal Care Aide (PCA) services as ordered on the Plan of Care in three (3) of three (3) three pat[ent care records reviewedi(Patients !#1, #2,and #3) Failure to provide PCA services as ordered places all patients at risk for not having their needs met and substandard care. I The findings are: Offilce of*Ith 'LABO STATE FORM Systarns Manaement I officeLong Term Care of TITLE W) DATE O, JSUPPUER REPRESEN7ATIVF'S SIGNATURE ~.i IoIwn~ndc 0e IfBW r ~ vulaivo 9112J0 PRINTED: 11106/2009 FORM APPROVED New York State Department of Health STATEMENT OF OEFICIENCIES AND PLAN OF CORRZGTICr (XI) PROVIDERISUPPLIER/CLIA IDENTIFICATION NUMBER; LC011D (X2) MULTIPLE CONSTRUCTION . A BUILDING (X3) DATE SURVEY . WING STREET ADDRESS. CITY, STATE, ZIP COWE 181 WEST MAIN STREET SASYLON, NY 11702 io PREFIX TAG C 093/20 NAME OF PROVIDER OR SUPPUIFR ALL METRO HEALTH CARE (X4) I0 PREFIX TAG - BA13YLON SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IENrFYING INFORMATION) PROV'1ER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SNOULO BE CROS..REFERENCEO TO THE APPROPRIATE DEFICIENCY) (XI) COMPLETE DATE H 614 Continued From page 1 1) Patient #1 has an admission date of 4128/09 with the diagnosis of Dementia, The Suffolk County Department of Social Services (SCOSS) Shared Aide Care Plan -dated 8/28/09 documents an increase of PCA hours to "23 hour, a week". The plan includes "PCA to arrive at .6:30am and 3:30 pin". The agency's 'Client Schedule Report' lacks documentation that the patient received the PCA service in the morning. During interview with the Coordinator on the case on 9/30/09, the Coordihator stated that the agency has "not been able to staff'the morning H 614 hou., H 614 CLINICAL SUPERVISION It is the policy of All Metro Health Care that all patients be provided services according to the Physician's Plan of Care or the Prior", Approval, for DS cases. If there is a change in the Plan of CarelPrior Approval, the schedule change is to be made in the Scheduling System as soon as we are made aware. If All Metro is unable to staff the case as requested, the entity ordering/approving the services is to be notified immediately so that the referral source has the opportunity to approach another agency regarding the unfilled hours. The staff shall make an earnest effort to rearrange schedules and fill hours until the case can either be permanently restaffed or referred elsewhere. It is further our policy that such communications with a family member or referral source be documented in the chart 2) Patient #2 has an admission date of 11/21/06 with diagnoses which include Hypertension, Bursitis and Hard of Hiearing. The SCOSS Shared Aide Care Plan dated or the ProHealth system for the edification of other associates working on the case The' currentcasbloa as- eee~ hvizdfr ltsoe ndrf wercot.te whil resain efIforts-were the. sein f h a t m 3/27/09 documents orders for 20 hours of PCA service a week. The plan includes "PCA to leave when a.m. tasks complete!". The patient attends Day Care. The "Client Schedule Report" lacks documentation that the patient received the PCA service in the rnorning from 7/30/09 - 9/02/09. The "Client Notes Print" dated 8/04/09 and 8/05/09 documents that the patient was "waiting for a specific PCA to provide care" and that the patient would"receive a shower at Day Care". During interview with tine Coordinator on 9/30109, the Coordinator stated that the agency did not office of Health Systems Management/Offlc of Long Tern Cre 'T t e w senid yetrefuses refe rlto'anoth6r agec'n th p' dtr,'refused t1o1leaVe1'AMHC,' althuhw haeve,-ongoingdfIicul. for.ditin wl.......... . be c;n 'g{dance..!n/.Iransferpng agency- h'.hatielt's dtr -cnpp.rI~ STATE FORM Version 09/12/043 7H6111 Ifcwntinuermn shIti 2 ff 3 PRINTED: 10/0C/2009 FORM APPROVED New York State Department of Health STATEMENT OF DEF CIENCIES AND PLAN O COR RCT O N PX2) IDENTIFICATION NUMBER:. '"IA. ( , MULTIPLE CONSTRUCTION S o 2UILDING WING CM{X3) ATE SUEY COMPLTED LCO411D : LC0411D NAME OFPROVIDER OR SUPPULR STREET ADDRESS. CITY,. STATE, ZIP CODE 09/3012009 181 WEST MAIN STREET ID PREFIX TAG PROVIOER'S PLANOF CORRECTION I(EACH CORRECTIVE ACTiON SHOULD BE DCROSS. Th EFEENCEO CY)TO APPRORATE X C0MPLETF VATE ALL METRO HEALTH CARE -BAj3YLQN i (X4)10 PREFIX TAG GASYLON, NY 11702 SUMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED OY FUL.L REGULATORY OR LSC I)EN'IFYING INFORMATION) H 614 Continued From page Z H 614 notify SCIDSS that they were not providing the PCA service as ordered. )'Patient has an admission date of 11/19/07 #3 with diagnoses of Hypertension, Congestive heart Failure, and Anemia. The SCOSS Shared Aide Care Plan dated All associates and On-Call staff will be reoriented to All Metro's policy regarding open hours and necessary communication to minimize the likelihood of patients being plac.d at. rsk. heo urcrpttw jlIe e DcS;Br Mgr.weeklyat the wt an ais6ciaited patient ntstoasrpre .; .communi.ation and,.. dieaa1ti& h 12/05/08 documents 33 hours of PCA services with tasks assIgned seven (7) days a week. The "Client Schedule Report" lacks documentation that the patient received service on Sundays from 6/29/109 - 9/20/09. I cumetion i b ,;mtter.with I -2aas ds in treated; , persoflqehplaefne r if.ecssary Branch Manager Responsible Individual and Director of Clinical Services Corpletion Date- 11-30-09 The "Client Schedule Report' dated 51/04109 0 " / " documents a conversation with the patient's son NSN .... (no service needed) on Sunday's Yv anymore". Duriihg Interview with t-c Coordinator on 9/30/09, the Coordinator did not provide documentation that SCDSS was notified of the change in frequency of PCA service as ordere d. / OffIce o i th Systems Mara';omarL e, 'Cff-am f Lanq Term Came STATE FORM Ver3ion O12C'8 7H6111 3 ol itmntinutnshoothee 3 PRINTED: 11/20/2009 New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIER/CLA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION FORM APPROVED (X3) DATE SURVEY COMPLETED A BUILDING LCO921A NAME OF PROVIDER OR SUPPUER B.WING STREET ADDRESS, CITY. STATE, ZIP CODE 11/03/2009 CARING HANDS HOME CARE INC (X4) ID 1 PREFIX i TAG SELDEN, NY 11784 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 36 JANICE LANE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) . H 000 Initial Comments Re-Licensure and Complaint Investigation ( NY00077942 and NY00077870) survey was conducted at Caring Hands Home Care, Inc. on . I 11/03/09. One (1) Patient care record was reviewed and H 000 66.1(a)(l) 04 A) The director of nursing shall bei e designated individual responsible for orrection of H204 B) Corrective action , aken is a new admission package to be - 'igned by current patient. In-service rovided to the nursing supervisor ') Current admission package to be eviewed at QA meeting scheduled for . identified as Patient #1. One (1) homevisit was made to Patient #1. o Eight (8) personnel records were reviewed and identified as Employees #1 - #8. Iniprevent 12/1 5/09 The art i2/ude0i.the admission package is to bp~ audit tool. to included in the chalurt audit to To recurrence of this issue charts H204 H 2041 766.1 (a)(1) Patient rights will be audited monthly times 2 till D) Following chart audit a written report Section 766.1 Patient rights. (a) governing authority shall establish written The policies regarding the rights of the patient and I shall ensure the development of procedures implementing such policies. These rights, policies and procedures shall afford each patient the right to: (1) be informed of these rights, and the right to exercise such rights, in writing prior to the i initiation of care, as evidenced by written ; documentation in the clinical record; (2) be given a statement of the services available by the agency and related charges; 100% compliance is met. a will be generated by the QI. Staff findings will be reviewed at the quarterl' QIC meeting/ongoing in-service to. continue. The GA / operator are to include this deficiency on its calendar and tickler system. Ongoing in-services, to be provided as needed. I '1f- " k (3) be advised before care is initiated of the extent to which payment for agency services may be expected from any third party payors and the extent to which payment may be required from the patient. (I) The agency shall advise the patient of any Office of Health Systems Management I Office of Long -Term Care LABORATORYDIRECTOR'S OR PROVIoER"SUPPLIER REPRESENTATIVE'S SIGNATURE STATE FORM Veso Y 11:0910851 TI J0$.,J1 " /jj4 I(XIVDATE )'iIi. if cofhruatonshLet Ilof 26 PRINTED: 11/20/2009 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES ,AND PLAN OF CORRECTION (X1) PROVIDERISUPPLIERICUA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED LC092tA NAME OF PROVIDER OR SUPPLIER B. WING 11/0312009 STREET ADDRESS, CITY, STATE,.ZIP CODE CARING HANDS HOME CARE INC (X4) ID PREFIX TAG 36 JANICE LANE SELDEN, NY 11784 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X) COMPLETE DATE SUMiARY STATEMENT OF DEFICIENCIES . (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H 204 Continued From page 1 changes in information provided under this paragraph or paragraph (2) of this subdivision as soon as possible, but no later than 30 calendar days from the date the agency becomes aware of the change. (ii) All information required by this paragraph shall be provided to the patient both orally and in writing; (4) be informed of all services the agency is to provide, when and how services will be provided, and the name and functions of any person and affiliated agency providing care and services. This Regulation is not met as evidenced by: Based on record reviews and staff interview, the agency failed to provide a complete Admission Package as requested for review. This was evident for the agency Admission Package. H 204 I Failure to have a complete Admission Package Iplaces patients at risk for not being able to exercise their rights. The findings are: During an entrance conference, the Owner was given a list of items needed to conduct a Re-Licensure and Complaints survey. One of the items requested was the agency's Admission Package. Throughout the survey, multiple requests were made to provide the agency's Admission package. At 2:00 PM, the Owner provided copy of the "Patient Rights and Responsibilities", "Emergency Telephone Numbers"and a "Referral Forms" for review. During an interview on 11/03/09, the Owner was Office of Health Systems Management Office of Long Term Care STATE FORM Version NYS 11117/2009 _'# 108511 If conpnuat n sheet 2of26 PRINTED: 11/20/2009 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDERISUPPLIER/CLIA IDENTIFICATION NUMBER: (X2)MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED LCO921A NAME OF PROVIDER OR SUPPLIER . B. WING 11103/2009 STREET ADDRESS, CITY, STATE, ZIP CODE CARING H ANDS HOME CARE INC (X4) ID PREFIX TAG 36 JANICE LANE SELDEN, NY 11784 ID PREFIX . TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)" x COMPLETE [ATE ) SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H 2041 Continued From page 2 informed that this is not thecomplete Admission Package. The Owner stated: "I guess, then I don't have an Admission Package right now-' H 618 766.5(b)(3) Clinical supervision H 204 H 618 /- 766.5 Clinical supervision. The governing authority shall ensure for all health care services that: (b)all staff delivering care in patient homes are adequately supervised. The department shall consider the following factors as evidence of adequate supervision:I (3) clinical records are kept complete and changes in patient condition, adverse reactions, and problems with informal supports or home environment are charted promptly and reported to Supervisory staff. This Regulation is not met as evidenced by: Based on record review and staff interview, the Governing Authority (GA) failed to ensure that the I .\ home care agency provides supervision to the staff delivering patient care. The agency Registered Nurse (RN) and the Physical Therapist (PT) failed, to notify the supervisory staff and/or the physician regarding changes in the patient's clinical status. This was evident in one (1) of one (1) patient care record reviewed (Patient #1). Failure to ensure that the RN and the PT are supervised and notify the supervisory staff and/or physician regarding changes in the patient's . clinical status places the patient at risk for poor quality of care and the potential for negative patient outcome. The findings are: Office of Health Systems Management/ Office of Long Term Care STATE FORM Version NYS 11117/2009 108511 , Ii Ifcontinuation sheel of 26 3 PRINTED: 11/20/2009 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PILAN OF CORRECTION (Xl) PROVIDERJSUPPLIERICLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING __o (X3) DATE SURVEY COMPLETED . LCO921A NAME OF PROVIDER OR SUPPLIER : B. WING 11/0312009 STREET ADDRESS, CITY, STATE, ZIP CODE CARING HANDS HOME.CAR E INC (X4} IO PREFIX TAG 36 JANICE LANE SELDEN, NY 11784 I2 PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (XE) COMPLETE DATE SUMMARY STATEMENr OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H 618 Continued From page 3 Patient #1 has re-admission date of 4/28/06 with the diagnoses including Acute Encephalomyelitis, Quadriplegia and Tracheostomy with Ventilator Dependence. The Plan of Care dated 4/28/09 to 10/28/09 documents the orders for "Skilled RN 7 (seven) D (days) x 24H (twenty four hours) ongoing respiratory and neurological assessment with skilled intervention when needed. VS (vital signs) BID (twice a.day)" and "PT 3 (three) times a week" for "PROM (passive range of motion) via H 618 PT only". The Plan of Care documentsorders for the medications: "Diovan 80mg /HCTZ 12.5rgPO (by mouth) qam (every morning) Hold for SBP (Systolic Blood Pressure)< (less than) 120 & DBP (Diastolic Blood Pressure) <90. Divan 80mg PO every PM (evening) Hold for SBP < 120 & DBP <90". .The Plan of Care does not include orders that would require physician notification for elevation in patients vital signs, such as BP( blood pressure) and HR (heart rate) parameters. The Skilled RN and the PT patient care visit notes document observed elevation in the patient's vital signs, such as BP and HR on multiple days. The patient care record lacks documentation that the Skilled RN and the PT had informed/notified the supervisory staff and/or physician regarding the changes in the patient's clinical status. The Skilled RN visit notes documents the following: Office of Health Systems Management /Office of Long Term Care. STATE FORM Version NYS 11/17/2009 _ 108511 If continuation sheet 4 of 26 PRINTED: 11/20/2009 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIERCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION. A. BUILDING (X3) DATE SURVEY COMPLETED LCO921A_ NAME OF PROVIDIER OR SUPPLER B. WING STREET ADDRESS, CITY. STATE, ZIP CODE 11103/2009 CARING HANDS HOME CARE INC (X4) Ib PREFIX TAG 36 JANICE LANE SELDEN, NY 11784 PROVIDERSPLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE SUMMARY STATEMENT OF DEFICIENCIES ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION ) OR [C IENTIYIN INFRMAION)TAGDEFICIENCY) [ COMPLETE (X5) i DATE H 618 Continued From page 4 On 9/15/09 (4:00 PM to 12:00 AM) BP was noted as "135/90, HR 104". Vital signs were not repeated during tie shift. On 9/23/09 (12:00 AM to 8:00 AM) BP wasnoted as "129/99". There is no documentation of the BP being repeated during the shift. On 10/01/09 (7:00 AM to.3:00 PM), and 10/03/09 (4:00 PM to 1:00 AM). There.were no vital signs ,documented. On 10/12/09 (12:00 AM.to 8:00 AM), the BP is documented as "155/93", and (8:00 AM to 4:00 "PM) BP was. noted as "85/55". On 10/15/09 (7:00 AM to 3:00 PM) the BP is documented as: "141/101V There is no documentation of the BP being repeated during H 618 the shift. On 10/17/09 (8:00 AM to 12:00 AM) the BP is documented as: "141/102". There is no documentation of the BP being repeated during the shiftThe PT visit notes documents the following: On 6/09/09 - the pre treatment BP is documented as "151/105" and post treatment BP "133/91". On 6/18/09 - the pre treatment BP is documented as: "143196" and post treatment BP "135/93". * On 6/20/09 - the pre treatment BP is documented as: "136/95, HR 112" and post treatment BP "109/74, HR 107". The agency policy and procedure for "Clinical Supervision" lacks documentation of the date the J 1 -)I 108511 I i IfI4&.t tcontinu.ation shoet 5 ot26 Office of Health Systems Management /Office of Long Term Care STATE FORM Version NYS 11/17/2009 * New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDERISUPPLIERICLIA IDENTIFICATION NUMBER.(X2) MULTIPLE CONSTRUCTION" A BUILDIdIr W e PRINTED: 11/2012009 FORM APPROVED (X3) DATE SURVEY MPLETED LC0921A NAME OF PROVIDER OR SUPPLIER - - - 11/0312009 11/4vul, STREET ADDRESS, CITY, STE, ZIP CO CARING HANDS HOME CARE INC (X4) PREFIX TAG L% Over 36 JANICE LANE SELDEN, NY 11754 U[F[n1=I ID PREFIX TAG WWJ]A. m11 Mona i (5) COMPLETE DATE ID _ _ SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) _ _ __ PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE ,DEFICIENCY) F H 618 i Continued From page 5 j GA approved the policy and procedure. [ The "Clinical Supervision" policy and procedure documents the Ifollowing under ocumheading " Prced re the nts H 618 7~66.5 (B)(3) Clinical Supervision 8 61 8A) The nursing supervisor on designer of each case responsible for correction. B) The current nursing g supervisor and one other RN on each case has been oriented to their responsibility on their case. Weekly written nursing supervisory reports to be submitted to the director of Procedure documents:g IV "All staff delivering care in patient homes is -. Iach case shall be the responsible adequately supervised... I C. Clinical records are kept complete and changes in patient condition, adverse reactions , and problems with informal supports or home I environment are charted promptly and reported to the supervisory staff. * D. Plans of Care are revised as needed by the patient and changes are reported to the patient's physician and other staff providing care to the patient. * E. All nursing personnel must notify Caring Hands immediately with any changes in patients condition. Nursing Supervisor will address i supervision accordingly.' Changes in the plan of I care must be made to the authorized practitioner i and other agencies which authorize payment for services, as appropriate and necessary." During a'n interview with the agency Owner on 111/03/09; the Owner did not provide additionalI documentation and/or an explanation for the i' F nursing. They are to include VS review for the week. Nursing Supervisor to obtain MID orders for correct. VS parameters for . notification to MD. Each nurse and therapist to be in-serviced at home on correction by 12/15/09 C) To prevent the reoccurrence of this issue all charts will be audited monthly timeS2till 100% compliance is met. Sting I/ 10/10. Quarterly audits will be preformed to ensure compliance. D) The QI staff will develop a VS audit tool to be I * findings. SH H . 714 766.6(a)(6) Patient care record 7 included in chart review based on PStaff H 714 revised P&P clinical supervision. 766.6 Patient care record, * (a) The agency shall maintain a confidential record for each patient admitted to care to include: Office of Health Systems Management I Office of Long Term Care STATE FORM will perform audit based on an established calendar by the director of nursing. The QI staff Will generate following chart audit a written report. Findings will be presented for Ing ongoing in-services to WOntin Version NYS 11/17/2009 onnioaion o If sheet-e oi26 continue as needed. The GA/operator Itw2 PRINTED: 11f20/2009 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES. AND PLAN OF CORRECTION XI)PROVIDERISUPPLIERCLIA t IIDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A BUILDING __________ (X3)DATE SURVEY COMPLETED LC0921A NAME OF PROVIDER OR SUPPLIER B.WING STREET ADDRESS, CITY, STATE, ZIP CODE 1110312009 CARING HANDS HOME CARE INC (m) [a PREFIX TAG 36 JANICE LANE SELDEN, NY 11784 10 PREFIX TAG PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE * DEFICIENCY) (Xs) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES ((EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H 618 j Continued From page 5 GA approved the policy and procedure, H 618 to include the above I fl in its d fieiency on its calendar and rt structurig to take tilier system. Organizational The "Clinical Supervision" policy and procedure documents the following under the heading Procedure documents: IV. "All staff delivering care in patient homes is place over the Dcxt month involving upper gcmcnt. adequately supervised... .. SC C. Clinical records are kept complete and changes in patient condition, adverse reactions and problems with informal supports or home environment are charted promptly and reported to the supervisory staff.. D. Plans of Care are revised as needed by the patient and changes are reported to the patient's physician and other staff providing care to the, patient. E. All nursing personnel must notify Caring Hands immediately with any changes in patient's condition. Nursing Supervisor will address supervision accordingly.' Changes in the plan.of care must be made to the authorized practitioner and other agencies which authorize payment for services, as appropriate and necessary," During an interview with the agency Owner on 11/03/09, the Owner did not provide additional documentation and/or an explanation for the findings. H 714 766.6(a)(6) Patient care record 766.6 Patient care record. (a) The agency shall maintain a confidential, record.for each patient admitted to care to include: ,ffice of Health Systems Management I Office of Long Term Care Version NYS 11/17/2009 TATE FORM , H 714 108511 -fV - sheet Itcontinuation 6of26 PRINTED: 11/20/2009 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDERJSUPPLIERCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A BUILDING (X3) DATE SURVEY COMPLETED LCO921A NAME OF PROVIDER OR SUPPLIER B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 11103/2009 CARING HANDS HOME CARE INC (X4) ID PREFIXJ TAG 36 JANICE LANE SELDEN, NY 11784 ID PREFIX - SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) I I PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE (x5) COMPLETE DATE TAG I DEFICIENCY) H 714 Continued From page 6 (6) supervisory reports of the registered 1 professional nurse, licensed practical nurse or the therapist, if applicable, of the home health aide or personal care aide. This Regulation is not met as evidenced by: i Based on record review and staff interview, the I agency failed to ensure that the patient care record is complete and includes documentation of the Physical Therapy (PT) home visits as ordered in the Plan of Care. This was evident in one (1) of one (1) patient record reviewed (Patient #1). H 714 714 Patient care records A) All pt otes for July August and September ave been obtained and reviewed by e director of nursing. The director ofnursing cOnducted in-serviceI training with the current pt on the importance of timely submission of pt notes and review of current parameters of BP. She has signed an affidavit of the above a post training review will be administered 12/10/09 to ensure learning has occurred. B) To prevent reoccurrence of this deficiency monthly chart audits will j - / Failure to ensure that the patient's record is complete places the patient at risk for unmet needs and poor quality of care. The finding are: iPatient #1 has a re-admission date of 4/28/06 with the diagnoses including Acute Encephalomyelitis, Quadriplegia and be preformed times 2 till 100% compliance is met. Starting 1/10/10. PT notes reviewed to be included in chart audit tool. The director of nursing w inr staff in writing Tracheostomy with Ventilator Dependence. The Plan of Care dated 4/28/09 to 10/28/09 I documents an order for "PT 3 (three) times a Iweek" for "PROM (passive range of motion) via PT only". regarding the auditing process prior to commencement. D)'QI auditor will generate timely report and indings f A present finig for discussion at the PT onlemergency Q meeting on 12/15/09 I The patient care record lacks documentation of 1the.PT visit notes for July, August, September and at the quarterly QIC meetings. Ongoing in-services to continue. GA, and October 2009. During an interview on 11/03/09 with the Owner, the Owner provided the PT visit notes from I January 2, 2009 - June 29, 2009. During the the visit notes for stated that omust have survey, the OwnerJuly, August,"the PT Office of Health Systems Management /Office of Long Term Care STATE FORM Version NYS 11117/2009 to include the above deficiency on its calendar and in its Tickler system. Upper management restructuring to occur over the next month I i 108511 I,c tht 7 of 26 PRINTED: 11/20/2009 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDERJSUPPLIERCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A BUILDING (X3) DATE SURVEY COMPLETED LCO921A NAME OF PROVIDER OR SUPPUER B.WING STREET ADDRESS. CITY. STATE ZIP CODE 11/Q3/2009 CARING HANDS HOME CARE INC. (X4) ID PREFIX TAG 36 JANICE LANE SELDEN, NY 11784 ID PREFIX TAG PROVIDEIRS PLAN OF CORRECTION (EACH CORRECrIVEACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE. PRECEDED BY FULL REGULATORY OR LSC !DENTIFYING INFORMATION) DEFICIENCY) H 714 Continued From page 7 September and October 2009 on her computer". The Owner further stated that the agency's policy for visit note submission is one (1) month. The Owner did not provide additional documentation to explain the incomplete patient care record. H10021 766.9(a) Governing authority I.- H 714 HI002 766.9 (A) Governing Authority. H1002 The agencies governing body/operator has implemented the t following agency changes to improve management and operation; ensuring safe patient care, striving to meet DO-.regulatory body standards I Section 766.9 Goyerning authority. The governing authority or operator, as defined in Part 700 of this Title, of a licensed home care seryices agency shall: (a) be responsible for the management and operation of the agency; (b) ensure compliance of the home care services. by employing a quality improvement consultant as, of 12/15/09, reorganizing the quality Improvement Committee and providing appropriate staff in- agency with all applicable Federal, State and I local statutes, rules and regulations. This Regulation is not met as evidenced by: Based on patient record review, home visit, policy and procedures review, personnel record ieview and staff interview, the Governing Authority (GA) failed to ensure compliance with all applicable Federal, State, and local statutes, rules and regulations.o service, which will be ongoing: In addition the following issues have addntefolo ingsu have been addressed accordingly: Patient rights (766.1), Clinical Supervision (766.5), Patient Care Records (766.6), Governing Authority (766.9), Personnel (766.11) and Records and Reports (766.12) B) In order to prevent re-occurrence of above mentioned issues and other similar issues the agency's governing body/operator has developed a - Failure to ensure compliance with all rules and regulations, and to ensure the provision of responsible operation and management of the home care agency places all patients at risk for poor quality of care. This was evident in the following deficiencies: system to oversee individual and committee activities on an on-going 766.1 Patient-Rights 766.5 Clinical Supervision 766.6 Patient Care Record [766.9 Governing Authority Office of Health Systems Management /Office of Long Term Care STATE FORM Version NYS 11117/2009 . basis. C) A new quality Improvement Plan has been created; audit tools have been and will created on an on-going basis; a 682 e revi cd repul ting/filing system has lhbwmimplemented; the QIC meetltinuation sheet 8of26 agendanow includes standing time ; 00 PRINTED: 11/20/2009 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) ,PROM1DERtSUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A BUILDING B. WING (X3I DATE SURVEY COMPLETED LC0921A NAME OF PROVIDER OR SUPPUER STREET ADDRESS, CITY. STATE. ZIP CODE 111/0312009 36 JANICE LANE SELDEN, NY 11784 I D PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) X5) COMPLETE DATE CARING HANDS HOME CARE INC (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H o714 o Continued From page 7 September and October'2009 on her computer". The Owner further stated that the agency's policy for visit note submission is one (1) month. The Owner did not provide additional documentation to explain the incomplete patient care record. H 714 -. j H1002 766.9(a) Governing authority Section 766.9 Governing authority. The governing authority or operator, as defined in Part 700 of this Title, of a licensed home care H1002 .. allotments for the following areas: medical orders, clinical supervision, patient care, record reviews, personal reviews and an anual statistical summary reporting a - services agency shall: (a) be responsible for the management and operation of the agency, (b) ensure cof the home cae services agency with all applicable Federal, State and local statutes, rules and regulations. This Regulation is not met as evidenced by: " Based on patient record review, home visit, policy and procedures review, personnel record review and staff interview, the Governing Authority (GA) failed to ensure compliance with all applicable Federal, State, and local statutes, rules and regulations. Failure to ensure compliance with all rules'and regulations, and to ensure the provision of responsible operation and management of the home care agency places all patients at risk for poor quality of care. This was evident in the following deficiencies: 766.1, 766.5 766.6 766.9 Patient Rights Clinical Supervision Patient Care Record Governing Authority (b nuecompliance othhmecrsrvescalendar body/operator wi l utilize a reporting and filing will be preformed according to an established calendar (the HPN will be accessed on a daily basis) D) The agency's governing to see that all areas of concern are addressed in a timely manner by the. appointed personnel rid take immediate action if/when there is variance.GA to include the abve i inc y o i clude and above deficiency on its calendar and in its Tickler system. Upper management restructuring to occur over the next month. / Office of Health Systems Management / Office of Long Term Care STATE FORM Version NYS 11/17/2009 108511 Ifconinution sheet 8 of 26 New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION. (Xl) PROVIDER)SUPPLIERICLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING PRINTED: 11/20/2009 FORM APPROVED (X3) DATE SURVEY COMPLETED LCO921A NAME OF PROVIDER OR SUPPLIER B. WING 11/0312009 STREET ADDRESS. CITY, STATE, ZIP CODE CARING HANDS HOME CARE INC (X4) ID PREFIX TAG SELDEN, SE6DEN, NYN '11784 L 1 ID PREFIX TAG 36 JANICE LANE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) J PROVDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCEDTO THE APPROP I AT 1 0(5) COMPLETE DATE ~DEFICIENC) H1002 Continued From page 8 766.11 Personnel 766.12 Records and Reports I. H1002 H10061 766.9(c) Governing authority Sction76revisions Section 766.9 Governing, authority. The governing authority or operator, as defined in Part 700 of this Title, of a licensed home care services agency shall: (c) ensure the development of a written H1006 1006 766.9(C) Governing authority 'Emergency management and disaster plan isn't complete" "No of P&P manual" "Criminal History Record Check lacks info" A) be agency's governing body/operator isthe designated body to ensure continued'compliance to corrective action has been taken; The has been assigned to review the individual emergency plan for the audit patient A date of 12/14/09 has been given and the plan is to be ...... . deficiency H1006 B) The following procedures to be followed to assure health care needs of patients continue to be met in emergencies that interfere with delivery of services, and orientation of all em loyees to their responsibilities in carrying out such a plan. emergency plan which-is current and includes This Regulation is not met as evidenced by: Based on record review of the agency's emergency plan, policy and procedure and staff interview, the Governing Authority (GA) failed to. develop a complete emergency plan. Failure to develop a complete emergency plan places all patients at risk for not having their needs met in an emergent situationThe findings are: The agency "Emergency Management and Disaster Preparedness Plan" (Policy VII-18) lacks documented evidence of a call down list of agency staff, a contact list of community partners, collaboration with community partners in planning efforts and participation in disaster drills and sbitdt s h mrec I meeting on 12/15/09. The director of nursing has been assigned the task of. implementing and updating the "Emergency Management and Disaster Plan" to include a call down list contact with community partners and participating in a disaster drill n exercises. Disaster drill to take place December 20 2009.The month of Decem be mare on o Jany has been marked on the QI calendar for an entire P&P review. The QIC Committee has been notified and have agreed to attend. te exercises. The emergency plan lacks policies and procedures addressing the procedure for Office of Health Systems Management / Office of Long Term Care STATE FORM Version NYS 11/17/2009 onservices to CHHC employees to occur after Jan.31, 2010.esgoing inservices as needed. C) To prevent reoccurrence of issue/ the emergency preparedness plan of the agency is to C l?OS1eviewed quarterly at the Q! conbnuation sheet 9ot 26 committee meeting. Quarterly/j, (j z)/7 PRINTED: 11/20/2009 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X) PROVIDERISUPPLIERICLIA. IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A BUILDING ___________ (X3) DATE SURVEY COMPLETED LCe921A NAME OF PROVIDER OR SUPPUER B. WING STREET ADDRESS, CITY. STATE, ZIP CODE 1110312009 CARING HANDS HOME CARE INC (X4) ID PREFIX TAG 36 JANICE LANE SELDEN, NY 11784 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) VS) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H1002 Continued From page 8' 76611 Personnel 766.12 Records and Reports H1006 766.9(c).Governing authority Section 766.9 Governing authority. The governing authority or operator, as defined in Part 700 agencyTitle, of a licensed home care services of this shall:,teG service awill H1002 H1006 written report isto be submitted to the GA review quarterly D) Auditor eiwqatryD uio generate timely reports and present findings for discussion in the quality improvement meeting. On going in-services to continue.GA to include the above deficiency on its calendar and in its Tickler -,ysem. (c) ensure the development of a written emergency plan which is current and includes procedures to be followed to assure health care needs of patients continue to be met in emergencies that interfere with delivery of services, and orientation of all employees to their responsibilities in carrying out such a plan. This Regulation is not met as evidenced by: Based on record review of the agency's emergency plan, policy and procedure and staff interview, the Governing Authority (GA) failed to develop a complete emergency plan. Failure to develop a complete emergency plan places all patients at risk for not having their needs met in an emergent situation. The findings are: The agency "Emergency Management and Disaster Preparedness Plan" (Policy VII-18) lacks documented evidence of a call down list of agency staff, a contact list of community partners, collaboration with community partners in planning efforts and participation in disaster drills and exercises. The emergency plan lacks policies and procedures addressing the procedure for Office of Health Systems Management I Office of Long Term Care STATE FORM Version NYS 11/17/2009 108511 If mn Iheet 9of I26 PRINTED: 11/20/2009 New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A BUILDING FORM APPROVED (X3) DATE SURVEY COMPLETED ___ LC0921A NAME OF PROVIDER OR SUPPLIER B.WING________ STREET ADDRESS, CITY, STATE, ZIP CODE 11/03/2009 36 JANICE LANE SELDEN, NY 11784 IO PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) CARING HANDS HOME CARE INC (X4) IO PREFIX i TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) i I (X5) COMPLETE DATE H1006 Continued From page 9 maintaining the agency's call-down list and the I procedure for the agency to respond to requests I for information by community partners in an emergency, annual review and update of plan i and orientation of staff.' During interview with the agency's Owner on 11/03/09, the Owner did not provide an explanation for the incomplete emergency plan. H1006 [11008 Governing authority A) the governing body operator of the agency is to develop a new policy for criminal history checks. Tlhis is to include supervision of temporary staff and the scanning of finger printing cards. B) To prevent H1008 I H10081 766.9(d) Governing authority i Section 766.9 Governing authority. The governing authority or operator, as defined in Part 700 agencyTitle, of a licensed home care services of this shall: sevice agncy shalPolicy I policies regarding the management and operation reoccurrence of this issue the CHRC policy is to be completed and reviewed at the January 22 QIC committee meeting. C) The agency's quality improvement staff will develop a audit tool to include an uitto oicue -heeo, and procedure review. The review process will be ongoing D) The QIC committee to submit its quarterly report to the governing . (d) adopt and approve amendments to written of the home care services agency and the * I This Regulation is not met as evidenced by: Based on record review and staff interview, the Governing'Authority (GA) failed to maintain written policies and procedures which are current and complete. This was evident for the agency policy and procedure manual. Failure to maintain current and complete policies and procedures places the patients at risk for provision of health care services. caresevices.authority for review and acceptance. to prevent a repeat deficiency again all information to be reviewed by the newly appointed QIC Czar fbr acceptance by 1/22/l0.Ongoing inservices to continue. A to include the above deficiency on its calendar and in its Tickler system. Physician poor quality of care. iThe findings are: appointed on the QIC to review this policy individually for suggestions. 1) The agency policy and procedure manual lacks documentation of review and revision since the year 2007. * STATE FORM 2) The policy and procedure for Criminal History Version NYS 11/17/2009 ____ _____________________ Office of Health Systems ManagementI Office of Long Term Care UM 10f11 1iuti 21 01 ~a~tM/a PRINTED: 11/2012009 New York State Department of Health. STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMER: (X2) MULTIPLE CONSTRUCTION A BUILDING FORM APPROVED (X3) DATE SURVEY COMPLETED B. WING _ LCO921A NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE, ZIP CODE 1110312009 36 JANICE LANE CARING HANDS HOME CARE INC (X4) ID PREFIX TAG - SELDEN, NY,11784 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) I (XS) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) I ___I H1008 Continued Fr:om page 10 i H1008 Record Check (CHRC) lacks documentation that .the policy was reviewed to include the changes in the policy regarding the supervision of the temporary staff, and the scanning of finger printing cards. During an interview with the agency's Owner on and incomplete. . H1014 766.9(G) Governing uthority A) The agency's governing authority/operator has initiated contact with a local agency f for a contract for ancillary services. p I-1IFLA,ST,OT and MSW B) To prevent re-occurrence of this issue pre QIC reoccurreemeeting is to ofetis issue the committee include review of contracts in the QIC quarterly meeting C) The agency's quality improvement staffwill develop an audit tool based o the need of this repeated DOH deficiency. A designated QIC will perform audits. The designated member will notify is" brwlloifis writing to the GA/operator for the review. D) The corrective action to ensure this repeat practice will not occur again is the findings are to reviewed monthly times 2 fill 100% compliance is met. By the newly appointed QL/Czar. The agency's governing body/operator will utilize areas of concern have been addressed and take immediate action if deemed necessary I 11/03/09, the Owner did not provide an I explanation for the policies not being reviewed I ,agencies REPEAT DEFICIENCY FROM 7/17/2007. SURVEY -on I H1014 766.9(g) Governing authority .Smember Section 766.9 ro Governing'authority.deintdm The governing authority or operator, as defined in I Part 700 of this Title, of a licensed home care services agency shall: (g) employ or contraet for a sufficient number of I staff to coordinate, direct and deliver services to patients accepted for care in accordance with prevailing standards of professional practice. This Regulation is not met as evidenced by: Based on record review and staff interview, the Governing Authority (GA) failed to employ or contract staff to provide the services identified on the agency's license. This was evident for personnel files/contracts for Speech Language Pathology (SLP), Occupational Therapy (OT), Medical Social Work (MSW), and Home Health Aide (hha) services. Failure to employ or contract staff to provide SLP, OT, MSW, and hha services places patients at risk for not having their care needs met Office of Health Systems Management/ Office of Long Term Care STATE FORM Version NYS 11/17t2009 - H1014 reporting calendar to see that all C.- 7< 108511 A/ if continuationsheet 11 of'26 PRINTED: 11/20/2009 FORM APPROVED New York State Department of Health STATEMENTOF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDERISUPPLIERCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING o_" (X3) DATE SURVEY COMPLETED LCO921A NAME OF PROVIDER OR SUPPLIER * RWING__________ 1110312009 STREET ADDRESS. CITY. STATE, ZIP CODE CARING HANDS HOME CARE INC (X4) ID PREFIX TAG SELDEN, NY 11784 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 36 JANICE LANE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H1014 Continued From page 11 The finding are: The personnel records and/or contract for the SLP, OT, MSW and hha Services identified on the agency's license wererequested. The agency's Owner did not provide the information requested. During interview with the agency's Owner on 11103/09, the Owner stated that she "does not have" a personnel files or contracts for these H1014 H1036 766.9 (1) Governing authority A) The-agencies governing body/operator has implemented the following agency changes to improve management and operation insuring safe patient care, striving to. meet DOW regulatory body standards by employing a QI Czar Catherine McLaughlin RN... A. QI czar has been immediately retained services at this time. REPEAT DEFICIENCY FROM 7117/2007 SURVEY . .I and all current deficiencies have been reviewed with her. She has greed to an emergency meeting on 12/15/09. Monthly review of Hi036 766.9(I) Governing authority Section 766.9,Governing authority. H1036 required records will be done times 2. till 100% compliance is met.. Also " The governing authority or operator, as defined inp Part 700 of this Title, of a licensed home care . services agency shall: will initiate QIC meetings quarterly.A physician has been retained for the QIC Committee.He as agreed to met Quarterle and to be ....... (I) appoint a quality improvement committee to available for consulting when necessary.Dr.Brent Spers/107 establish. and oversee standards of care. The quality improvement committee shall consist of a consumer and appropriate health professional persons including a physician if professional health care services are provided.The committee shall meet at least four times a year to: S(1) review policies pertaining to the delivery of the health care services provided by the agency and recommend changes.in such policies to the governing authority for adoption; (2) conduct a clinical record review of the safety,. adequacy, type and quality of services provided b erkssare.Dr.BFrn berkshire Dr. Farmingville NY 11738/Tel 63,1-9285800/Lic#147779. B) In order to prevent reoccurrence of the repeat eficiency H1036 the QI plan created and overseen by the newly appointed QI. czar. She will.oversee individual and committee activity on an ongoing basis C) The tools used are to be a revised reporting system for the QIC including monthly vll Npr Yl which includes: Office of Health Systems Management IOffice of Long Term Care Version NYS 11/17/2009 STATE FORM record audits for 100% compliance meeting agenda will now include a 1'" ician and consumer. The It continuation sheet 12 of 26 operator of the agency i nw 'PRINTED: 11/20/2009 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPUER/CLIA IDENTIFICATION NUMBER: MULTIPLE CONSTRUCTION (X2) L A BUILDING _ (X3) DATE SURVEY COMPLETED LC0921A, NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY. STATE, ZIP CODE 1110312009 CARING HANDS HOME CARE INC (X4) IO PREFIX TAG 36 JANICE LANE SELDEN, NY 11784 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) I - ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE H1036 Continued From page 12 (i) random selection of records of patients currently receiving services and patients discharged from the agency within the past three months; and '(ii) all cases with identified patient complaints as specified in subdivision (j) of this section; (3) prepare and submit a written summary of review findings to the governing authority for necessary action; and (4) assist the agency in maintaining liais6n with other health care providers in the community. This Regulation is not met as evidenced by: Based on record review and interview, the Governing Authority (GA) failed to ensure that the Quality Improvement (QI) committee met four " H1036 actively putrsuing a consumer. acte p)ruige cove advocate. D) The QI above corrective action will be now Be agency's governing body/operator overseen by the newly appointed QI czar Catherine McLaughlin RN. The times a year; includes a physician and a consumer and patient care records/ policies/procedures are reviewed. This was will utilize the reporting calendar to see that this deficient practice does evident for the Quality Improvement (01) meeting minutes. Failure of the quality improvement committee to establish and oversee standards of care places patients at risk for receiving poor quality care: The findings are: not happen again.This Deficent practice will be included in the GA Tickler system. I 1)The 01 meeting minutes from the year 2008 present were requested during the entrance conference. The Owner provided one (1) meeting dated "February 5, 2009". There is no documented evidence of QI meetings conducted in the year 2008. Office of Health Systems Management/ Office of.Long Term Care STATE FORM Version NYS 11/17/2009 * ,* 108511 , A./ , Itination sheet 13 of 26 New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLJER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING PRINTED: 11/20/2009 FORM APPROVED (X3) DATE SURVEY COMPLETED LCO921A NAME OF PROVIDER OR SUPPUER B:"WING ___________ 11/03/2009 STREET ADDRESS, CITY, STATE, ZIP CODE CARING HANDS HOME CARE INC (X4) ID PREFIX TAG , 36 JANICE LANE SELDEN, NY 11784 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) .XS) j COMPLETE DATE I SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H1036! Continued From page 13 2) The Qi meeting minutes dated 2/05/09 does not include documented evidence of physician and consumer attendance. 3) There is no documented evidence that the agency reviewed policies and procedures i pertaining to the delivery of the health care services provided by the agency. The QI meeting minutes lack documentation that the agency conducted a clinical record review of the active I patient, and any discharged patients in the past three (3) months. I During an interview with the agency's Owner on H1036 1 11/03109; the Owner stated that agency "had not 1conducted" any meetings in 2008. The Owner stated that she "does not currently" have a physician and consumer for quarterly meeting minutes. REPEAT DEFICIENCY FROM 7/17/2007 .SURVEY H1142! 766.9(o) Governing Authority o Section 766.9 Governing authority (o) Health Provider Network Access and Reporting Requirements. The governing authority o or operator of an agency shall obtain from the Department' s Health Provider Network (HPN),' HPN accounts for each agency that it operates and ensure that sufficient, knowledgeable staff will be available to and shall maintain and keep current such accounts. At a minimum, twenty-four hour, seven-day a week contacts for emergency communication and alerts, must be designated by each agency in the HPN Communications Directory. A policy defining the agency ' s HPN H1142 i - coverage consistent with the agency' s hours of Office of Health Systems Management I Office of Long Term Care STATE FORM Version NYS 11/17/2009 . se 108511 /(1 If'ontinuatonsheet 14of26 o o1 PRINTED: 11/20/009, New- York State Department of Health STATEMENT OF DEFICIENCIESPPoVIDERWSUPPUER/CIA (XI) AND, PLAN OF CORRECTION: IDENTIFICATION NUMBER: .. ... .. , .'.-. FORM APPROVED " (X2) MUI TIPLE CONSTRUCTION,% -" A BUILDING W , ,2 .... IB. INGi . (XDATE SURVEY COMPLETED _" - _ -, ; " , NAME OF PROVIDER OR SUPPLIER , - LC092iA B". . 1110312009: STREET ADDRESS CITY.,STATE; ZIP CODE, * CARING HANDS HO1ME CARE UNC - (X4) lID." "-ISUMMARY STATEMENT OF DEFICIENCIES 36 JANICE.LANE SLEN 18 ID - PROVIDERSPLANOFCORRECION ' (xs - PREFIX TAG 4 (EACI-.OEFIClENCYMUST8EPRECEDEDBYFULLREGULATORY OR LSC IDENTIFYING INFORMATION) ' PREFIX TAG (EACH CORRECTIVE ACTION SHOULD BE COMP TO THE AP PCROS-REFERENCED ETE PRIATE DATE DEFICIENCY> I". - Hi . 2 Continued F om page 14 a b te operation shall be created and reviewed by the 1142 ' "., '!' -: ' ' -.. ". ' < "" . :;" ' agency no less than annually. Maintenance of each agenrcy sHPN aCcountS shall consist of, I but not be limited to, the following: (1) sufficient designation of the agency's HPN coordinator(s) to allow for HPN individual user, application; 11 42 776.9: (0) "ITPI' 1 resnsib.ed sig A),Te goverping bdloerator wil be the e for th "' ' o : :: [ '- ' , ~ activities and occurrences tillal -IPN, coordinator is retained by the 12/1./09lQIC m'etngB) To prevent o ' t - ~occurrences oftegoenng: .. ', .. ,: . " (2) designation by the governing authority or opeatosufficient staff users of geny of ofan opeator of an agency o sbody/operator the HPN accounts to ensure rapid response to' " requests for information by the State and/or local o.the g n : .o of the agency t- f a. :' t aigc revewvand plan HPN'taini , , new coordinator and Ql'in-servces - Department of Health; ', o - i o. .. ... ., ' ', 7 . ;: '., " (. 83) adherence to the requirements of the HPN user contract; and - ': . regarding 1-WN maintenance. To ... highly: acdiess'this ielieditdetkciency. h ighly ae tis ioodiciency . fr 7/17/0 a -.. ..d...... . must be,trained prompny. and issu a speiiceeiod for regtlatirybodyupdates:and discussions will be -Ancluddeo n.the QLC. meet . v~ included ro me QK .. , me. m tartif.. ... 12/15. f,s i ' the"of . designated to accessgheHv?,Nsystm to beatngcirmg). Tfhe Gsvrnn " ' .. - "14 ""' " ' current and c6mplete updates of the -Communications Directory reflecting changes " ;.1; oo that include, but arenot limited to, general ." InformatIon and personnel role changes as soon -l as they occur, and at a minimum, on a monthly , b asis. . : ~~.. ,s euation- i'n~ ..met as evidenced, by, Reult-, -e is'not ,s ,: .vdfie _" .: :7 by o IS, - " , : -Tdm b datalepdn ! IPN an.6 e '' yoperaorwillpresentpertent: . data r-..rdn i a.d.-.e: ' .... " . - "Based oi record review and, staff interviwi het, aeny,fai!kd to develop complete Policy and ] proce-dlure-n r~..aihtain a complete, ., .,. 1_ regulatory'bdy inforpatioi-7i te , QIC nieeting. D) TheCgo.vemg reiew times 2 till 100% compliane is achciccd.of I-IPN c-mplian. and accordingly. Ongoing in-services to continue. The GA to-include the itsT ckler system. ) 1085 CommunicatiOr Directory This was evident for: o .| body/operator. will perform monthly I the agency 's "Emergency Management and, I Disaster, Preparedness Plan" and Health Provider N etw o r ( H ON )a cc o un t , .o ": " ,ao Netor k " ..... . . lS a~ regulatory body information ], . " " other l l v a O ! Y c m u n e a ( . S procedures:and maintaia.,complete- Failuire to develop complete policy and Commun'ication. Directory places the agency for., not receiving information from the Department of Health necessary for the operation of the agency, abOVe deliiencyonits cakndar and Office of Health Systems Management / Office of Long: Term Care STATE FORM Version NYS 11/1712009: "c,,.JiJ , -/ ./Lj... .. Conbhuaionsheet 15 of 2P PRINTED: 1112012009 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING B. WING LCO921A NAME OF PROVIDER OR SUPPUER 110312009 STREET ADDRESS. CITY. STATE, ZIP CODE CARING HANDS HOME CARE INC (X4) ID i PREFIX i TAG 36 JANICE LANE SELDEN, NY 11784 . SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) D PREFIX TAG H1142 PROMiDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (xs) COMPLETE I DATE H11421 Continued From page 15 Qflc eP (-c--& . ] The findings are: * 1)The agency policy and procedure for "Emergency Management and Disaster Preparedness Plan" includes the title of the hand i written one word "HPN" on the same policy and procedure. The policy includes two (2) statements regarding the HPN. The statements are:. 1) "B.Emergency * and Disaster Preparedness", documents that the agency will "Participation in the NYS DOH HPN System" and 2) the "Owner", "RN is the designated person for maintenance of the HPN. account. In her absence the designated person i will be" ... "RN/VP of Operation". 2) The agency Communication Directory lacks documentation of the agency's 24 by 7 Contact; Ithe Office the Administrator; the Director of Patient Services; the Governing Body President and members; HPN Coordinator; Criminal History Record Check Authorized Person; Emergency. , Response Coordinator and all positions identified 1for the Home Care Registry. 3) The "Contact Information for Caring Hands Home Care, Inc." on the HPN documents an . incorrect telephone.for the agency. The documented number: "631-218-8761" is not inservice. InI During an interview with the agency's Owner on 11/03/09, the Owner stated that the correct number for agency is "631 736-3073". The Owner provided no explanation for the incomplete Communication Directory and incorrect agency number documented on the Office of Health Systems Management I Office of Long Term Care STATEFORM Version NYS 11/17/2009 108511 -, " It$'ircontinuation sheet 16 of 26 PRINTED: 11/20/2009 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDERISUPPLIERICLA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION - A. LCO921A NAME OF PROVIDER OR SUPPLIER (X3) DATE SURVEY COMPLETED BUILDING B. WING STREET ADDRESS, CITY,STATE, ZIP CODE 1110312009 CARING HANDS HOME CARE INC (X4) ID PREFIX TAG 36 JANICE LANE SELDEN, NY 11784 ID PREFIX TAG ' PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H11421 Continued From page 16 H1142 HPN. o [ IREPEAT DEFICIENCY FROM 7117/2007 H1330 766.11 (D) (4) personnel A) The director of nursing should SSURVEY H1330 766.11(d)(4) Personnel I i 766.11 Personnel. H1330 ensure that all PPD's are current on all personnel B) The director of nursing has obtained alt up to date PPD's on all current employees. I The governing authority or operator shall ensure for all health care personnel: ' Available to the DOH upon request. C) The QI Czar to monitor staff files monthly times 2 till 100% compliance is met. Starting 12/10/09. Then quarterly there after. The (d)that a record of the following tests, examinations or other required documentation is maintained for all personnel who have direct Director of nursing will inform staff process prior to commencement. D) Auditor will generate timely reports and present findings for discussion in the QIC meeting. Ongoing inserices to continue. Upper management restructuring to occur over the next month. A to include the above deficiency on its calendar and in its Tickler system. contact: (4) ppd (Mantoux) skin test for tuberculosis prior to assuming patient care duties and no less than every year thereafter for negative . Ifindings. Positive findings shall require appropriate I clinical follow up but no repeat skin test.The agency shall develop and implement policies regarding follow up of positive test results. I This Regulation is not met as evidenced by: Based on record review and staff interview, the Governing Authority (GA) failed to ensure that all I personnel have annual PPD/Mantoux skin tests for Tuberculosis. This was evident in four (4) of ipatient n writing regarding the new auditing (if OJe__- ' liB-I. j eight (8) personnel records reviewed (Employees #5, #6, #7 and #8). iFailure to ensure that all personnel have the required annual PPD (Mantoux) skin test, places the patients at risk for possible exposure to communicable disease. The findings are: 1) Employee #8 Registered Nurse (RN) has a Office of Health Systems Management/ Office of Long Term Care STATE FORM Version NYS 11/1712009 108511 If contnuation sheet 17 of 26 PRINTED: 11/20/2009 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING _____ _____ (X3) DATE SURVEY COMPLETED LCO921A NAME OF PROVIDER OR SUPPLIER B. WING STREET ADDRESS, CITY, STATE. ZIP CODE 11103/2009 CARING HANDS HOME CARE INC (X4) ID PREFIX I TAG I 3JAE NE ISELDEN, NY 11784 ID PREFIX 'TAG , PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETE DATE (X5) 36 JANICE LANE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H13301 Continued From page 17 1hire date of 3/06/09. The personnel record lacks documentation of the required ppd skin test prior to employment. 12) Employee #5 (RN) has a hire date of 7/30107. The personnel record lacks documentation of an I annual required PPD for the year 2009. 3) Employee #6 (RN) has a hire date of August 2007. The personnel record lacks documentation of an annual PPD for the year 2009. I 4) Employee #7 (RN) has a hire date of 4/24/06. I H1330- S The personnel record lacks documentation of the required PPD prior to employment and annually. During an interview on 11/03/09 with the agency Owner, the Owner did not provide an explanation for the employees not receiving PPD/Mantoux testing. H1332 1 766.11 (d)(5) Personnel 766.11 Personnel. The governing authority or operator shall ensure for all health care personnel: H1332 1(d) that a record of the following tests, I examinations or other required documentation is maintained for all personnel who have direct (5) an annual, or more frequent if necessary, health status assessment to assure that all personnel are free from any health impairment that is of potential risk to the patient, family or to employees or that may interfere with the I patient contact: performance of duties. This Regulation is not met as evidenced by: Office of Health Systems Management I Office of Long Term Care STATE FORM Version NYS 11/1712009 Ifcontinuaton sheet 18 of 26 PRINTED: 11/20/2009 New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING FORM APPROVED (X3) DATE SURVEY COMPLETED LCO921A .. NAME OF PROVIDER OR SUPPLIER WING STREET ADDRESS, CITY, STATE. ZIP CODE 1110312009 CARING HANDS HOME CARE INC (X4)ID TAG 36 JANICE LANE SELDEN, NY 11784 ID PREFiX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) . COMPLETE DATE I SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H1332.Continued From page 18 Based onrecord reviews and staff interview, the 1 agency failed to perform annual health assessments for employees. This was evident in three (3) of eight (8) personnel records reviewed. I (Employees #5, #6, and #7) .nua H1332 () 1332 766.110) (5) Personnel A)y e director of nursingshall ensure hat all personnel have a complete health assessment. B) The Failure to perform annual health assessments forall employees places all patients at risk for exposure I potential health risks. The findings are: il tdirector of nursing has obtained up to curenl ele pes onnel l currently employed personnel/ available to the DOH upon their request. C) The newly appointed I1)Employee #5 is a Registered Nurse (RN) with a hire date of July 30, 2007. The personnel record lacks documentation of an annual health assessment for the year 2009. The last QIC Czar to monitor staff files monthly starting 12/10/09- monthly at times 2 till 100% compliance is to be updated as necessary The i documented health assessment is dated "September 2008". met, then quarterly. QI auditing tool director of nursing will inform the staff in writing regarding the new 2) Employee #6 is a RN with a hire date of August 2007. The personnel record lacks documentation of an annual health assessment I for the year 2009. The last documented health I assessment is "9/22/08". 3) Employee #7 is a RNwith a hire date of 4/24/06. The personnel record lacks documentation of pre-employment health assessment for year 2006 and annual health assessments for years 2007, 2008 and 2009. ~month. I auditing process prior to commencement. D) The governing authority will include the deficiency Hi132 in its tickler calendar. The QI czar to provide Written reports monthly or quarterly as needed. Upper management restructuringGA occur over the next The to )operator to include m 1 11/03/09, the Owner did not provide an explanation for the lack of annual employee health assessments: H1350! 766.11 (k) Personnel 766.11 Personnel. Office of Health Systems Management / Office of Long Term Care During interview,with the agency's Owner on Hl 332 on its Calendar and in its Tickler system. i H1350 STATE FORM Version NYS 11/17/2009 U BOW 108511 9 " bA u Ifcontinuation sheet 19 of 26 New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDERISUPPUERiCLA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A.COMPLETED A. BUILDING B. WING PRINTED:1 1/20(2009 FORM APPROVED (X3) DATE SURVEY LCO921A NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11103/2009 36 JANICE LANE SELDEN, NY 11784 ID ,PREFIX TAG I PROVIDERs PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) I CARING HANDS HOME CARE INC (X4) ID PREFIX 1 TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) I COMPLETE DATE H13501 Continued From page 19 1The governing authority or operator shall ensure H1350 " . - I I for all health care personnel: (k) that an annual assessment of the t. H1350 766.11 (K) Personnel A) The director of nursing.shall ensure that all personnel have complete up to date annual performance assessments B) The director of nursing has obtained all up to date annual in home performance assessments oh all currenty employed personnel available to-DO1 upon request. C) The newly appointed QIC czar to monitor employee files monthly times 2 till 100% compliance is obtained. Then quarterly QI auditing tool to.be updated as necessary. The director of nursing will inform the staff in writing regarding the new auditing process prior to I performance and effectiveness of all personnel is conducted including at least one in-home visit to observe performance, if applicable. This Regulation is not met as evidenced by: Based on record reviews and staff interview, the agency failed to complete annual assessments of the performance and effectiveness of personnel F which includes at least one in-home observation. ,This was evident for two (2) of seven (7) iemployees requiring annual performance evaluations (Employees #4 and #7). Failure to perform an annual'performance assessment of staff which includes at least one iin-home observation places all patients at risk for i I I I poor quality care. SThe findings are: . commencement D) Upper 1). Employee #4 is a Physical Therapy (PT) with a re-hire date of 10121/06. The personnel record 1lacks annual performance assessments for years management restructuring will occur over the next month. The GA will 2007 nd 208. .include deficiency H11350 on its calendar ad in its Tickler system. The QI Czar to provide written monthly report or quarterly as needed. L l){ CC3jO AC -" 2) Employee #7 is a Registered Nurse (RN) with a hire date of 4/24/06.. The personnel record lacks annual performance assessments for years 1 2007 and 2008. During an interview with the agency's Owner on 11/03/09, the Owner did not provide an explanation for the missing performance assessments. REPEAT DEFICIENCY FROM 7/17/2007 SURVEY Office of Health Systems Management I Office of Long Term Care STATE FORM Version NYS 11/17/2009 I ,4 ) YO U . of 26 108511 ontnuaton sheet ,iv- PRINTED: 11/20/2009 New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER!SUPPUER/CLIA IDENTIFICATION NUMBER* (X2) MULTIPLE CONSTRUCTION A. BUILDING FOR MAP PRO VED (X3) DATE SURVEY COMPLETED LCO921A NAME OF PROVIDER OR SUPPLIER B. WING 11/0312009 S rREET ADDRESS CITY, STAT E. ZIP CODE CARING HANDS HOME CARE INC (X4) I PREFIX TAG SELDEN, NY 11784 ID PREFIX TAG . " 36 JANICE LANE / PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE oDEFICIENCY) I X5) COMPLETE DATE I T SUMMARy STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H13541 766.11(1)(1) Personnel H1354 766.11 Personnel. ] fIor all health care personnel: 6 o o The governing authority or operator shall ensure 1354 766.11 (1) Personnel A) director of nursing shall be the The dectr ingsal be designated individuwl responsible for the implementation of a Caring II 1(1) that a program is implemented and enforced for the prevention of circumstances which'could result in an employee or patient/client becoming exposed to significant risk body substances which could put them at significant risk of HIV or other blood-borne pathogen infection during the provision of services, as defined in sections 63.1 and 63.9 of this Title. Such a program shall I include: , I barriers during job-related activities which involve, or may involve, exposure to significant risk body substances. Such preventive action shall be taken by the employee with each patient/client and shall constitute an essential element for the prevention of bi-directional spread of HIV or other blood-bome pathogen; (ii) use of scientifically accepted preventive practices during job-related activities which involve the use of contaminated instruments or . Hands Home Care in-service of blood-borne pathogens related risks and health carc workers infection control state mandated in-service. B) According to the agency's personnel policy all staff will receive annual blood borne pathogen in-services and infection control in-services. All current employees of Caring Hands c t y f g Home Care have been in-serviced (i).use of scientifically accepted protective and updated on. infection control and blood bomc pathogens. Available to DOH upon request. All staff has received a written notification of this update in the. policy and Procedure. C) The new QIC Czar to review monthly 2 times till 100% compliance is met. In-services to be included on The employee audit tool staff to be notified in writing of the equipment which may cause puncture injuries; and (iii) training at the time of employment and yearly staff development programs on.the use of protective equipment, preventive practices, and changes in in-services by 12/10/09. QIC to meet and discuss findings at QIC meeting. D) The 12/1 governing body/operator to include . 125/09 circumstances which represent a significant risk for all employees whose job-related tasks involve, i or may involve, exposure to significant risk body substances; ; Office of Health Systems Management / Office of Long Ternm Care STATE FORM Version NYS 11117/2009 I DOH deficiency H1354 on the GA calendar and tickler system QIC to review. Qic minutes to be reviewed - ongoing. ongoing. 108511 If se 21 of 26 PRINTED: 11/20/2009 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPUERCLIA IDENTIFICATION NUMBER (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED LCO921A. NAME OF PROVIDER OR SUPPLIER B. WING 11103/2009 STREET ADDRESS, CITY, STATE, ZIP CODE 36 JANICE LANE CARING HANDS HOME CARE INC (X4) ID PREFIX i TAG I SELDEN, NY 11784 ID PREFIX TAG I I SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL o REGULATORY OR LSC IDENTIFYING INFORMATION) j PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) I COMPLETE DATE H13541 Continued From page 21 (iv) provision of personal protective equipment for employees which is appropriate to the tasks being performed; i (v) a system for monitoring preventive programs to assure compliance and safety. This Regulation is not met as evidenced by: Based on personnel record reviews and staff interview, the agency failed to ensure that employees receive annual Standard Precautions training- This was evident in four (4) of eight (8) personnel records reviewed. (Employees #1, #2, #7, and #8) Failure to ensure that employees receive the required annual in-service places patients at risk for poor quality care. I H1354-- LCP-]C / I The findings are: I" I 1)Employee #8.Registered Nurse (RN) has a hire date of 3/06/09. The personnel record lacks documentation that the employee received Standard Precautions training during orientation. .2) Employee #1 RN has-a hire date of April 2006. The personnel record lacks documentation of the 1 required annual Standard Precautions training for the years 2007 and 2008. 3) Employee #2 is a RN with a hire date of 4115/06. The personnel record lacks documentation of the required annual Standard Precautions training for years 2007 and 2008. 4) Employee #7 is a RN with a hire date of 4/24/06. The personnel record lacks documentation of the required annual Standard Precautions training for years 2007 and 2008. Office of Health Systems Management I Office of Long Term Care STATE FORM Version NYS 11/17/2009 689 108511 Ifoninuatin s et 22of26 PRINTED: 11120/2009 New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDERJSUPPLIERJCLIA IDENTIFICATION NUMBER " (V2)MULTIPLE CONSTRUCTION FORM APPROVED (X3) DATE SURVEY COMPLETED LCO92IA LCO921A NAME OF PROVIDER OR SUPPLIER ~~~B. WING___________ s11/03/2009 A BUILDING __________ STREET ADDRESS. CITY, STATE, ZIP CODE CARING HANDS HOME CARE INC (X4) ID PREFIX TAG 36 JANICE LANE SELDEN, NY 11784 ID 'PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) I COMPLETE DATE (x5) H1354; Continued From page 22 During an interview with the agencys Owner on 11/03/09, the Owner did not provide an explanation for the employees not receiving Standard Precautions training. I H1354 -o H1432 766.12 (A) (3) Records and repots A) The newly appointed czar Catherine McLaughlin is the designated individual responsible for H1432i 766.12(a)(3) Records and reports .766.12 Records and reports.. (a) The governing authority or operator shall ensure the prompt.submission of all records and reports.required by the department and that: (3) at a minimum, the following reports and records are retained by the home care services agency and available to the department upon IH1432 . correction and compliance of DOH repeated deficiency from 7/17/07 B) An emergency QIC meeting has been scheduled for 12/15/09 QIC is to include C.M. RN (czar) B.D. RN (dir. Of Nsg) and another member to be named. All DOH deficiencies, corections, chart audits and employee file audits to be reviewed by the GAC on 12/20/09 C) QIC request: minute review to be included on the GA calendar and tickler system. D) The governing body! operator will perform biannual review of minutes to ensure the QIC has adequately covered QIC meeting and other regulatory body information accordingly. Upper managemcnt changes to occur over the next month. (i) minutes of the meetlngs of the governing authority and the committees thereof which shall be retained for three years from the date of the 1 meeting; (ii) records of alJ financial transactions directly related to delivery of patient care which shall be retained three years from the date of the transaction;. (iii) personnel records, which shall be retained three years from the date of, employee termination or resignation; (iv) records of grievances which shall be retained for three and complaints date of years from the resolution; services; and (v) all records related to patient care and (vi) any other records required to be kept by this Office of Health Systems Management / Office of Long Term Care STATE FORM Version NYS 11/17/2009 106511 b t sheet 230r26 PRINTED: 11/20/2009 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROV1DERJSUPPLiERCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED ,_- LC0921A NAME OF PROVIDER OR SUPPLIER B.WING STREET ADDRESS, CITY, STATE, ZIP CODE 11103/2009 CARING HANDS HOME CARE INC (X4) JD PREFIX I TAGI SUMMARY STATEMENT OF DEFICIENCIES 36 JANICE LANE SELDEN, NY 11784 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (xs) COMPLETE DATE (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H14321 Continued From page 23 Part or Part 765. 1This Regulation is not met as evidenced by: Based on record review and staff interview, the agency failed to maintain accurate Quality Assurance (QA) meeting minutes for the years 12006 - 2008. The GA's alteration of QA meeting minutes places all patients at risk for poor quality care. The findings are: A request for QI meeting minutes from 2008 present was made during the entrance I conference. Multiple requests were again made to the Owner for QI meeting minutes to be reviewed. The minutes dated "9/08/2008" and the "Oct. 5, 12008" sign in sheet document that the dates of both of these documents were altered. The QI meeting minutes dated 09108/0& and 110/05/08 were identical minutes for the year o 2006. The number "six (6)" in the date (2006) was altered and changed to an eight (8) (2008). H1432- IDuring an interview with the Owner on 11/03/09, the Owner stated: "OK, I did not have any (QI) meetings in 2008". REPEAT DEFICIENCY FROM 711712007 SURVEY H1454 i 766.12(c) Records and reports 766.12 Records and reports. (c) The home care services agency shall fu~rnish '/annually to the department a copy of: Office of Health Systems Management I Office of Long Term Care STATE FORM Version NYS 11117/2009 H1454 , 108511 continuation sheet 24 of 26 PRINTED: 11/29/2009 FORM APPROVED New York State Department f Health, STATEMENT OF DEFIGIENCIES AND OFcORREcTION (X!) PRVIDER/SUPPLIERJCLI IDENTIFICATION'NUMBER: DLAN 4~ , (X2) MuLTI - CNSTRUCION (X3) DATE SURVEY' COMPLETED BUILDING,__________ LC NAME OF PROVIDER-OR SUIPPLIER- A o" &W1G.. STREET ADDRESS; CITY., STATE zIP CODEa 11/03120090;. " CARING HANDSHOMECAREINC ""' CARNGHNDSlj tc O ~ 'X4) ID PREFIX "T .. 11 -. - ;. z SELDEN,NY 117.84 - .'.""36JANICELANE- SUMM'RY STATEMENT OF DERCIENCIES 1 " .... PREFIX : : TAG (EAC HDEFiCIENCY MUST BE PRECEDED BY FULL REGULATORY ,, -" .j : : ": i INFORMATION) OR1; IDENTIFYING - LSC .' o ' %: " ' P R OV IDE R'S P LA N OF C6FIRC ifO .. .. "." RE h, j COMPtETE (EACH ORRECTIVE ACI1 N sHoutD BE ") DATE ",:CROSS-REFERENCED CqIENCY . ... DEF TO THE APPROPRIATE .; , .' ' H1454 ,Continued From page 24 H1454 (1) statistica"(suhimaries of all health care se'rvices delivered on forms provided by the departnent ' . ''>;. . ]41454 766.2 Records and rLpor s statistical report A) the governin, authority/ operator will be the., . 'and ,. (2) if a for-profit corporation, a list of the principal stockholders and the number and percent of the total issued and outstanding shares of the corporation held by each, duly certified by the ,secretary of the corporation as to completeness ard accuracy; ". (3) if.a not-for-profit corporaion, a list of directors, officers and corporate members, f such h.embers number 10 or fewer; and . " individualresponsibleforcorrection ensuring compliance. 13). statistical reports ibr 2007 and 2008.' Ah S o _ are completed and up to date. Available upon request. C) TO prevent re-occurrence of this issue and or similar issues a specific period for regulatory body updates are to beincluded in'tle QIC ' o . .(4)bther such records and reports as may be legally required by the department. . meetingof 215/09 in-serviSf d-sign pron prior to . meeting. The in-services are designated tomet comphane ongoing. D) QZ-czar 'to includU (d) The agency shall furnish simultaneously to the department Copies of all notices and documents required to be filed with the Securities and 'EXchange Commission. . This Regulation is not met as evidenced by. Based on record review and staff interview, the : "genc; failed to submit complete reportsfor 005 statistical reports inQI audit " . tol llrerts to be sdbinittedo'.QA'.. quarterly and i"-hly.until. :compliance ismeL.The. goVei iiin .: c tb2atno. . reviev of inindtes to ensure thdQI araequatedy&,coveed this topi& Mdcf oiliher regulatory body inato Tle GA toinclude -Aacrdiny deficiency -11454 on its cal Ll nd " 2.007. Thiswt evident for the agen.cs was submission Of statistica-surmmaries i :l"' *[ Tie'agency ssbrnissin of statistical r6ports [the fi'bding thateh agency. has only "Pending o'data with errors~sulrmitted for theyears 2005-t5e ocue2007 Therei nodocumentdevidence that : age7 submitted a00F uplementa repor or 0 tIa.2 008 atisticailreport. * . , - .t~~cit s : e"~~ ... ., ot s end.. sytemyafic changes to b m. tover heet month.. . . ' " I . The agency's, werwas made aware of theo missing informationdutiiig ,. /1 the entrance M6 10851r " / -- Officeof Health Systems Management/Officeof Lng Term Care STATE FORM Versior NYS,11/1712009 ---.--.- o6nhiuation sheet 25 of 26 PRINTED: 11/20/2009 New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION M L A. BUILDING FORM APPROVED (X3) DATE SURVEY COMPLETED COLED LCO921A NAME OF PROVIDER OR SUPPLIER B.WING 36 JANICE L E" STREET ADDRESS. CITY. STATE, ZIP CODE 11/03I2009 CARING HANDS HOME CARE INC (X4) ID PREFIX TAG 36 JANICE LANE SELDJEN, NY 11784 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY-FULL REGULATORY OR LSC IDENTIFYING INFORMATION) j tD PREFIX TAG IRSEFRNE I 'I PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE PRULDE TIlE AON C CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) . (X5) ICOMPTE i COPLTE DATE H1454 Continued Frompage 25 Iconference on 11/03/09.. No further information and explanation was provided by the Owner. H1454 )AC ." 'tU -II Dffice of Health Systems Management Office of Long Term Care TATE RVersion 11/17/2009 108511 Ifcontinuaion shet 26 of 26 PRINTED: 12/07/2009 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDERJSUPPLIERICLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED LC0921 A NAME OF PROVIDER OR SUPPLIER 11/03/2009 STREET ADDRESS, CITY, STATE, ZIP CODE CARING HANDS HOME CARE INC (X4)ID SUMMARY STATEMENT OF DEFICIENCIES 36 JANICE LANE SELDEN, NY 11784 ID PROV DER'S PLAN OF CORRECTION . (X5) PREFIX TAG (EACI DEFICIENCY. MUSI BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PREFIX TAG (EACH CORRECTIVE ACIION SHlOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETE DATE H1454 Continued From page 25 conference on 11/03/09. No further information and explanation was provided by the Owner.-,A H1454 l1 ,4 Off ice of Health Systems Management Office of Long Term Care . Version NYS 11/17/2009 STATE FORM 6 108511 " I 1o of 26 26 STATE OF NEW YORK DEPARTMENT OF HEALTH Metropolitan Area Regional Office 90 Church Street, New York, NY 10007 Richard F. Daines M.D. Commissioner James W. Clyne, Jr. Executive Deputy Commissioner October 28, 2009 Visiting Nurse Service of New York Attn: Elizabeth Buff VP for Quality Services & Clinical Excellence 1250 Broadway New York, NY 10001 Plan of Correction/CHHA Re: 337008 Provider: Survey Date: September 24, 2009 Dear Ms. Buff: Please be advised that this office has reviewed the Plan of Correction relating to the recent Complaint Investigation Survey of your Certified Home Health Agency. All items were found to be acceptable and it is expected that you will implement this plan within the time frames that were submitted. A post approval review will be conducted to verify the correction of deficiencies cited. If you have any questions regarding this matter, please contact this office at (212) 417-5888. Sincerely, Cheryl Phoenix-Tannis,, RN. MSN, CS Program Manager MARO - Home Care, Hospice, and Adult Services /jt x DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTkRS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING 337008 NAME OF PROVIDER OR SUPPLIER VNS OFNY HOME CARE CHIBA STREET ADDRESS, CITY, STATE, ZIP CODE T 107 EAST 70 ' STREET NEW YORK, NY 10021 IPRINTED: 10/02/2009 FORM APPROVED OMB NO. 0938-391 (X3) DATE SURVEY COMPLETED C 09/24/2009 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-' REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE G 159 INITIAL COMMENTS An onsite complaint investigation was conducted on 9/24/09. (Complaint#NY00075471) The Complaint log was reviewed. The following staff were interviewed: Vice President of Quality Services, Director of Quality Management. Three (3) Clinical records were reviewed and identified as Patients # 1-3. 484:18(a) PLAN OF CARE The plan of care developed in consultation with the agency staff covers all pertinent diagnoses, including mental status, types of services and equipment required, frequency of visits, prognosis, rehabilitation potential, functional limitations, activities permitted, nutritional requirements, medications and treatments, any safety measures to protect against injury, instructions for timely discharge or referral, and any other appropriate items. This STANDARD is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to provide home health aide services in accordance to the Plan of Care. This was evident in one (1) of three (3) clinical records reviewed. (Patient # 1) Failure to implement physician orders in the Plan of Care places the patient at risk for not receiving services as needed, .Brooklyn The findings are: Patient # 1 has a start of care date of 4/25/09 with diagnoses which include Diabetes, Hypertension, G 000 G G159 VNS Home Care submits that its policies, systems and procedures relating to patient care and its comprehensive quality management program for monitoring patient care are appropriate and satisfy both federal and state requirements. It is also important to make clear that the submission of this Plan of Correction is not to be construed as an admission that the cited deficiencies are accurate or that at the time of the survey the agency did not have policies, procedures and systems in place to ensure compliance with federal and state law. 1,' for Allegedly Affected Patient I. Plan Delay of home health aide service start until 5/15/09: Investigation of this case (Patient # 1) revealed that alteration in the frequency and duration of Home Health Aide services from frequency and duration documented in the plan of care initiated 4/25/09 was properly conducted and appropriate . but was not properly documented in the patient's record as per the following circumstances: h "" The start of care date was 4/25/09 but the home health aide service was not started until 5/15/09 At the patient's request, HHA service start was delayed because the patient had personal issues which needed attention. The patient's mother was ill in a Hospital and her deceased sister's children needed her oversight at school as well as at requested court dates. Service was initiated on 5/15/09 at the patient's request. TITLE Vice President for Quality Services & Clinical Excellence (X6) DATE 10/20/2009 LABORATORY DIRECTOR'S OR PROVIDERSUPPLIER REPRESENTATIVE'S SIGNATURE Elizabeth Buff / denotes a deficiency which the institution may be excused from correcting providing it is determined that other A,. ficiency statement ending with an asterisk (*) safeguards provide sufficient protection to the patients. Except for nursing homes, the findings above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the datethese documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99 ATG1I2ooo Event ID: LPBT1 1 Facility ID: 1816 If continuation sheet 1 of 5 )EPARTMENT OF HEALTH AND HUMAN SERVICES "ENTERS FOR MEDICARE & MEDICAID SERVICES_ TATEMENT OF DEFICIENCIES AND PLAN )F CORRECTION (XI) PROVIDERISUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING PRINTED: 10/02/2009 FORM APPROVED OMBND..0938;391 (X3) DATE SURVEY COMPLETED' ' B, WING 337008 ,IAME OF PROVIDER OR SUPPLIER VNS OFNY HOME CARE CHHA STREET ADDRESS, CITY, STATE, ZIP CODE 107 EAST 7 0 TH STREET NEW YORK, NY 10021 ID PREFIX TAG C 09/24/2009 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSSREFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 3159 G 159 Continued From page 1 Seizure Disorder, Osteoarthritis, Hyperthyroid, Depression. . Corrective action was taken to enter addendum documentation to the patient's record to reflect the \ Completion Date: September 25,2009 above. The plan of care initiated on 4/25/09 documents a physician order for "home health aide 2-3 hrs/day for 2-3 days/wk for 6 wks." The clinical record documents that the agency provided home health aide services on "5/15/09". pdate e The plan of care dated 4/25/09 - 6/24/09 and 6/25/09 - 8/22/09 documents a physician order for: "home health aide 2-3 hrs/day'for 2-3 days/wk for 6 wks." There is no documentation that the agency provided hha services 6/9/09 - 6/22/09 On 9/24/09 at 3 pmn, the Director of Quality Assessment/Management was interviewed and stated: "We will look for additional documentation." N No documentation of home health aide service provided 6/9/09-6/22/09: , There is no documentation that the provided HHA services 6/9/09 to 6/22/09 because the final of HHA service was 6/8/09. The early termination of the HHA service was because of the inconsistent availability of the' patient. The patient also had' 17 dogs that she refused to lock up which represented a safety issue for the HHAs. The physician agreed to the discontinuation of the HHA. Corrective action was taken to * enter addendum documentation to the patient's record to reflect the above. Th c \agency k Completion Date: September 25,2009 Patient #1 was discharged on 8/22/09. LABORATORY DIRECTOR'S OR.PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE Elizabeth Buff TITLE Vice President for Quality Services & Clinical Excellence (X6) DATE 10/20/2009 -/ //. denotes a deficiency which the institution may be excused from correcting providing it is determined that other .Aicicncy statement endin'gIwith an asterisk (*) tfeguards provide sufficient protection to the patients. Except for nursing homes, the findings above are disclosable 90 days following the date of survey whether or not a Ian of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available ,the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. Event ID: LPBT11 Facility ID: 1816 ORM CMS-2567(02-99) ATG1 20oo If continuation sheet 2 of 5 DEPARTMENT OF HEALTH AND HUMAN. SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING 337008 NAME OF PROVIDER OR SUPPLIER VNS OFNY HOME CARE CHHA STREET ADDRESS, CITY, STATE, ZIP CODE 107 EAST 70'" STREET NEW YORK, NY 10021 ID PREFIX TAG PRINTED: 10/02/2009 FORM APPROVED OMB NO. 0938-391 (X3) DATE SURVEY COMPLETED C 09/24/2009 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSSREFERENCED TO THE APPROPRIATE DEFICIENCY), (X5) COMPLETE DATE .II. Plan to Identify Other Potentially Affected Patients The Quality Management staff will review the case records of all the patients assigned to this nurse to assess her compliance with agency policy for "Plan of Care Development, Implementation, Coordination, and Evaluation" in meeting agency expectations that the plan of care is updated to accurately reflect the services being followed and to identify other potentially affected patients. Any issue in not updating the Plan of Care to accurately reflect that HHA services are being followed in accordance with the Plan of Care .4 \ that is identified will be brought to the nurse's attention by the Queens Clinical Director and/or, the Patient Service Manager and corrective action will be taken where indicated. Completion Date: November 16", 2009 III. Measures and Systems The Quality Improvement Director has reviewed the current policy for "Plan of Care S' Development, Implementation, Coordination, and Evaluation" to evaluate the need for revision. The current policy requires no revision. The Queens Regional Administrator and Completion Date: October I. th2009 Clinical Director will review the above SOD with the Patient Service Manager and the nurse involved with the SOD and review the agency policy for "Plan of Care Development, Implementation, Coordination, and Evaluation" and the nurse's responsibility for following agency policy. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE Elizabeth Buff . TITLE Clinical Excellence~ Vice President for Quality ~~~Services.& (X6) DATE 10/20/2009 z'// Completion Date: October 30", 2009 . that other A;. _,ficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined protection to the patients. Except for nursing homes, the findings above are disclosable 90 days following the date of survey whether or not a safeguards provide sufficient made available plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are to the facility. If deficiencies are cited, an approved plan of correction is requisite to continuedprogram participation. FORM CMS-2567(02-99 ATt1t20o Event ID: LPBT1 1 Facility ID: 1816 . If continuation sheet 3 of 5 )EPARTMENT OF HEALTH AND HUMAN SERVICES ENTERS FOR MEDICARE & MEDICAID SERVICES ;TATEMENT OF DEFICIENCIES AND PLAN )F CORRECTION (XI) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A.BUILDR.G B. WING PRINTED: 10/02/2009 FORM APPROVED OMB NO: 0938-391' (X3) DATE SURVEY COMPLETED C 337008 ____________________________________________09/24/2009 qAME OF PROVIDER OR SUPPLIER VNS OFNY HOME CARE CHHA STREET ADDRESS, CITY, STATE, ZIP CODE m 107 EAST 7 0' STREET NEW YORK, NY 10021 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX. TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSSREFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The Queens Regional Administrator and Clinical Director will review the above SOD Vith the team involved with the SOD and review the agency policy for "Plan of Care Development, Implementation, Coordination, and Evaluation" and the nurses' responsibility Completion Date: October h 301 2009 for following agency policy. N "; At the next regional staff meeting, the Queens Regional Administrator and/or Clinical Director will review the above SOD and the agency policy for "Plan of Care Development, Implementation, Coordination, and Evaluation". The staff's responsibility for following agency. policy will be reviewed. The Quality Improvement Director will develop a case review tool that will be used for . concurrent review of randomly selected patient records to monitor compliance with ordered HHA services on the Plan of Care. The Quality Management staff will initiate an audit of randomly selected concurrent patient records on this team to determine. if a pattern of noncompliance to agency policy exists. If a Spattern is identified, further monthly auditing and staff remediation will take place. Any issue in not updating the Plan of Care to accurately reflect that HHA services are being followed in accordance with the Plan of Care that is identified will be brought to the nurses' attention by the Queens Clinical Director and/or the Patient Service Manager and corrective action taken. Completion Date: December 9 , 2009 Completion Date: October 23 nd2009 Completion Date: November 30", 2009 LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE Elizabeth Buff afeguards ~~ /1 - TITLE Vice President for Quality Services & Clinical Excellence (X6) DATE 10/20/2009 2I , i...ficiency statementending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other afeguards provide sufficient protection to the patients. Except for nursing homes, the findings above are disclosable 90 days following the date of survey whether or not a Ian of correction is provided. For nursing homes, the above'findings and plans of correction are disclosable 14 days following the date these documents are made available the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. fORM CMS-2567(02-99) ATG1t2Soo ID: LPBT 11 Facility ID: 1816 Event If continuation sheet 4 of 5 DEPARTMENTF OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDER/SUPPLIER!CLIA IDENTIFiCATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING PRINTED: 10/02/2009 FORM APPROVED O 0MB NO. 0938-391 (X3) DATE SURVEY COMPLETED C 337008 NAME OF PROVIDER OR SUPPLIER VNS OFNY HOME CARE CHHA STREET ADDRESS, CITY, STATE, ZIP CODE 107 EAST 70'" STREET NEW YORK, NY 10021 ID PREFIX TAG 091241209 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSSREFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE N IV. Mofiitoring Systems \ \. N ' The Quality Improvement Director will oversee the monitoring process for this SOD. A report will be prepared for any patterns identified and provided to the: * * 0 a * * 0 Chief Operating Officer Vice President for Quality Services Vice President of Operations for Acute Care Quality Improvement Director Regional Administrator for the Queens office The Patient Service Manager for this teame Completion Date: December 3 I 2009 team The staff nurses assigned to this team Findings and actions resulting from this audit will also be reported at quarterly Professional Advisory Committee; Board Quality Comittee, and Board of Director meetings. Completion Date: 31 st March 2010 LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE Elizabeth Buff TITLE Vice President for Quality Services & Clinical Excellence (X6)DATE 10/20/2009 A, ..zficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. Except for nursing homes, the findings above are disclosable 90 days following the date of survey whether ornot a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) ATG12000 Event ID: LPBTll Facility ID: 1816 L. If continuation sheet 5 of 5 JSTATE Richard F Daines, M:D. Commissioner OF NEW YORK DEPARTMENT OF HEALTH Metropolitan Area Regional Office New York, NY 10007 90 Church Street Wendy E. Saunders Executive Deputy Commissioner April 23, 2009 Visiting Nurse Service of New York Home Care Attn: Elizabeth Buff, VP for Quality Services &Clinical Excellence 1250 Broadway New York, NY 10001 Re: Response to Plan of Correction Survey Date:. March 31, 2009 License: 337008 Dear Ms. Buff: Please be advised that the Plan of Correction relating to the recent Recertification survey of your agency have been reviewed by this office. All items were found to be acceptable and it is expected that you will implement this plan within the time frames that were submitted. A post approval review will be conductedto verify the correction of deficiencies. If you have any questions. regarding this matter, please contact (212) 417-5888. Sincerely, Cheryl Phoenix-Tannis, RN, MSN, CS Program Manager Home Health and Hospices Services Metropolitan Area Regional Offices /jt 1VingtServe OfNewYork WeBring The CaringHome 1250 Broadway, New York NY, 10001 April 21, 2009 Cheryl Phoenix-Tannis, RN, MSN, CS Program Manager Home Care, Hospice Services State of New York, Department of Health 90 Church Street New York, NY 10007 Re: Re-Certification Survey Provider: #337008 Survey Date: March 31, 2009 Dear Ms. Phoenix-Tannis: In response to your letter dated April 14, 2009, attached you will find our Agency's plan of correction for the above-cited survey. If you have any questions please call Peter Ungvarski, Liaison for Regulatory Compliance at 212-609-6355 or Elizabeth Buff, Vice President for Quality Services & Clinical Excellence at 212-609-6334. Sincerely, * Elizabeth Buff Vice President for Quality Services & Clinical Excellence ---------------------------- ----- DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER: FORM APPROVEE OMB NO. 0938-391 (X3) DATE SURVEY COMPLETED "ATEMENT OF DEFICIENCIES -,ND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER A. BUILDING B.WING 337008 03/31/2009 STREET ADDRESS, CITY, STATE, ZIP CODE VNS OFNY HOME CARE CHHA 107 EAST 70 " STREET NEW YORK, NY 10021 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSSREFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) GOOO INITIAL COMMENTS A Recertification Survey was conducted at Visiting Nurse Services on March 23, 2009 through March 31,2009. Twenty five (25) clinical records were reviewed and identified as Patients #1 through #25. The record reviews were inclusive of three complaint investigations: #NY0066933 (CR #1), #NY 0069221 (CR #2) and #NY 0068651 (CR#3) Four (4) of the clinical records reviewed were patients receiving services from the Long Term Home Health Care Program (LTHHCP), (Patients #3, #16, #17, and #25). Ten (10) home visits were made to Patients #4, #5, #6, #12, #13, #14, #15, #16, #17 and #18. Two (2) of the home visits weremade to patients receiving services from the LTHHCP (Patients #16 and # 17). Eleven (11) personnel records were reviewed and identified as Employees #1 through #11. 484.14(g) CORRDINATION OF PATIENT SERVICES All personnel furnishing services maintain liaison to ensure that their efforts are coordinated effectively and support the objectives outlined in the plan of care. This STANDARD is not met as evidence by: Based on record reviews and interview, the agency failed to coordinate of patients' Plan of Care. This was GOOO VNS Home Care submits that its policies, systems and procedures relating to patient care and its comprehensive quality management program for monitoring patient care are appropriate and satisfy both federal and state requirements. It is also important to make clear that the submission of this Plan of Correction is not to be construed as an admission that the cited deficiencies are accurate or that at the time of the survey the agency did not have policies, procedures and systems in place to ensure compliance with federal and state law. G 143 G143 Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other o;'+eguards provide sufficient protection to the patients. Except for nursing homes; the findings'above are disclosable 90 days following the date of survey whether or not a of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made - .lable to the facility. If deficiencies are cited, an approved plan df correction is requisite to continued program participation. (X6) DATE TITLE LABORATORY DIRECTOR'S OR PROVIDERJSUPPLIER REPRESENTATIVE'S SIGNATURE Vice President for Quality Elizabeth Buff 04/21/2009 Services & Clinical Excellence FORM CMS-2567(0P9) Previous Versions Obso6 If continuation sheet Page 1 of 9 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS Fd'R MEDICARE & MEDICAID SERVICES (XI) PROVIDERSUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING FORM APPROVED .MB NO. 0938-391 (X3) DATE SURVEY COMPLETED "ATEMENT OF DEFICIENCIES iND PLAN OF CORRECTION 337008 03/31/2009 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS,T CITY, STATE, ZIP CODE 107 EAST 70 STREET VNS OFNY HOME CARE CHHA (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued from page 1 1EA YOT STREET NEW YORK, NY 10021 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSSREFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE G143 evident for 7 (seven) of twenty five (25) clinical records reviewed. (Patients # 8,12, 15,16,17, 24, and G143 25) Failure to coordinate patient services has the potential for substandard care. Thefindings are: .Patient #16 (HV) was admitted to the agency on 3/05/09 with diagnosis of Congestive Heart Failure, Coronary Artery Disease, Cardiac Defibrillator Implant Replacement, Hypertension and Dementia. During the certification period of 3/05/09 to 5/03/09, the physician ordered social work services for one (1) to two(2) times a month for two (2) months. I. Plan for Allegedly Affected Patients . Plan for Follow-up for Patient#16: Patient # 16 was discharged 04/08/09 The Clinical Director for LTC-and Social Work Manager will meet with the Social Worker involved in this patient's care and review the SOD and her responsibility to follow the agency's policy for "First Visit" in meeting the. agency expectations that the scheduling of the initial visit is made within the specified time frames. The Social Worker visited according to the Plan of Care: in March a visit was made on 3/24/09 and once in April on 4/1/09 prior to discharge (physician ordered social work services for one (1) to two(2) times a month for two (2) months.) Plan for Follow-up for Patient#17: . Patient #17 is active. The Clinical Director for LTC and Social Work Manager will meet with the Social Worker involved in this patient's care and review the SOD and the Social Worker's responsibilityto follow the agency's policy for "First Visit" in meeting the agency expectations that the scheduling of the initial visit is made within the specified time frames. Completion Date: May 8,2009 The clinical record documents that the initial visit was made on 3/24/09. There is no further . documentation of social work visits during this time period. 2.Patient #17 (HV) was admitted to the agency on 2/27/09 with diagnosis of Diabetes Type2, Hypertension, Malignant Neoplasm Colon, Joint Pain of Pelvis, Seizure Unspecified and Muscle Weakness. During the certification period 2/27/09 to 4/27/09, the physician ordered social work services for one (1) to two (2) times a month for two (2) months. Completion Date: May 8,2009 denotes a deficiency which the institution may be excused from correcting providing it is determined that other Any deficiency statement ending with an asterisk (*) sl'eguards provide sufficient protection to the patients. Except for nursing homes, the findings above are disclosable 90 days following the date of survey whether or not a of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made ... ,able to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. (X6) DATE TITLE LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE 04/21/2009 Vice President for Quality Elizabeth Buff Excellence Services & Clinical If continuation sheet Page 2 of 9 FORM CMS-2567(02/99) Previous Versions Obsolete DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION A. .UDNCOMPLETED BUILDING FORM APPROVEE OMB NO,0938-391 (X3) DATE SURVEY .IATEMENT OF DEFICIENCIES IDENTIFICATION NUMBER:- iAND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER 337008 B.WING 03/31/2009 STREET ADDRESS, CITY, STATE, ZIP CODE VNS OFNY HOME CARE CHHA (X4) ID PREFIX TAG 107 EAST 70 T H STREET NEW YORK, NY 10021 ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSSREFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Continued from Page 2 G143 The clinical record documents a social work initial visit on "3/13/09". There is no further documentation of social work Visits during this period. G143 The Social Worker is visiting according to the Plan of Care: inMarch a visit was made on 03/13/09 and then on 03/27/09 and in April on 04/10/09 (physician ordered social work to services for one (1) two(2) times a month for A nutrition assessment and visits were ordered by the to physicians on "2/27/09" for one (1) two (2) times two (2) months.) The Dietician involved in this patient's care followed the agency's policy for "First Visit" in ("within five (5) working days "). The patient was admitted on Friday February 27 and 5 working days - excluding Saturday and Sunday - means that the first visit should have been made by 3/6/09 and it was in fact made on 3/3/09. The Dietician is visiting according to the Plan of Care: in March a visit was made on 3/9/09 and in April on 04/06/09 (physician ordered nutrition services for one (1) to two(2) times a month for two (2) months.) Plan for Follow-up for Patient#25 a month for two (2) months. The clinical record documents the initial nutrition assessment was madeon "3/03/09". There is no further documentation of nutrition visits during this period. Cornpletioi Date: May 8,2009 3. Patient #25 was admitted to the agency on 2/26/09 with diagnosis of Diabetes Type2, Hypertension, Congestive Heart Failure, Depression and Joint Repladement Hip. During the certification period 2/26/09 to 4/26/09, the physician ordered social work visits for one (1) to two (2) times a month for two (2) months Patient #25 was discharged on 03/26/09. The Clinical Director for LTC and Social Work Manager will meet with the Social Worker involved in this patient's care and review the SOD and the Social Worker's responsibility to follow the agency's policy for "First Visit" in meeting the agency expectations that the. scheduling of the initial visit is made within the specified time frames. Completio Date: May 8,2009 is Any deficiency statement ending with an asterisk () denotes a deficiency which the institution may be excused from correcting providing it determined that other -f'guards provide sufficient protection to the patients. Except for nursing homes, the findings above are disclosable 90 days following the date of survey whether or not a of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made .,table to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. (X6) DATE TITLE LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE Elizabeth Buff Vice President for Quality Services & Clinical Excellence 04/21/2009 FORM CMS-2567(02/99) Previous Versions Obsolete If continuation sheet Page 3 of 9 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS F6R MEDICARE & MEDICAID SERVICES TATEMENT OF DEFICIENCIES A-ND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER (XI) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION FORM APPROVED OMB NO. 0938-391 (X3) DATE SURVEY COMPLETED A. BUILDING 337008 B.WING STREET ADDRESS, CITY, STATE, ZIP CODE 107 EAST 7 0 TH STREET 03/31/2009 VNS OFNY HOME CARE CHIA (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) NEW YORK, NY 10021 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS: REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE G143 Continued from Page 3 The clinical record documents the social work initial visit was made on "3/30/09". There is no further documentation of social work visits during this period The Clinical Director and Administrator of the Long Term Home Health Care program was interviewed on 3/27/09 at 1:30pm and confirmed that the services had not been provided as ordered in the Plans of Care and this "was no in accordance "with the agency policy which states that the agency will provide Social Work (SW) services and Nutrition services for patient within five (5) working days of the referral 4.Patients #12 (HV) was admitted to the agency, on 12/31/08 with diagnosis of Lower Leg Injury, Pressure Ulcer, Diabetes Type2, Difficulty on walking, Dementia and Hypertension. During the certification period 12/24/08 to 2/21/09, the physician ordered social work visits for one (1) to two (2) times a month one (1) month The clinical record documents the'social work initial assessment was made on "1/13/09'7. There is no further documentation of social work visits during this period G143 No Social Work visits were made before discharge. Plan for Follow-up for Patient#12 Patient #12 is active. The Clinical Director for the Bronx and Social Work Manager will meet with the Social Worker involved in this patient's care and review the SOD and the Social Worker's responsibility to follow the agency's policy-for "First Visit" in meeting the agency expectations that the scheduling of the initial visit is made within the specified time frames. They will also review the agency policy for coordination of care. When the Social Worker called to schedule a visit in February the patient's son declined and the plan of carewas not modified to reflect the patient's needs. The Clinical Director for Congregate Care and the Patient Service Manager will meet with the Completion Date: May 8,2009 Any deficiency statement ending with an asterisk (*)denotes a deficiency which the institution may be excused from correcting providing it is determined that other sqfeguards provide sufficient protection to the patients- Except for nursing homes, the findings above are disclosable 90 days following the date of survey whether or not a of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the .date these documents are made .Jable to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. (X6) DATE TITLE LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE Elizabeth Buff FORM CMS-2567(02/99) Previous Versions Obsolete Vice President for Quality Services & Clinical Excellence 04/21/2009 If continuation sheet Page 4 of 9 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. ATEMENT OF DEFICIENCIES _&ND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER (XI) PROVIDER/SUPPLIER/CLIA IDNIIAINNUMBER: IDENTIFICATION (X2) MULTIPLE CONSTRUCTION A. BUILDING FORM APPROVEE OMB NO. 0938-391 (X3) DATE SURVEY COMPLETED 337008 107 EAST 70 B.WING 03/31/2009 STREET ADDRESS,"CITY, STATE, ZIP CODE r VNS OFNY HOME CARE CHHA (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES,(EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) NEW YORK NY 10021 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSSREFERENCED TO THE APPROPRIATE DEFICIENCY) . N0W YORK, NY 10021 STREET (X5) COMPLETE DATE Continued From page 4 G143 G143 Coordinator of Care and involved in this patient's care and review the SOD and the Nurse's responsibility in modifying and maintaining the plan of care to reflect exact services provided for the patient. Plan for Follow-up for Patient#24 Patient #24 was discharged on 04/06/09. The Clinical Director for Congregate Care will' meet and Social Work Manager will meet with the Social Worker involved in this patient's care and review the SOD and the Social Worker's responsibility to follow the agency's policy for "First Visit" in meeting the agency expectations that the scheduling of the initial visit is made within the specified time frames. They will also review the agency policy for coordination of care. The Clinical Director for Congregate Care and the Patient Service Manager will meet with the Coordinator of Care and involved in this patient's care and review the SOD and the Nurse's responsibility in modifying and maintaining the plan of care to reflect exact services provided for the patient. Completio Date: May 8,2009 5. Patient #24 was admitted to the agency on 2/07/09 with diagnosis of Coronary Artery Disease, Congestive Heart Failure, Atrial Fibrillation, Hypertension and Glaucoma During the certification period 2/07/09 to .4/07/09 the physician ordered social work visits for two (2) to four (4) times a month for one (1) month, The Clinical record documents the social work initial visit was made on 2/15/09. There is no further documentation of. social work visits during this period. The Quality Improvement Specialist of the Certified Home Health agency was interviewed on 3/30/09 at 1:00pm and confirmed that the services had not been provided as ordered in Plans of Care. Completio Date: May 8,2009 Completio Date: May 8,2009 Any deficiency statement ending with an asterisk () denotes a deficiency which the institution may be excused from correcting providing it is determined that other not a 'F'tguards provide sufficient protection to the patients. Except for nursing homes, the findings above are disclosable 90 days following the date of survey whether or of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made . dable to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. (X6) DATE TITLE LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE Vice President for Quality Eliiabeth Buff Services & Clinical Excellence 04/21/2009 FORM CMS-2567(02/99) Previous Versions Obsolete If continuation sheet Page 5 of 9 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES (Xl) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION FORM APPROVED OMB NO. 0938-391 A. BUILDING B.WING (X3) DATE SURVEY COMPLETED STATEMENT OF DEFICIENCIES \ND PLAN OF CORRECTION 337008 03/31/2009 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VNS OFNY HOME CARE CHHA (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 107 EAST 70 NEW YOMK NY 10021 TH STREET ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSSREFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE G143 Continued From page 5 G143 Plan for Follow-up for Patient#8 Patient #8 is active. The Clinical Director for Queens Acute Care and the Patient Service Manager will meet with the Coordinator of Care and involved in this patient's care and review the SOD and the Nurse's responsibility in modifying and maintaining the plan of care to reflect exact dates and times of requests. The nurse placed Physical Therapy and Nutrition Services on the initial plan of care but did not make requests for these services at the same time. 6.Patient #8 was admitted to the agency with a diagnosis of Diabetes Type2, Morbid Obesity, Hypertension, Depression, Hyperlipidemia and Difficulty in Walking. The initial plan of care dated 2/24/09 documents orders for the following : Physical Therapy one (I)n to (3) times per week For nine weeks to teach, activities in daily living training, therapeutic exercises, gait training, coordination/ balance activities and transfer training. Nutritionist one (1) to (2) times per week for four weeks to assess for nutritional needs/ intake. The clinical record documents a Physical Therapy note dated "3/20/09". There is no documented evidence of a Physical Therapy visit between the date of the order and 3/20/09. The clinical record documents a Nutritionist note dated "3/17/09". There is no documented evidence of a Nutritionist visit between the date of the order and 3/17/09. The agency Policy and Procedure for "Provision of Services" documents that services ard to be provided "within five (5) working days of order by the physician" Completion Date: May 8,2009 Plan for Follow-up for Patient#15 7.Patient #15 was admitted to the agency with a diagnosis of Liver Disorder, Hypertension, Kidney Cyst, Coronary Artery Disease, Dementia and Difficulty in walking. The initial plan of care dated 3/13/09 documents Patient #15 is active. The Director of Rehabilitation QA/education. and Rehabilitation Manager will meet with the Physical Therapist involved in this patient's care Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. Except for nursing homes, the findings above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. (X6) DATE TITLE ' A BORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE e BuffVice . .... t uff .. .. President for Quality IServices & Clinical Excellence 04/21/2009 FORM CMS-2567(02/99) Previous Versions Obsolete If continuation sheet Page 6 of 9 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE, & MEDICAID SERVICES STATEMENT OF DEFICIENCIES tND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER (XI) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION FORM APPROVEE OMB.NO. 0938-391 (X3) DATE SURVEY COMPLETED 337008 A. BUILDING B.WING 03/31/2009 STREET ADDRESS, CITY, STATE, ZIP CODE VNS OFNY HOME CARE CHHA SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 107 EAST 7 0 TH STREET 0 NY 10021 NE Y NEW YORK, NY 10021 ID PREFIX TAG (X4) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSSREFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE G143 Continued From page 6 orders for the following: Physical Therapy Evaluation for gait training, The clinical record documents a Physical Therapy note dated "3/27/009". There is no documented evidence of a Physical Therapy visit between the date of the order and 3/27/09. On 3/27/09 at 3pm the Quality Improvement Specialist was interviewed and stated that the agency "did not send" the Physical Therapist or Nutritionist. within the timeframe outlined in the Agency Policy. G143 and review the SOD and the Physical Therapist's responsibility to follow the agency's policy for "First Visit" in meeting the agency expectations that the scheduling of the initial visit is made within the specified time frames Completio Date: May 8.2009 A Nutritionist was never ordered for this patient. II. Plan to Identify Other Potentially Affected Patients' The Social Work Managers, Patient Service Managers, and Rehabilitation Managers and will randomly select records of the staff identified in the SOD to'assess their compliance with the agency's policy for "First Visit" in meeting the agency expectations that the scheduling of the initial visit is made within the specified time frames and to review their ability to maintain or modify the plan of care when indicated regarding visit frequency as well as to confirm the steps/actions outlined in Section I were effective and to identify other potentially affected patients.. The Vice President for Quality Services and Liaison for Regulatory Compliance reviewed and revised the agency quality assurance monitoring plan for 2009 to include concurrent review of patient records to monitor compliance with agency policies for initiating the first visit for social work, rehabilitation therapy and nutrition services as well as following the plan Completi Date: Ma 24,2009 Implemen ation Date June,200 Any deficiency statement ending with an asterisk (*)denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. Except for nursing homes, the findings above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. (X6) DATE TITLE I A BORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE Suf ....abhouffServices FORM CMS-2567(02/99) Previous Versions Obsolete Vice President for Quality & Clinical Excellence 04/21/2009 If continuation sheet Page 2 of 9 DEPARTMENT OF HEALTH AND HUMAN. SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES (Xl) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION A. BUILDING FORM APPROVED OMB NO. 0938-391 (X3) DATE SURVEY COMPLETED STATEMENT OF DEFICIENCIES IDENTIFICATION NUMBER: .ND PLAN OF CORRECTION -337008 NAME OF PROVIDER OR SUPPLIER B. WING 03/31/2009 STREET ADDRESS, CITY, STATE, ZIP CODE VNS OFNY HOME CARE CLHA (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 107 NEW07 RKAN 1021E NEW YORK, NY 10021. ID PREFIX TAG' PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSSREFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE EAST 70' STREET Continued From page 7 G143 G143 of care for such services in order to identify other potentially affected patients.. III. Measures and Systems The Vice President for Quality Services and Liaison for Regulatory Compliance will review the current policies for "First Visit" and "Interdisciplinary Coordination of Care" to. evaluate the need for revision. The Regional Administrators and Program Directors throughout the agency will meet with the staff and review this SOD and in-service all nurses, social workers therapists and Dieticians regarding the agency policy for "First Visit" and "Interdisciplinary Coordination of Care" and their responsibilities for following agency policy. The Vice President for Quality Services & Completion Date: May 1,2009 Completion Date: June 26,2009 Clinical Excellence and Regulatory Compliance Liaison will develop a process for on-going case reviews for 2009that will monitor not only the initial visits made by social workers, therapists and dieticians but also their compliance with the visit frequency in the plan of care. Implement ation Date: June.2009 The agency has developed a plan and process to include social workers inthe electronic patient record in order to facilitate and improve interdisciplinary communication and compliance with the plan of care. This training process is currently in progress. Implement ation Date: 2009 Any deficiency statement ending with an asterisk () denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. Except for nursing homes; the findings above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. (X6) DATE TITLE 'JBORATORY.DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE . BVice President for Quality 04/21/2009, .....abeth Buff FORM CMS-2567(02/99) Previous Versions Obsolete 'Services & Clinical Excellence If continuation sheet Page a of 9 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES (XI) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION FORM APPROVE] OMB NO. 0938-39 (X3) DATE SURVEY COMPLETED STATEMENT OF DEFICIENCIES \ND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER 337008 A. BUILDING B.WING 03/31/2009 STREET ADDRESS, CITY, STATE, ZIP CODE VNS OFNY HOME CARE CHHA (X4) ID PREFIX TAG SUMMARY STATEMENTOF DEFICIENCIES (EACH " DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 107 EAST 70'" STREET NEW YORK, NY 10021 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSSREFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETI DATE Continued From page 8 G143 G143Improvement IV. Monitoring Systems The Vice President for Quality Services & Clinical Excellence and Manger for Quality oversee the on-going monitoring process for this SOD and produce monthly "Compliance Scorecards" that will be provided to the:.Jl,26 * * 0 Implemen ation Date: Chief Operating Officer Vice Presidents of Operations Regional Administrators * * 0 0 Program Directors Clinical Directors Patient Service Managers Rehabilitation Managers . Social Work Managers 0 Clinical Staff Findings and actions taken to address areas that do not meet agency thresholds will also be reported at quarterly Professional Advisory Committee, Board Quality Committee, and Implemen ation Date Third Quarte 2009 Board of Director meetings and to the Chief Executive Officer. Any deficiency statement ending with an asterisk () denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. Except for nursing homes, the findings above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. (X6) DATE TITLE B3ORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE Vice President for Quality 04/21/2009 .. zabeth Buff FORM CMS-2567(02/99) Previous Versions Obsolete Services & Clinical Excellence If continuation sheet Page 9 of 9 o r". 0,L I " :i 1 ri. rtiAN.R OJCRYIol Llflltl. ".V I'TqLri'' U wIti"i .N -, I York State Dani o"H GVDCENCE3 " h'. ON9TR1N FORM APPROVED pR0VPWL1PfflCFSWUK PM) DA BU*o ,,,MA Sam ME OP PRO o- 01 s' frlDR.oDts AT4WcoO MORMI)PPUE , ~ JWJS OR !ALA e ARE& INT OR Al .. ~ DUAIVAMRB VE SU'I1 104 WHDPARINVr .K.JWM 110112 " ppEM :TAG- eI~l. TAG By nu BW32 P*ace oeftwW.' I1WYINO NIPoJNWATIO. OR M REGI.LA1. SU MA.TAB.i.TODF..... lEACH CORRMThA=ONSLOD EM TO fQ1AlPMMIF lSSfflRERN Th following plan of correction issubmitted in with applicable law and regulation for continued Medicare/ Medicaid certification. PRWDEM PLA OF C'R14LOIft DA J 74 7637a(3)(55) Cb WRbcords 720 72.0-accordance MY3. CliICa Records. (a) eny shag- natain a confdont - . The-,M cftO record for sao pd lmt Iftft~d to care or *acce~tsdfor rrEUR * J 720 I. The following actiotn isbeing taken for the areas identified under this 3 lag. Patient #4-All services that the patient required were provided based on the Physician's verba, order. The 'lack (3)Med l Orref W193 be: of documentation of a Physician's silature. on th Plan of Care within thirty (30) days will be addressed 03/15/10 i'ned by ft auUftrtW 30 MianiW with this patient's Physician. Patient #6- services that the patient required were All ds a12I ssuance of =W cbWg in mecal orders i" prtbri bll .-wh'lwhilevurWs so er, W irnuda a Jwrn and oral chaigln and changes Made by tlephone by Such P=M W,end provided based on die Physician's verbal order. The lack of documentation of a Physician's signature on th (30)days will be addressed Plan of Care within thirty with this patient's Physician. 03/15/10 Ths RequI m is met as evlde ed by: nck h Patient # 11 - All services that the patient required were provided based on the Physician's verbal order. The lack of documentation of a Physician's signature on the 03/15/10 Plan of Care within thirty (30) days will be addressed ' with this patient's Physician. .Based on rlamord reviei "dgtidby tm and tff b evmiew, um e agency faued to esuli .tMedibal oife This sfOWIdet int n 1 0)dI vente (17) oIkniM 'ordS reviewed. {Pftlft 4,195, #101 #0, #11, 112, *14, #16, and 118). Faiure t MSie ri. ihm f M do". lack of documentation of a Physician's signature on the Plan of Care within thirty (30) days will be addressed 03/15/10 Patient .12- All services that the patient required were provided based on the Physician's verbal order. The withthis patient's Physician. Patient 1l4- All services that the patient required were provided based on the Physician's verbal order. The lack of documentation of aPhysician's s;gnatureon th tha, m areq d by the Physician t thi (30) das the * padeis at risk fr'fit I .ld r am. ke F'lidings .' with this patient's Physician. Plan of Carm within thirty (30) dayt will be addressed 03/15/10 Patient.# 10- All services that the alient required were provided based on the Physician's verbal order. The , lack of documentation of a Physician's signature on the Plan of Care within thirty (30) days will be addressed 03/15/10 1) Plfent 6 ha an admision date ofJ25/09. "bePlan of Care initlateld on am=_0 l dcWwm w of ' h ichllft sgnature unil 1 /vim, with this patient's Physician. Patient #9- services that the patient required were All pIrovided based on the Phyiician's verbal order. The lack of documentation of a Physician's signature on th Plan of Care within thirty (30) days will be addressed 03/I 5/10 2)Pnti~nt hat n.admlgion date ot'7105/0, STh Man of Cam itIated on G11/109-lMks,. ., .. ... owith this patient's Physician. " " ' .. .. .S1"ATE IR.- vefalnlN lIIjlzc - " F"" if eREnMsITM Id FW1 ff 'SI o r r D. 0. LVU I ;rm ILrO .rIV iJLWMrKf 11 L I 11r1. *, ,1 I oNe wYork$=m Dwae TA E OF DBICI.I) WAND PLAN OF CRRWTION _Ha -------- U uA L0ONSTRij px Mm&nPj N S R0 WpNU 423 DATE StrY. COWILVIE MEMriCA11OMAR938. EL VMS oiE F PROVER OR SUPPLIE 9 EETADMISM crY, STAM ZIP CODE 11110 o I D .AWAREDRPVE'SUWE 104 MID SUKAM STATEMBfOf W g~lCES ppjaIm *TAG p=AC amqctl~My MSTP~iCE SY1ALU PRUM I o tOV1DER PLAO OFWcO, 1O (EACHO ORREMMVACiIINIGHOUDBE XW0 MAFOFYrE RER1LATOW OR~ LSC IDrS4TIFYI UMMIM TADWflOMU GOIIMET D P1s) J720 C ullned Ft page I o720 Patient #15- All services thatthe patieht. required were' provided based on the Physician's verbal order. The Ik of documentation of aPhysician's signature on the Plan of Care within thirty (30). days will be addressed with this patient's Physician. dboU enWI f a phpt. Sinatua urlti 10/1W09. The Plan of Care Mtiaed On 11114 09 lacis docaameJ;AaUon of a phyziianl Until , " 1225/0 3) Patent #11 has a1n AdQi1W 'W dat of W W9, Twh.Plan of"Cay initiated on 10/04109 [OCks d&imell1 Uon of a physk*ns slgn ft unil 03/15/10 Patient #4-All services that the patient required were provided based on the Physician's verbal order. The lack of documentation of aPhysician's signature on the Plan of Care within thirty (30) days will be addressed with this patient's Physician. 2/03M09 kntanm P sIcign's Ordens d&td 101M6/M and Ihyiimn's mnlalbn of a 10/2 0/9.lack docjftftta09. Ioau unl ci of 3" bj 2010. 7a = ' pj IaWa Order dated /11509 lad daoumenad-on ofa physicin's signature. 4) P 'Th" 03/151/0 * Patient #16- All services that the patient required were provided based on the Physician's verbal order.. Te lack of documenuttion of a Physician's signature on the Plan of Care within thirty (30) days will be addressed with this patient's Physician. A letter signed by the Medical Director and 03/15/10 w t#1a has an 07/0. 4) PaftR Caisiu n admission d~I of Wclcs Sdia ihon l date, of doauena Ulin of 2 phyainin siynatore utIl Unll 12M/O Piln Of C" inal~lki on 71 MJ a s -specific Administrator will be sent to each Physician notifying them that failure to sign a patient's orders within the receipt of ordered services. thirty (30) day period may affect the patient's 03/15/16 W17/09. aur Plan al Cam lnhaninsignaue The ail of fa phpyila 11103108 lado II. H following corrective action will he . o o iimplemented to identify other patients participating . Irntim Pk~Ilian s Orders date~d & I'1109 andpatie 5(12109 ia.'"gwj ON= oW Wgrklaum ulrf 7MU0M. fapr. py1 In' S o in the program that may be affecied by the same practice: A report will be generated identifying all instances of unsignd orders, regardless of whether thirty (30) or more days have expired. The agency will follow-up with'the relevant physician in all cases where we have 5) Paden1M I4 has an rdmss an date of M1/' :i The1 ' Ofacare ihli oil 9 1f/09 id pI o n iftl~aW Ol S11 ani 1/10W k dol'n? LI Of p m . yet to receive signed orders. The process identified in Section III will be followed, except in eases where the signed order Nalready late. Inthose cases, acopy of the orders will be sent proiptly to the physician with a letter, via return receipt request. SrlIrlgus. Interlm P1 do =I'I iofof.p*WIani '&s 03/05/10 'y n Orde..l dad 0 t'lc 9 t mwfr m. Proactively, inAprilthe all 4 85s due during 2010, afull program printout of upcoming week will be reviewed for timely signatures. Physicians who have outstanding orders will be contacted by the Medical 04/15/10 6) PN.nt ondaMof91 hRs admd an 09. , Director. The Plan of *-doomr"ado" Carmdated 11117109-1115/10 lafccs -fpmhyscanals ibre. bnter Phoscinss Order dMWe 1QWIQ 111w r-TepOys 4 F.TD t el7 2 " F r D. 0. LV IV I 1 I rwfl IF, IL% I L II . L|11III~ wa'~'. r , .. . STA'TIdT t. 1PM A.JD F M VoAPPROVIX SMop g4g/o M"ra Z 'S7PUcOrIRI2RDAT ~~~ NiW.Yolf PU.!IcRLN ~A 1w.E r1R "WEOF PRWM~l~OR SUPPI.D pAIgEI~1s (M10O WSATM - o .. 4STREGtDJIEBS. ITY.ATE ZiP COWl DELWAR DRORR 104. , ICDM -- -G'; O PFWMMER IAI OF COMInTU , , H, -, J 720 Contnud Fum page 2 J720 Ill. The following system changes will be implemented to assure continuing oanrpliance ' docmenttio Of dhe p1Wakcbad StnaflF1. 7) praru' 1t i dacW * aI a 1 01MD5 5"iUrI "certification with 03/19/10 02/05/10 ~The Piwm ofe In~itad om ummub -ok 13/0. 0iWf a "PI of regulations: All Plans of Care will be printed by the first day of the period. Allentered by thet nurse. be printed on the day'th order is interim orders will All orders will b faxed to those Physicians who accept facsimiles aid then sent through the mail with a stamped, self-addressed return envelope. Itthe Physician does not accept facsimiles, the order will be 8)ae-n-D n im IsL. t#15 . 6 . da o11ln of W/i 0/08 Thb anof Cmf Inlat on 1I0 .. '*naMtj t douIMfnnlteon of1i PJS . 9) NRM The PIO- Ill an 0dnIrsiss da of 101/0 eaWN oftiOM on U10 bft 1o/12/1"0.a"ha 'a of -:i1 10) Pl-I-#"6"- an anbgkh d cIam 200.19 The Pa oirC;m W aW 12 '19 dm=Meia of piIl radnii 1II2J1O. . 02105/10 03/19/10 mailed. If the order is not returned within 10 days, it will be shut via certified mail: If we do riot recqive the sigped order within the next the Physician. .still days, the Nurse / Nursing Supervisor will call seven (7) If the signed order, within the next seven (7)days is not received, a messenger will be sent to the Physician's office with another copy of the order, and 03/26/10 ,,-g M W ihl, Adwin ffir a 'ftI Dlked' ofPaU tSvkha ( ) a 1n3110 Wi M" 11111 Ned Offt haft WQ41 ge on10 request the Physician to sign it, If compliance isstill nbt achieved, the agency will request that the patient take the orders to the Physician I[fl The program's compliance will he monitored v utilizing the following quality assurance system: The Performance Improvement Committee will review 200/. of all orders sent out the prewious month on a weekly basis. A compliance threshold of 85% within six (6)months will be achieved. If the threshold is not achieved, the physicians involved will be contacted by the Medical Director, who will report his achieveirients and recomnendations al die siext Professional Advisory Committee (AC) meeting. 04/02/10 smvqP-6o U .Oa 4114M0, # AdllftSW OI'dhU emi *MPli. ftoed- " " t been on their next visit, to have them.signed. 05/01/10 Mm f * 10/01/10 , J . 11/01/10 l~ n M OYS W.,Mf . 1 -aFU oW UE * Vesbt NYS 1112 019 FrmiUl / 3 PRINTED: 03/122010 FORM APP ROVED New York State Department of Healtht STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDERSUPPLIERJCUA IDENTIFICATION NUMBER: k. MULTIPLE CONSTRUCTION BUILDING __________ (X3) DATE SURVEY COMPLETED LC0939C NAME OF PROVIDER OR SUPPLIER - B.WING STREET ADDRESS, CITY, STATE. ZIP CODE "0211812010 GENTIVA HEALTH SERVICES -'HAUPPAUGE (X4) ID PREFIX TAG 888 VETERANS MEMORIAL HIGHWAY, SUITE 210 IAUPPAUGE, NY 11788 AD PREFIX TAG PROVIDER'S PLAN OF CORRECIONxs (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H 000 Initial Comments -A Re-Licensure Sdrvey was conducted at Gentiva Health Services on 2/17/2010 and 2/18/2010. Five (5) Patient Care Records were reviewed and identified as Patients #1 to #5. One (1) Home Visit was made to Patient #1. Nine (9) Personnel Records were- reviewed and identified as Employees #1 to #9. The following was reviewed during the survey: policies-and procedures for the agency's Emergency Preparedness Plan, Health Provider Network and Directory, Criminal History Record Check, Clinical Supervision, On CaH, Adyisory Board of Directors, HIV Confidentiality, and Photo ID.The Complaint Log, Patient Information ' " Admission Packets and Quality _Assurancelimprovement Committee Meeting Minutes were reviewed. H 204 766.1(a)(1) Patient rights Section 766.1 Patient rights. H 000 Actions for Specific Patients Affected: - - - H.204 The Manager of Clinical Practice (MCP) provided corrective counseling and re-education to the RN Case Manager for patienl #1 on 2/22/10 regarding the necessity to properly complete all consents to accurately reflect the services provided by the Licensed Agency and the need to document the Insurance Policy # on the consenj as well. A corrected consent has been obtained for patient number 1. Measures or Systemic Chanes to Prevent ye: i Chngs3o/10en Reauror Mandator meeting held on 3/3/10 for all acnicians. The Director of Clinical Operations and Services (DCOS) instructed all clinicians regarding the necessity to properly complete all to accurately reflect the services provided by the Licensed Agency and the need to document the Insurance Policy # on the consent 2122/10 '(a) The governing authority shall establish written -Recurrence: policies regarding the rights of the patient and,. shall ensure the development of procedures implementing such policies. These rights, policies and procedures shall afford each patient the right to: .consents to: 1) be informed of these rights, and the right to - 3/3/0 iitiation of care, as evidenced prior to the "Mandatory exrisetin such rights, in writing by'written ocreasvinedbwten documentation in the clinical record; - -Please M " -,4ceof) see meeting f 3/3/10. Attachment 0, sMqn-in sheet for .. e of 31... ' (2) be given a statement of the services available Office of Health Systesa"gm nt/ TDATEr LABORATORY DIRECTOR'S OR-PROVIDERSUPPUER REWSENTATIVES SIGNATURE 'FORM o -111712009 Version NYS S'rTE " OBJ711 T FOMjo If cmtinuation sheet 1 01' PRINTED: 03/1 2/2010 New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION .: FORM APPROVED (XI) PROVIDER/SUPPLIER/CLIA IDENTIFICATI .ON NUMBER: LC0939C ~ X BUILDING B. WING (X2) MULTIPLE CONSTRUCTION _________ (X3) DATE SURVEY COMPLETED 0211812010 STREET ADDRESS. CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER GENTIVA HEALTH SERVICES -HAUPPAUGE (X4) ID PREFIX TAG 888 VETERANS MEMORIAL HIGHWAY, SUITE 210 HAUPPAUGE, NY 11788 In PREFIX TAG PROVIDER'S PLAN OF CORRECTION "E5) (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TOTHE APPROPRATE DEFICIENCY) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ' H 204 Continued From page 1 by,the agency and relate d charges; H 204 !M Pmgqram to Monitor b ."" The DCOS and Quality Assurance Nurse (QA RNj will conduct 2months of 100% record review of afl active charts, with an agency goal of 100% compliance with accurate completion of consents. 100 % audit will be ongoing until 6/14/10 and ongoin (3) be advised before care is initiated of the extent to which payment for agency services may be expected from any third party payors and the extent to which payment may be required from the patient. (i) The agency shall advise the patient of any' changes in information provided under this paragraph or paragraph (2) of this subdivision as soon as possible, but no later than 30 calendar "maintained, days from the date the'agency becomes aware of the change. (ii) All' informatiop required by this paragraph shall be provided to the patient both orally and in writing; (4) be informed of all services the agency is to provide, when and how services will be provided, and the name and functions of any person .and affiliated agency providing care and services.. This Regulation is not met as evidenced by: Based on record-review, home visit (HV) and staff interview, the Governing Authority failed to ensure that the patients are provided accurate information regarding the available agency Services and patient liability for services provided. This was evident in five (5) of five {5) records reviewed and one (1) of one (1) home visit (Patient #1). . a 100% rate of compliance is achieved for 2 consecutive months' at such time auditing will be reduced to 50% of clinical records of active Patients on a monthly basis with the goal of 100% rate of compliance. ff this goal is not the agency will resume 100% audits until 2 consecutive months of compliance is achieved again. This will continue on an ongoing basis. Inaddition, if any clinician isfound as a result of the audit to be deficient inbe counseled regardingof the consent, the correct completion he/she will complete all consents tothe necessity to properly accurately reflect the services provided by the Ucensed Agency and to document the insurance policy # in the appropriate'area of the consent, Inaddition, it will be required that the clinician obtain a new consent immediately that accurately reflects the services provided under the Licensed Agency. - Measures or Systemic Changes to Prevent Recurrence: Gentiva's Compliance and Legal Department reviewed the deficiency findings and as a result 5115/1o Failure to ensure that the patients are provided accurate information regarding the available . agency services and liability, places the patients .at risk for not being able to exercise rights. the consent has been revised to omit all references addressing Medicare billing and services that are not on the agencies license (see Attachment A). The new form Is being printed in duplicate and will be made available to caregivers. The~findings are: Office of.Health Systems Management / Office of Long Term Care STATE FORM Version NYSi 1/17/2009 tan OBJ711 7 If conlinuation sheet 2 of/ PRINTED: 03/1212010 FORM APPROVED New ork State Department of Health STATEMENT OF DEFICIENCIES (Xi) PROVIOER/SUPPIJERCLLA AND PLANOF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIOER OR SUPPLIER L93CB. 0939o .C (?X2 MULTIPLE CONSTRUCTION WiNG____________ (X3) DATE SURVEY comLE rEo 0o211812010 . (S STREETADDRESS. CITY, STATE, ZIP CODE " lIHAUPPAUGE, NY 11788' .. 888 VETERANS MEMORIAL HIGHWAY, SUITE-210 ID PROVIDER'S PLAN OF CORRECTION GENTVA SEVICS- AUPPUGE EALH GENTIVA HEALTH SERVICES - HAUPPAUGE PREFIX (X4)'ID TAG (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) SUMMARY sTATEmENT OF DEFICIENCIES PRFIX TAG H204 Continued From page 2 H 204 CROSS-REFER.ENCED TO THEAPPROPRLATE DEFICIENCY) Actions for Patients Potentiatly Affected and Measures or Systemic Changes to Prevent (EACH CORRECTIVE ACTION SHOULD BE COMPLETE DATE a) The "Home Care Consent" form for Patients .e #1 to #6 documents the following agency Services:, RN (Registered Nurse), LPN (Licensed Practical Nurse), Physical Therapy , Medical Social Services, Transportation; Housekeeping (or Homemaker), Speech/Language Pathology,, Home Health Aide, Nutritional Services, -. Occupational Therapy and Hospice Services. The agency license dated '/1 6/04 does not include the services of Transportation and Hospice Services. The agency revised license dated 4/23/2008 did not include the services of Transportation, Nutritional and Hospice Ser'vices. The updated consent will be utilized for all patients identified inthe above referenced 100% audit 5/15110 and requiring corrected consents. Additio'naly the ongoing deficiencies noted for Patients 1,2, 3,4 and 5 will be rectified through the utilization of the updated consent; updated consents will be obtained. The, new consent will be utilized going forward. Actions for Patients Potentially Affected and Measures or Systemic Changes to Prevent to.Pr..en Recurrence:es To identify patients having the potential to be affected by the same deficiency the DCOS and -Q-A RN will.conduct a 100% audit of al active .charts.The MCPs will complete a 100% audit of consents at start of care to ensure that the correct services and insurance policy # ae correctlyentered on all consents for all Patients. If any consents are found to be .deficient, clinicianwill be requiredto the 4obtain consent immediately. a new PA Program to Monitor. Results of record audits will be Presentedto 6.1300 the Professional Advisor, Committee (PAC at ) PAC meetings and PAC input will be incorPorated into the monitoring of records. PAC meeting minutes, includinq the reporting .ofthe record audit results, will be sent to the Goveming body, The OCOS will have overall responsibility to ensure that all corrective actions are completed. 6114110 ongoing b) During home visit to Patient #1 on 2/17/10with the agency's Nursing Supervisor, the Patient Information Packet was reviewed. The "Nutrition Services" is checked off by the nurse as an available agency service. The "Home Care Consent" form under section titled as "Authorization for Payment/Assignment of Insurance Benefits" documents "Icertify thato the information provided by me is correct. I authorize my insurance companl (ies) including as appropriate Medicare; Medicaid and other governmental programs to furnish any agent Of Gentiva Health Services any..and all information : pertaining to my insurance benefits and status of claims submitted by'Gentiva Health Services". " (patient signed her name) the insured , authorize payment directly to Gentiva -Health Services for Medicare, Medicaid, or other govemment program benefits (as applicable) and b2i other insurance benefits otherwise payable to Office of Health Systems Managementl Office of Long Term Care STATE FORM . . Version NYS 1111712009 68, OBJ711 .. Ifcontinuation sheet 3 of/ 10k gkqc a * " "PRINTED: 03/1212010 FORM APPROVED (X3) DATE SURVEY New York State Department of Health DEICENIE STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION X1-PROVIDER/SUPPLIEPJCLIA IDENTIFICATION NUMBER: .(X2) MULTIPLE CONSTRUCTION COMPLETED SA MULBUILDING LC0939C NAME OF PROVIDER OR SUPPLIER B.WING STREET ADDRESS, CITY, STATE. ZIP CODE 02/1812010 GENTIVA HEALTH.SERVICES -.HAUPPAUGE (X4) ID0 PREFIX TAG 888 VETERANS MEMORIAL HIGHWAY, SUITE 210 HAUPPAUGE, NY 11788 ID PREFIX TAG PROVIDRS pLAN OF CORRECTION BC (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H204 Continued From page 3 under Policy to be blank. #. :H 620 Actions for Specific Patients Affected: ... The clinician for palient #2and #4 was counseled 2/22/10 This area on the form was found . .oby .. .. the MCP regarding lack.of notification of physian regarding changes in the paients the phsca readnIhnesipatient's wound) and clinical status (the sie of the h ae~ the necessity to include the pressure ietting of wound vac device as ordered by the physician in documentation regarding care to a Wound with -a wound vac inplace. Measures or Systemic Changes to Prevent Recurrence: The areas addressing Medicare billing and the ys nge notesada aen documented services that are not the agency's license were not crossed out on the form by the .oall nurse. The licensed agency is not authorized to bill Medicare for agency services. o * ' During interview on 2/18/10 with the agency's Mandatory meeting held on 3/3/ld for all Director of Clinical Services (DCS) and Nursing The Director of Ctinical Operations and clinicians.(DCOS) instructed all clinicians that the sServices thedoCS stated docmened nurse Superv sors "Shold ave he ptiet insurance carrier on the consent form. The DCevcs(CO)isrceSaloiiin the necessity of notification of physician regarding nsu of changes inpafient clinical status (such as did not provide an explanation for the inaccurate .. changes inwound size) and of the necessity to information documented on the agency's "Home include the pressure setting of the wound vac Care Consent" form. o device as ordered by physician in all documentation regarding care to a wound with a H 620 H 620 766.5(b)(4) Clinical supervision o vac in place. Please see Attachment D. wound -sign-in 766.5 Clinical supervision. The governing authority shall ensure for all health care services 3/3110 sheet for Mandatory meeting of 3/3/10. and A e n fP Actions for PatientsPotentially Affected and that: h QA Program to Monitor: . (b) all staff delivering care in patient homes are adequately supervised. The department shall consider the following factors as evidence of . adequate supervision: (4) plans of care are revised as needed and changes are reported to the patient's authorized. practitioner, other staff providing care to the patient, -and other agencies which authorize payment for services, as appropriate and necessary. This Regulation is .not met as evidenced by: Based on record review and staff interview, the ,agency.failed to ensure that the professional staff office of Health Systems Management! Office of Long Term Care STATE FORM Version NYS-11/17/2009 -. o 6114/10 and To identify patients having the potential to be and to ensure on affected by the same deficiency, the deficient practice will not recur (QA program),the DCOS and Quality Assurance Nurse (QA RN)) will conduct 2 months of 100% record review of all active charts. with an agqency goal of 100% compliance with compliance with notification of phyisican regarding changes in the patient's clinical status (the size of the patient's wound) and pressure setting of wound vac. inclusion of o W9. OBJ7 11 If continuation sheel 4 f/ / PRINTED: 03/12/2010 FORM APPROVED New York State Department of Health STATEMENT OF.DEFICIENCIES ,ND PLAN OF CORRECTION (X1) PROV(DERISUPpLEPJCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION B. WING (E) DATE SURVEY COMPLETED C939a 0211812010 NAME OF PROVIDER OR SUPPLIER STREET ADDRESSC[TY. STATE. ZIP CODE GENTIVA HEALTH SERVICES - HAUPPAUGE PREFIX PR.I HAUPPAUGE, NY 11788 PREFX ID PREFIX TAG 210 888 VETERANS MEMORIAL HIGHWAY, SUITE ,PROVIDER'S PLAN OF CORRECTiON rXh) (X) ID TAG STATEMENT OF DEFICIENCIES -SUMMARY (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY ORLSC IDENTIFYING INFORMATION) CRIVE COSREEECDT OLDBE ANTE APPROPRIATE (EACH CORRECTIVE ACTION SHOULD ROSS-REFERENCED TO TH COMPLETE DATE H.620 Continued From page 4 H 0C iH inform the perform the required wound care, regarding .physician and nursing spervisor changes medications are cUrrent/updated as ordered in wound status and ensure that the - 620 ]2osc~v. audit willbe ongoin 100 % until a 100% rate .. - needed. This was evident in one (1) of four (4) patients requiring wound care (Patient # 4) and one (1) of five (5) patient care records reviewed c ) (P 1ie atient Failure to ensure that the professional staff provide the ordered patient services and, inform the physician for changes in the patient clinical status, places the patients at risk for poor quality of care and unmet needs. ardevice The nding to 50% of clinical records ofactive patients on with the oal a monthly basisthis oal is notof 100% rate of maintained,the mpliance:" f 2 agency will resume 100% audits untilis compliance achieved I consecutive months of ongoinq basis. again. This will continue on an if any clinician is found as a result of In addition, i the audit to be deficient in the above noted documentation, helshe will be counseled regarding the necessity of notilicaton of physician of changes inpatient clinical status (such as changes in wound size) and of the necessity to include the pressure setting of the wound vac as ordered by the physician inall a wound with a wound T f documentation regarding i vac in place. Measures or Systemic Changes to Prevent Recurrence: R, orece 5/15/10 Tye 1The agency will institute the use of a weekly wound assessment conference form (See Attachment. B), which will enable the MCP to document conference with dinician weekly regarding: assessmentof wounds, including location, size, amount and description of drainage. signs and symptoms of infection; notification of the physician of any changes inthe wound; changes care of the wound as ordered by the physician. The form will also include inquiry if wound vac is in use and serve as a reminder from MCP to clinician regarding the inclusion of physician ordered pressure settings fro all documentation of wound care to a wound with a wound vac in " place. Use inthe deficient practice on an ongoing" recurrence of this form will serve as deter basis, . consecutive of com11piiance is achieved for 2 will be reduced months:at such time auditing 1) Patient# 4 has an admissiondate of 7/01/2009 with the diagnoses including Non-Healing Surgical Wound, Diabetes Mellitus Type Il and Hypertension (HTN).. The Plan of Care dated 12/28/2009 to 2125t2010 documents orders for the patient'.s wound care as: "cleanse with NS (normal saline) liquid or spray, pack with KCI White sponge and cover with occlusive dressing -.VAC at 125mm/Hg change dressing 3 x (three times) weekly". dated 12123/09 documents The nursing visit note dain the patient's wound dimensions as "5c.m x 3.8cm x 0.3cm" The nursing visit note dated 1/04/2010 documents the patient's wound dimensions as "5.6cm x 2.5;m x 0.3cm" . The nursing visit note dated 1/18/2010 documents the patient's wound-dimensiols as' "6cm x 2.8cm x D.3cm' Version) NYS 11/17/2009 )ice ofFORM Systems Management Offce of Long Term Care STATE Health .~ OBJ71 1 It otna]f she continaon sht PRINTED: 03/12/2010 FORM APPROVED of Health New York State Department STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDEPJSUPPLEERJCLIA IDENTIFICATION NUMBER: : (X2) MULTIPLE CONSTRUCTION _ ________"__ BUILDING B_WING _._" TE C MP)D COMPLETED 62/1812010 LCO939C NAME OF PROVIDER OR SUPPLIER GENTIVA HEALTH SERVICES-HAUPPAUGE ID (X4) ID PREFIX TAG . STREET ADDRESS. CITY, STATE, ZIP CODE 888 VETERANS MEMORIAL HIGHWAY, SUITE 210 " HAUPPAUGE, NY .11788 (x5) PLAN OF CORRECTION "PROVIDER'S (I I LDPBEPROMPEDATE (CORRENCIE TONHE PREFIX ' TAG CROSS-REFERENCED TO THE APPROPRIATE SUMMARY, STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY O LC IDENTIFYING INFORMATION) OR RGUATR LSC 0DEFICIENCY) TA H 62.0 Continued From page 5 the The nursing visit notes did not document that informednotified the physician nrsehad nurse 620 I-1 Measures or Systemic Changes to Prevent. Recurrence: -. regarding the increase in wound size. During interview on 2/18/2010 with the agency's Director of Clinical Services (DCS) and Nursing Supervisors, the Nursing Supervisor stated that the nurse "should have informed the physician wound regarding the changes in the patient's 2/12/10 The nursing visit notes dated 12/23109 to that the nurse ensured that the do not document wbund vAc pressurewas maintained at the ode pressure mPAC that The visit note dated 1/31/2010 documentsthe the nurse that h tenreta the patient called to inform required pressure. The VAC was "not holding" the note further documents that the nurse performed .IThe the wound care. There is no documentation that the nurse had of restored the required wound VAC pressure In order to monitor compliance and prevent recurrence of deficiency, the DCOS and QA RN will complete a 100% retrospective review of all patient charts upon discharge to ensure compliance with proper use of the Wound Care completed if any deficiency is identified. stQA Program to Monitor: 5/19110 and ongoing form (See Assessment Conference update clinician will be Attachement B). Counseling of Results of recrdaudits will be presented the Professional Advisory Committee (PAC) at meetings and PAC input will be into the monitoring of records. o e2incorporated reportig PAC meeting minutes. Including the of the recordaudit results, will be sent to the 611/10 Governing body. I ensure that all corrective actions are completed. DOOS will have overall responsibility to -25rrmm/Hg" as ordered by the physician. During interview on 2,18/2010 with the agency's DCS and Nursing Supervisors, the DCS' stated that the nurse should have ensured that the i wound VAC pressure was maintained restoredas Actions for Specific Patients Affected: I education to the RN Case Manager for patient #2 i The MCP provided corrective counseling and re- 2122/10 per the physician's orders. 2) Patient #2 has an admission date of 11/21/2005 with the diagnoses including Paralysis Agitans, Pressure Ulcer Buttock and . o . . . _new ' on 2/22/10 regarding failure to update and keep current the medication profile in the patient's home and the patient's agency chart according to the MD orders for the discontinuation of medications, dosage adjustments and initiation of medications. The Plan ofCare dated 12/30/2009 tQ 2/2712010 documents orders: 'Flonase 50mg.1 (one) spray .pOffie of Health Systems Management / Office of Lonb Term Care - Version NYS 11/1712009 STATE FORM OBJ7il1 1" Ifcontinuation sheet 6.o/ "3 0 PRINTED: 03/12/2010 FORM APPROVED "" New York Stte De artment of Health o3 STATEMENT OF DEFICIE'NCIES AND PLAN OF CORRECTION NAME OF PROVlDER OR SUPPLIER (X2)-MULTIPLE (XlI) PR VI RISUPPL ERCLIA' ZiP CODE. CITY, STATE A.BUILDING IDENTIFICATION NUMBER: ADDRESS, STREET B.WING" oL03C O DE I LN "PoIE' CONSTRUCTION FCRETO ' COMPLETED OF E (X4) G PREFIX TA ID ' ~ P IA E " SUITE 210 " MEMORIAL HIGHWAY, CODER S-TATNE, ZIP UCORRETIONPET 888 VETERANs SS IT . S ML A SPL N O SHVDE RE TAD R '. ID TA G PREF X 02118/2010 EC (EACH A R EGUL DEFICIENCY VDE PLERS NAR E U FPR A OF DEFICIENCIESFULL ) ORM TION EN Y G INF BY SUMMARYOSTATEMENT IFIN M .ID T PRECEDED R Y R LSC UST BE TO C EN ACTION H S O L CDEaEF (EA CH CORRECTIVE T H 620 From page 6 620 Continued PO 600mg iO0mg ostril daily, Musinex in each Ultracet (as needed) and (by mouth) prn needed P pm tablet odaily as 325/37.5mg 1 ". pain on. Profile last updated the incud TE "Medication The Ln of ICarS di notPUG th La above the did not document Ultracet an'd 12/29/09 Flonase, Mucinex medications of the Plan of Care. Prevent to System Changes Measures or eurne for all held on 3/3/10 Mandatory meeting Operations and of Clinical clinicians The Director s i clin ian S) instru cted all e S rvIce s (DCO profile inthe patient's to current the medication agency chart according and the patient's home of the discontinuation the MD orders for and initiation of 3/3/10 I per 32537.5mg. as adjustments medications, dosage instructed to Clinicians were QD (four as "325/375mg PC o medication Ultracet the Profile" furtherdocuments " The "Medication BID (twice a day)"..' "Easix 20mg P medication of :.that does "not include patient care record with The Consulted that the nurse had Ultracet documentation the appropriate to confirm the patient. the physician regimefor . times a day)". new medications. see PtcmnD noted during visits. Please meeting of 3/3/10. sheet forl!Mandatory sign-in and Affected Patients Potentially Actions for Monitor: QA Program to . to the present. of Th-lnfC r 3/05/2009ld PlansCare from i o in 6/14/.0 an potential tobe the patients having enurtohoe adto To identify aftcedby thLamsifiiecy d i " dosage and medication o the agency's stated 2/1 8/2010 with interview Supervisors, the DCS u hng Nursingon - .cs and " -Medication updated the patient's and. failed to update that the nurse ohome ". Profile in the patient's t care record. the patie Duringth ~ . - . updated Medication eth.. e ydi no prv survey, tea . Pr file for review and Quaity Assurance Program) theDCOS conduct 2 months of will an with Nurse (QA RN) ofallactivechart. 00% record review compliance with the 100% y proles in goal of a genc updated medication to MD of according maintenance agency chart the patient's of medications., the discontinuation orders for and initiation of new until dosage adiustnents auditwill ongoing be % medications. 100 auditing wil l such time : at active consecutive months clinical records of of be reduced to 50% goal the of with . recur(QA does not the deficient practice o" nurseo orders for the of Care documents2 mo (two times a he Plan ."2 x mo x . to visit the patient month for two months).o natological interventions far/he " interventions . 2 This audits until consecutive gain. will achieved a compliance is In .- addition, if '/f . onanongoing basis. " / v/ ' Continue . a monthly basis If is this goalnot. patients on compliance. 100% rate of will resume 100% gency a maintained, the months of. Neurological. cardiovascu status.ological status, pain assess cardiovascular .as ss neur *management Management ffce of Health Systems and.me(medication) Care Office of'Long Term IIc PRINTED: 03112/2010 FORM APPROVED *New York State Department of Health "X.DTESRE STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION o Xi)PROVIDER/SUPPLIERJCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A BUILDING WING STREET ADDRESS. CITY, STATE, ZIP CODE COMPLETED LC93C. 0218/2010 .888 VETERANS MEMORIAL HIGHWAY, SUITE 210 GENTIVA HEALTH SERVICES - HAUPPAUGE (X4) ID PREFIX TAG IAUPPAUGE, NY 11788 PREFIX 'TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY),, SUMMARY STATEMENT OFDEFICIENCIES (EACH DEFICIENCY MUSt BE PRECEDED BY FULL LSC IDENTIFYING INFORMATION) REGULATORY ORREUAOYO..Ct TA (X5) - COMPLETE DATE H 620 Continued From page 7 effectiveness, med compliance. H 620 s "c c " notes dated The record includes the nurse's no documentation 12/29/09 and 1/20/10. There is visit of a reason the patient was visited tMice a month as per the Plan of Care; There is no documentation of the physician's order to change the Plan of Care and documentation that the nurse had consulted %With the physician to change the visit frequency. During interview on 2/1812010 with the DCS and Nursing Supervisors, the DCS stated that the carrier insurance nursing would not approve the visits. additional - any clinician isfound as a result of the audit to be defident inthe above noted documentation, he/she will be counseled regarding the necessity of updating and keeping current the medication profile inthe patient's home and the patient's agency chart according to the MD orders for the discontinuation of medications, dosage adiustmeents and initiation of new medicatios. Measures or Systemic Changes to Prevent Recurrence: MCPs and Rehab Director or designee will include comprehensive review of medication profile inthe home and clinical record during all Supervisory 5119/10 and ongoing. The agency did' not provide additional information and/or documentation during the survey. ~C.) profile both inthe home and inthe clinical record are updated to reflect all changes in the patient's medication regimen, including discontinuation of mediations, dosage adjustments. Any deficiencies that are found will be documented on the Supervisory and Competency Evaluation Form 'and reviewed with the clinician. (See attachment , Measures or Systemic Chan-ges to Prevent -Recurrence: home visits to ensure that the patient's medication " * Inorder to monitor compliance and prevent 5119/10 and ongoing * recurrence of this deficiency, the DCOS and QA will complete a 100% retrospective review of all patient charts upon discharge to ensure compliance. Counseling of clinician regarding the necessity of updating and keeping current the medication profile in the patient's home and the patient's agency chart according to the MD orders for the discontinuation of medications, dosage adjustments and initiation of new medications will be completed if any deficiency is identified. I s 8 1~ )ffice of Health Systems Management / Office of Long Term Care Version NYS 11/17/2009 )TATE FORM " i ircontinuation sheet 8 /OBJ7l "ii0 -/EO PRINTED: 03/08/200. FORM APPROVED New York State Department of Health TAXEMENT OF OEF1CIENCJES kND PLAN OF CORRECTION . 0(1) PROVIDMESUPPLIER/CUA IDENTIFICATION NUMBER. . (X2) MULtIPLE CONSTRUCTION BUIWING B. WING (3) DATE SURVE'Y COMPLETED LC0939C NAME OF PROVIDER OR SUPPUER STREET ADDRESS. CrTy,sTATE ZIP CODE - 02/18/2010 888 VETERANS MEMORIAL HIGHWAY, SUITE 210 HAUPPAUGE, NY 11788 ID TAG PROVIDEOS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE. CRO5 EIERENCED TO THE APPROPRIATE "5(5) COMPLETE DATE, GENTIVA HEALTH SERVICES (X4) ID PREFIX TAG HAUPPAUGE SUMMARY STATEMIENT OF DEFICIENCIES (EACH DEFICIENCY MUST BEPRECEDED 1Y FULL REGULATORY OR L&C IDENT ING INFORMATION) DEFICIENCY) H 620 H 620 QA Program to Monitor: Results of record audits will be presentedto the Professional Advisory Committee (PAC) at PAC meetinos and PAC input will be incorporatedinto the monitoring of records. 6/01/10 PAC meeting minutes,including the reporting of the record audit results, will be sent to the Governing body. The OCOS will have overall responsibility to ensure that all correctjve actions are.completed. H 620 Actions for Specific Patients Affected The clinician for patient #2 was counseled by MCP on 2122/10 regarding lack of notification of physician regarding deviation from oidered visit frequency on plan of treatment and of the necessily to document all consultations with physician regarding any changes to the ordered plan of treatment, including changes to the visit frequency Measuresor Systemic Changes to Prevent Recurrence: Mandatory meeting held on 3/3/10 for all clinicians. The Director of Clinical Operations and Services (DCOS) instructed all clinicians regarding the importance of notification of physician regarding deviation from ordered visit. frequency on plan of treatment and of-the necessity to document all consultations with physician regarding any changes to .pe ordered plan of treatment, including changes to the visit frequency. Please see Attachment A sign-in sheet for Mandatonv meeting of31311. 2/22110 3/3/10 Office of He=alth Systen"s Management I Office of Long Term Care STATE FORM Version-NYS i1111712009 OBJ71 o/dill If trnue~ion sheet,'ef 8 coI New York State Department of Health STATEMENT OF DEFIIENCIES AND PLAN OF CORRECTION (XI) PROVDERJSUPPUER L.A IDENTIFICATION NUMBER (X2) MULTIPLE CONSTRUCTION A BUILDING B. WING __________ PRJNTED: 03108/2010 FORM APPROVED (X3) DATE SURVEY COMPLETED LCO939C NAME OF PROVIDER OR SUPPLIER - 02118/2010 STREr-7 ADDRESS, CITY, STATE, ZiP CODE GfENTIVA HEALTH SERVICES -HAUPPAUGE (X4) ID pREFX TAG 888 VETERANS MEMORIAL HIGHWAY, SUITE 210 HAUPPAUGE, NY 11788 ID PREFIX TAG PR&ONDERs PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHtOULD BE CRO6S-REFERENCED TO THE APPROPRIATE (X5) COMPLErE DATE SUMMARY STATEMENT OF DEFIC(ENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) : I 'DEFICIENCY) . H 620 H 620 Actions for Patients Potentially Affected and _QA gram to Monitor. Pro To identify patients having the potentialto be 6/14/10 and affectefd by the same deficiency, and to ensure ongoing that the deficient practice does not recur (QA Program),the DCOS and Quality Assurance Nvurse QA RN)) will conduct 2 monthsof 100% record review of all active charts, with an agency goal of 100% compliance with theplan of treatment inregards to visit frequency.100 % audit will be ongoing until a 100% rate ofcom#liance is achieved for 2 consecutive months; at such time auditing will be reduced to 50% of cinicalrecords activepatientson of a monthy basis with the goal of 100% rateof compliance. f this goal is not maintained, the agency wll resume 100% audits until 2 consecutive months of corneliance is achieved again. This will continue on an ongoing basis, In addition, if any clinician is found as a result of the audit to be deficient maintaining compliance with ordered frequency of visits as per plan of treatment, or in documentation of all consultations with physician regarding any changes to the ordered plan of treatment, including changes to visit frequency, will be counseled regarding the above noted issues. Measures or Systemic Chanles to Prevent Recurrence:: In order to monitor compliance and prevent recurrence of this deficiency, the DCOS and QA RN will complete a 100% retrospective review of all patient charts upon discharge to ensure compliance. Counseling of clinician will be completed if any deficiency is identified: 5/19/10 and ongoing Office of Health Systems Ml'argementl Office of Long Term Care STATE FORM VersIn-4MYS 11/1712009 0BJ711 Ifconinuation sheeteZf a o " . PRINTED: 03/08/2010 "FORM APPROVED DATE SURVEY" (X3) COMPLETED New York State Department of Health OF STATEM4ENT'J DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDERtSUPPLIER/CLIA IDENTIFICATION NUMBDER (X2) MULTIPLE CONSTRUCTION A. BUIIDINC : NAME OF PROV]DER OR SUPPLIER LC0939C . STREET ADDRESS. CITY. STATE, ZIP CODE ... o0211812010 GENTIVA HEALTH SERVICES - HAUPPAUGE (X4) ID0 PREF( TAG. 888 VETERANS MEMORIAL HIGHWAY, SUITE 210 HAUPPAUGE, NY 11788 ID pPEFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SIOULD 1E CROSS-REFERENCED TO THE APPROPRATE "(x5) COMPLETE DATE SUMA RY STATEENT OF DEFICIENCIES (EACH DEFICIENCY MUST BEPRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) DEFICIENCY) H 620 H 620 QA Programto Moniton Results of record audits will be presentedto 6/1110 the Professional Advisory Committee (PAC) at PAC meetings and PAC input will be Incorporated into the monitoring of records. PAC meeting minutes, including the reporting of the record audit results, will be sent to the Governing body. 1 The DCOS will have overall responsibility to * ensure that all corredtive actions are completed. " "" - o IOffice of Long Term Caie Office of HeaMt Systems Management] VersionNYS I1/1712009 STATE FORM if~i mI~uonshoetof 8 STATE OF NEW YORK DEPARTMENT OF HEALTH Metropolitan Area Regional Office 90 Church Street, New York, NY 10007 Richard F.Daines M.D. Commissioner James W. Clyne, Jr. Executive Deputy Commissioner March 26, 2010 Progressive Home Health Services, Inc. Attn: Eleanor Halley VP/Administrator 132 West 31st Street, 7 th Floor New York, NY 10001 Re: Response to Plan of Correction License: 1348L001 Survey Date: 01/14/2010 Dear Ms. Halley' Please be advised that the Plan of Correction relating to the recent Full Survey of your agency have been reviewed by this office. All items were found to be acceptable and it is expected that you will implement this plan within the time frames that. were submitted. A post approval review will be conducted to verify the correction of deficiencies. If you have any questions regarding this matter, please call our office at (212) 427-4921. Sincerely, Cheryl Phoenix-Tannis, RN, MSN, CS Regional Program Director Bureau of Home Health Care and Hospices Services Metropolitan Area Regional Offices /it PRINTED: 01/2912010 FORM APPROVED New York State Deparrnent of Health S-ATEMNENT OF DEFICIENCIES AND PLAN OF CORRECTION (l) PROVIDERSUPPLIERICUA IDENTIFiCATION NUMBER: MULTIPLE CONSTRUCTION QU_) A. BUILDING A. WING Q3)DATE SURVEY L LC0691C NAME OF PROVIDER OR SUPPLIER STREET DRESS. CIrT, STATE ZIP CO0DE 0111412010 132 WEST 31ST STREET, 7TH FLOOR NEW YORK, NY 10001 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THEAPPROPRIATE DEFICIENCY) (Y5) COMPLETE DATE PROGRESSIVE HOME HEALTH SERVICES AG (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H000 Initial Comments A full survey was conducted at Progressive Home Health Services Agency, Inc., 132 West 31 st Street, 7th Floor, New York, New York on January 14. 2010. Twelve (12) personnel records were reviewed * and are identified as Employee #1 to #12. -Five (5) patient care records were reviewed and are identified as Patient #1 to #5. The Policy and Procedure Manual,'Operating H 000 Please see attached transfer stmmaries (Attachments I and 2) These summaries were presented, reviewed and discussed by the President and the Director of Patient Services at the time of the survey. License, Complaint Log. Health Provider Network * (HPN) Policy and Procedure, Criminal History Record Check, Emergency Preparedness and Quality Improvement meeting minutes were reviewed. " , H 324' 768.2(a)(9) Patient service policies and procedures 766.2 Patient service policies and procedures. (a) The governing authority shall ensure for each health care service provided that: S..center. (9) a patient isdischarged by the agency after notification of the authorized practitioner, as defined in subdivision (b) of section 766.4 of this Part, and consultation with the patient and any other professional staff involved in coordinating the plan of care, no less than 48 hours prior to This Regulation Is not met as evidenced byp Based on record review and staff interview, the agency failed to notify the physician within 48 hours prior to patient discharges. This-was patient discharge. H 324 Patient number 4 was transferred by the patient's family member and physician to a certified home health agency for skilled services not provided by Progressive Home Health Services. The physician initialed the caie and transfer. A late note has been entered into the 3/7/20.0 patient's chart chirifying this. Patient number 5 was transferred by his i physician to an inpatient rehabilitation A late note clarifying this has been entered into his chart. Documentation for all patients who have impendingdischarges will be reviewed prior to discharge to insure that the physician is notified at least 48 hours prior to discharge. Responsibility: Director of Patient Services. evident from twQ (2) out of five (5) patient care Ofieo records reviewed (Patients #4 and 5). aaeet Oc'. f Ln T ni t ytm ... . TITLE I...tA LAS STATE FORM o. n BIG UAs cZK 1 Version IYS 11117d2009 OR DIRECTORSJ PRO VIOERtSUPePLIERa rO- 3I/7/o If vnlnjlUati 1if slihest 6 VXE) rS - PRINTED: 01/29(2010 FORM APPROVED New York.State Deparlment of Health TATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION X1 PROVIDER/SUPPIERJCLA IDENTIFICATION NUMBER: (A) MULTIPLE CONSTRUCTION A. BUILDING . DATE SURVEY COMPLETED LCD691C NAME OF PROVIDER OR SUPPLIER *2. WNG . _________ 011141201D STREET ADDRESS, CITY. STATE, ZIP CODE 132 WEST 31 ST STREET, 7TH FLOOR PROGRESSIVE HOME HEALTH SERVICES AG (X4) ID PREFIX I TAG . NEW YORK, NY 10001 ,ID PREFIX TAG i PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCEDTO THE APPROPRIATE DEFICIENCY W) COMPLETE DATE SUMMARY STATEMENT OF DEFiCIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTJFYING INFORMATION. H 324 Continued From page 1 - H 324 This paige intentionally left blank. Failure to ensure that the physician is notified within 48 hours of patient discharge places patients at risk for receiving poor discharge plans. The finding is: l)Patient N4 has diagnoses of Colon Cancer, Dementia, Constipation, Hypertension; History of Breast Cancer; Transient Isohemic Attack, DepressionThe patient care record contains a discharge summary dated 11113/09 documents the physician was notified on "11/13/09". 2) Patient#5 has diagnoses of Alzheimer's Disease, Mitra Valve Replacement, Hypertension and Hypercholeslerolerria. The patient care record contains a discharge summary dated 09/23/09 documents that the physician was on 09I23(09. On January 14, 2010, the President andDirector of Patient Services were interviewed and did not give an explanation for the physGiaj not being notified prior to discharge. H1036 766,9(l) Governing authority Section 766.9 Governing authority. The governing authority or operator, as defined in Part 700 of this Title, of a.licensed home care services agency shall: (I) appoint a quality improvement committee to establish and oversee standards of care. The H1036 quality improvernent committee shall consist of a' consumer and appropriate health professional Office of Health Systems Management f OffIce of Long Term CGare STATE FORM" Version NYS 11117J2009 C6ZK1I IfconiUdonslheci 2 oe. PRINTED: 0129/2010 New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDERVSUPPLIERCLIA o "IDFfIlFICATION NUMBER: ,2 MULTIPLE CONSTRUCTION A BUILDING FORM APPROVED ) DATE SURVEY COMPLETED LC0691C NAME OF PROVIDER OR SUPPLIER B.WING STREET ADDRESS, CITY, STATE, ZIP CODS 011114/2010 PROGRESSIVE HOME HEALTH SERVICES AG (X4) ID PREFIX TAG 132 WEST 31ST STREET, 7TH FLOOR NEWYORK, NY 10001 ID PREFIX TAG SUMPRY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORJMATION) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD a2 CROSS-REFERENCEDTO THE APPROPRIATE COMPILETE DATE DEFICIENCY) H1036 Continued From page2 persons including a physician if professional health care services are prcvided.The committee shall meet at least four times a year to: (1) review policies pertaining to the delivery of the health care services provided by the agenoy'and recommend changes in such policies to the governing authority for adoption; (2) conduct a clinical record review of the safety,' adequacy, type and quality of services provided which includes: (i) random selection of records of patients currently receiving services and patients discharged from the agency within the past three months; and (ii) all Cases with identified patient complaints as specified in subdivision (j) of this section, (3) prepare and submit a written summary of review findings to the governing authority for necessary action; and (4) assist the agency in maintaining liaison with other health care providers in the community. This Regulation is met as evidenced by: not Based on record review and staff interview, the agency failed to ensure the Quality Improvement (QI) Committee meeting are attended byi a physician and consumerFailure to ensure the Quality Improvement Committee performs the required functions places patients at risk for receiving poor quality services, unsafe and inadequate care. The findings are: Office of Health Systems Management / Offinm Lng Tern Care of STATE FORM Version NYS 11)1 7/209 M H1036 This page intentionally left blank. C6ZK1 I If ccnUnuUon allo t 3 of 6 F PRINTED:A 01i2912010 FORM APPROVED of Health Now York State Department STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDER/SUPPUERICIA. IDENTIFICATION NUMBER M; MULTIPLE CONBTRITION . (X3 DATE SURVEY COMPLETED A BUILDING LC0691C MAIJE OF PROVIDER OR SlJPPUER STREET ADDRESS. CITY. STATE. ZIP CODE 0111412010 132 WEST 31ST STREET, 7TH FLOOR NEWYORK. KY 1001 11I PREFIX TAG PROVIDERS PLAN OF CORRECUION (EACH OORRECTrVr AGTJON SHOULD BE CROSS-RFFRENCod TO Tm-APPROPRIATE DEFICIENCY) C5) COMPLETE PROGRESSIVE HOME HEALTH SERVICES AG M4) ID ! PREFIX 7AG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING 1NFORMATtoN DATE H103 1Continued From page 3 I The Q committee meeting minutes do not have H1036 The QI Committee attendance sheets provided to the surveyors are attached (Attachments 3a-e) These attendance sheets were presented to the surveyors by the President and the Director of Patient Services, and were reviewed and discussed at length during the closing conference. Progressive has a physician, as a member of the QI Committee Although a physician is not required by regulation since Progressive does not provide "professional health care services." (The physician was in fact present at each meeting of the QI Committee.) Progressive Home Health Services is conducting a search for an alternate consumer member who will be assigned when the primary consumer member is unable to attend the QI meeting. Responsibility: Director of Patient Services Expected date of completion: May 6, 2010 (next QI meeting) documented evidence of physician and consumer attendance for the following meeting: February 1, 2007,August 2, 2007, May 3, 2007, May 1, 2006 and May 7. 2009. I On January 14, 2010, the President and Director of Patient Services were interviewed and did not give an explanation for the physician and " consumer not attending the meetings. H1 142 7669(o) Governing Authority Section 766.9 Governing authority HI 142 5/6/2010 (a) Health Provider Network Access and Reporting Requirements The governing authority or operator of an agency shall obtain from the Department' s Health Provider Netwoik (HPN), * HPN accounts for each agency that it operates and ensure that sutficient, knowledgeable staff will be available to and shall maintain and keep current such accounts. At a minimum, twenty-four hour, seven-day a week contacts for emergency communication and alerts, must be designated by each agency in the HPN Communications Directory. A policy defining the agency' s HPN coverage consistent with the agency' s hours of operation shall be created and reviewed by the agency no less than annually. Maintenance of each agency' s HPN accounts shall consist of, but not be limited to, the following: (1) sufficient designation of the agency' s HPN coordinator(s) to allow for HPN individual user application; (2> designation by Ihe governing authority or operator of an agency of sufficient staff users of the HPN accounts to ensure rapid response to Office of Health Systems Management f Office of Lon Term Care STATE FORM Version NYS 1111 72009 C6ZK11 If corn0a, sheet 4 & 6 PRINTED: 0112912010 New York State Depariment of Health STATEMENT OF DEFICIENCIES (Xl) PROVIDER/SUPPIAE/CLIA 7 MULTIPLE CONSTRUCTION FORM APPROVED (X3) DATE SURVEY PROGESSVE SEVICE AG HME EALT (YA) IA PREFIX TAG 132 WEST 31ST STREET, 7TH FLOOR OSNEWYDRK, NY 10 ID PREFIX TAG PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETE DATE SUNRR IARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H1 1421 Continued From page 4 requests for information by the State.and/or local Department of Health; (3) adherence to the requirements of the HPN user contract; and (4) current and complete updates of the Communications Directory reflecting changes that include, but are not limited to, general information and personnel role changesas soon . as they occur, and at a minimum, on a monthly basis. H1142 This Regulation is not met as evidenced by: Based on observation and staff interview, the agency did not maintain a complete and.current Health Provider Network (HPN) Communications Directory. Failure to maintain a complete and current HPN Communications Directory places patients at risk for unsafe care during an emergent situationThe finding is' On January 14, 2010, the Administrator logged onto4he agency HPN Commtunications Directory and printed out a copy of the "Select a Role to Assign/Modify for Progressive Home Health Services, Inc." frorn HPN. There is no documentation of the contact names for the following roles: Order Official Prescriptions, Governing Body Chairman/President, Infection Control Practitioner. On January 14, 2010, the President and Director of Patient Services were interviewed and did not Office of Health Systams Management / Office of Long Term Care STATE FORM Version NYS 1IV1712009 C5ZK11 Ifr)ntluation $ne6 .of6 The President and the Director of Patient Services discussedduring the closing -conference of 1/14/10 survey the process for monthly review of the HPN Communications directory... All appropriate roles have been assigned in the HPN. The HPN Coordinator will review the HPN website during the first week of every month to assure that all roles remain current and the 20 available user slots are being utilized by Progressive Home Health Services to satisfy regulatory requirements. The HPN Coordinator will document that the task has been completed via an email sent to the Director of Patient Services. Responsibility: HPNCoordinator 1/14/2010 PRINTED: 01129fl01C FORM APPROVED New York State Department of Health &TAT9. ENT OF DEFICIENCIES AND PLAN OF CORRECTICN - (X) PROVIDERISUPPLIER/CLIA IDENTIFICATION NUMBER (X2) MULTIPLE CONSTRUCTION A- BUILDING (X3) DATE SURVEY COMPLETED "LCO694C NAME OF PROViDER OR SUPPLIER -TREET B. WING ADDRESS. CITY. STATE, ZiR CODE 0114/,W2010 PROGRESSIVE HOME HEALTH SERVICES AG (X4) ID PREFIX TAG 132 WEST 3SST STREET, 7TH FLOOR NEWYORK, NY 10001 ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES lEACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSO IDENTIF'YING INFORMIV'.ON) PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE E DRSICIEN I{APQRE Y) DEFICIENCY) o (xi COMPLETE DT ) H1142 Continued From page 5 giv e an explanafi an for the finding. H1142 This page intentionally left blank. Office of Health Sygtfems Management I Of fce of Lorg Term Care Version NYS 111712009 ST-'ATE FORM CZKI1 If crvlnuaton sheet Sof S New York State Department of Health STATEMENT OF DEFICIENCIGS AND PLAN OF CORRECTION (XI) PRCOIDERISUPPLIERJCLIA *I05,rlrFICATON NUMBER: (X2) MLInPLE CONSTRUCTION PRINTED: 0112W2C10 FORM APPROVED (X38 DATE SURVEY COMPLETED A BUILDING LC0691C NAME OF PROVIDER OR SUPPLIER - 0111412010 STREET ADDRESS CrTY. STATE, ZIP CODE PROGRESSIVE HOME HEALTH SERVICES AG. IXA) ED 1 32 WEST 31ST STREET, 7TH FLOOR NEW YORK, NY 10001 I PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MLJSTBE PRECEDED BY FULL REGULATORY OR Lsc IDENI1FYING INFORMATION) ID PREFIX TAG PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCIED TO THE APPROPRIATE DEFICIENCY) 1X52 COMPLETE DATE R 722 402.6(d) Criminal History Record Check Process Section 402.6 Criminal History Record Check Process. ...... (d) A provider may temporarily approve a prospective employee while the results of the criminal history record-cfheck are pending. The provider shall implement the supervision requirements identified in section 402.4 of this Part, applicable to the provider, during the period of temporary employment, ' R 722 Employee # 4 was hired on 12/5/06 and the fingerprint results were not received until 3/23/07 and Progressive was unable to locate/produce documented supervision after 2/11/07. Employee # 7 was hired on 5/12/07 and the fingerprint results were not retuneduntil 8/17/07 and Progressive ws unl to1locateprores was unable to locate/produce documented supervision after 6/1/07. (The challenge the agency faced was the projected DOH CHRC turnaround time (7-10 business days - see attachment # 4) when the reality for both DOH CHRC and the agency was a 45+ day turnaround.) In2008 after a self-audit of our cHRd staffing resources adjustments were This Regulation is not met as evidenced by: Based on ecrd reviews and staff interview, the agency did not document weekly supervision for all employees required for Criminal History Record Check (CHlRC). This was evident for two (2) of twelve (12) personnel records reviewed (Employees #4 and 7). Failure to document weekly supervision While awaiting the results of the CHRC places patients at risk for receiving unsafe Care. 6/20/2008 Supervisionerocses, ocedur and Superesion processes, procedures and made to assure consistent supervision including assigning a full-time dedicated staff member to oversee all aspects of the agency's CHRC process/tiacking. In addition, since the implementation addition, LieScnhe leentour The findings are: 1) Employee #4 is a Home Health Aide hired by the agency on "12/5t06_' 2) Employee #7 Is a Home Health Aide hired by the agency on "5/12/07. ~~in There is no documented evidence of weekly supervision of Employee #4 between 02/11107 and 03/23/07 while awaiting the results of the in 2009 of Live Scan none of our active Aides have pending CHRC results. criminal history record check until the CHRC results returnedThere is no documented evidence of weekly Responsibility. 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Damnes M.D: Commissioner New York, NY 10007 Metropolitan Area Regional Office 90 Church Street, James W.Clyne, Jr. Executive Deputy Commissioner June 22, 2 0 10 Metropolitan Jewish Licensed Home Care Attn: Laurie Chichester, VP 6323 Seventh Avenue Brooklyn, NY 11220 Re: Response to Plan of Correction License: 1295L001 Survey Date: 5/6/2010 Dear Ms. Chichester: / relating to the recent State Re-licensure Please be 'advised that the Plan of Correction office. Survey of your agency have been reviewed by this that you will implement this plan All items were found to be acceptable and it is expected approval revie.v will be conducted.to within the time frames that were submitted. A post verify the correction of deficiencies. our office at (212) 427-4921. If you have any questions regarding this matter, pleasecall Sincerely,' 7 Cheryl Phoenix-Tannis, RN, MSN, CS Regional Program Director Bureau of Home Health Care and Hospices Services Metropolitan Area Regional Offices !jt PRINTED: 05/24f2010 -FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDERJSUPPLIERCLIA IDENTIFICATION NUMBER: o :. (X2) MULTIPLE CONSTRUCTION A.BUILDING I& WING {X3) DATE SURVEY COMPLETED LCO 23A NAME OF PROVIDER OR SUPPLIER BI0510612010 STREET ADDRESS, CITY, STATE, ZIP CODE METROPOLITAN JEWISH LICENSED HOME Ci (Y.4) ID PREFIX TAG 6323 SEVENTH AVENUE -BROOKLYN, NY 11220 ID PREFIX TAG PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE TO THE APPROPRIATE DCROSS-REFERENCED DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) i H000 initial Comments I A State re-licensure survey was conducted at I Metropolitan Jewish Licensed Home Care Services Agency on May 6, 2010. Four (4) personnel records were reviewed and are identified as Employees #1 to #4. Four (4) patient care records were reviewed and are identified as Patients #1 to #4. -The Policy and Procedure Manual, Complaint Log, Admission Packet and Quality Improvement meeting minutes were reviewed. H 2221 766.1(a)(8) Patient rights Section 766.1 Patient rights. (a) The governing authority shall establish written policies regarding the rights of the patient and shall ensure the development of procedures implementing such policies. These rights, policies and procedures shall afford each patient the right - H 000 I, H 222 Responsible Patties: Vice-President and Director 6f Patient Services Corrective action plan: The LHCSA's Patient Rights policy has beep revised to include the correct contact number for complaints to the NYSDOH (attachment # 1) Completion date: Done Completed to:nubrfrcmlittoteNSO (8) voice complaints and recommend changes in policies and services to agency staff, the New York State Department of Health or any outside representative of the patient's choice. The expression of such complaints by the patient or his/her designee shall be free from interference, coercion, discrimination or reprisal. This Regulation is not met as evidenced by: Based on record review and interview, the agency failed to revise policies to include the correct phone number to contact the New York State Department of Health ( NYSDOH),for complaints, * This was-evident for the agency Patient Rights policy and procedure, Office of Health Systems Management ( Office of Long Termi Care LABORATORY DIRECTOR'S OR PROVIDERISUPPLIER REPRESENTATIVE'S SIGNATURE oo F -- VersionNYS 11/1772 9 ' i , -TITLE ' DATE (KG 451 & o Ifcontinuatir sheet l of 13 l -New York State DeDartmentof Health . TATEMENT OF DEFICIENCIES D PLAN OF CORRECTION X MULTIPLE CONSTRUCTION (XI) POIDEISUPPIERCLA IDENTIFICATION NUMBER:.MOMPNEUD __ - A BUILDING " ~~~~ x,, IIXATE WING B. 6323 SEVENTH AVENUE BROOKLYN, NY 11220 ""_ ~ SURVEY (3DR EOPLE COMPETE PRINTED: 0512412010 FORM APPROVED L 0523A LAME OF PROVIDER OR SUPPLIER 0510612010 STREET ADDRESS, CITY, STATE, ZIP CODE - METROPOLITAN JEWISH LICENSED HOME C) (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION(X5) ID COMPLETE (EACH CORRECTIVE ACTION SHOULD BE PREFIX DATE CROSS-REFERENCED TO THE APPROPRIATE TAG I~DEFICIENCY) H 222; Continued From page 1 Failure to update patient rights policies and procedures places patients at risk for not having agency staff promote and protect all patient rights. The findings is: 1The agency: "Attachment I: Patient Rights" document found in the agency policy and procedure manual documents the following information: "Voice complaints and recommend changes in policies and services to agency staff, the New York State Department of Health (800) " 206-8125 The documented phone number ins not the correct contact informationfor NYSDOH complaints. H 222 i" I On May 6, 2010 at 4:05 p.m., the agency Vice President of Home Care was interviewed and did Snot provide a explanation. H 2241 766.1(a)(9) Patient rights S"Corrective Responsible Parties:'Vice-President and s Patient Services Director of . , H 224 actionplan: Policies completed. iAdmission agdmit- N/A Section 766.1 Patient rights. written * (a) The governing authority shall establish and policies regarding the rights of the patient shall ensure the development of procedures implementing such policies. These rights, policies and procedures shall afford each patient the right to: 1 ...... (9) submit patient complaints about the care and services provided or not provided and complaints concerning lack of respect for property by anyone Ifurnishing service on behalf of the agency, to be such informed of the procedure for filing Office of Health Systems Management /Office of Long Term Care Version NYS 11117/2009 STATE FORM revised The LHCSA's Patient Rights policy has been number for i to, includethe correct contact complaints to the NYSDOH (attachment # ). The LHCSA's Patient Complaint policy regardihg the investigation of and response to complaints in accordance with 766.9(j)is also available !.attachment #2). For patients admitted into. the LHCSA, we will utilize a 2 page Admission Agreement (attachment #3) to docume'nt that the patient has received information regarding their right to register a i complaint. c 46511 fcontinuation sheet 2 of13 PRINTED: 05/24/2010 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES (Xli) PROVIDER/SUPPLIER/CLIA. (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER. A. BUILDING LC523AB. NAME OF PROVIDER OR SUPPLIER WING STREET ADDRESS, CITY, STATE, ZIP CODE 0510612010 METROPOLITAN JEWISH LICENSED HOME Cj (X4) ION PREFXI TAG TG I 6323 SEVENTH AVENUE BROOKLYN, NY 11220 ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) I ~DEFICIENCY) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED To THE APPROPRIATE (X5) COMPLETE DATE H224 Continued. From page 2 S224 complaints, and to have the agency investigate such complaints in accordance with the I provisions of subdivision 0) of section 766.9 of this Part The agency is also responsible for i notifying the patient or his/her designee that if the patient is not satisfied by the response the patient I may complain to the Department of Health's Office of Health Systems Management. This Regulation is not met as evidenced by: Based on record review and interview, the agency did not provide patients with * complete information for lodging complaints. I This was evident for the agency admission letter. Failure to provide complete complaint information Iplaces patients at risk for not being able to fully exercise the right to make a complaint. The findings are: Charts for LHCSA patients will be audited monthly to ensure Admission Agreement is received back from patient. Completion date: Policies - done Use of Admission Agreement - when patients are a t *The agency: "admission letter" documents the following information: "To contact the Telehealth Program immediately at 718-759-4733 if you have any problems, concerns or questions about I the equipment." * There is no documented evidence informing patients the agency has within 15 days to explain the complaint investigation findings and the decision rendered. There is no documented evidence of informing. patients of an appeals process and the appealof - must be reviewed by a member or committee the governing body within 30 days of receipt of the appeal. There is no documented evidence of informing patients the right to voice complaints and recommend changes in policies and services to Office of Health systems Management I Office of Long Term Care Version NYS 1111712009 STATE FORM 465.11 Ifcontinuston sheet 3of 13 PRINTED: 05/2412010 FORM APPROVED 4ew York State Department of Health ... TATEMENT OF DEFICIENCIES ND PLAN OF CORRECTION (X1) PROVIDER/SUPPLiERCLIA IDENTIFICATION NUMBER: MULTIPLE CONSTRUCTION (X2) A. BUILDING B WING _ (X)DATE SURVEY COMPLETED I 05/0612010 LC0523A lAME OF PROVIDER OR SUPPLIER METROPOLITAN JEWISH LICENSED HOME Cl (X4) ID PREFIX TRF TAGT STREET ADDRESS. CITY, STATE. ZIP CODE 6323 SEVENTH AVENUE BROOKLYN, NY 11220 I ID PREFIX . TAG H 224 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X5) COMPLETE DATE H 224 Continued From page 3 agency staff, the New York State Department of Health or any outside representative of the patients choice. On May 6, 2010 at 1:30 p.m., the agency Vice President of Home Care was interviewed and did not provide an explanation for the findings. H 2321 766.1(c) Patient rights Section 766.1 Patient rights. (c)if a patient lacks capacity to exercise these rights, the rights shall be exercised by an to individual, guardian or entity legally authorized represent the patient This Regulation is not met as evidenced by: Based on record review and interview, the agency failed to have written and complete information regarding the rights of patients with diminished mental capacity to have a representative exercise all patient rights. This was evident for the agency Patient Rights policy and procedure. Failure to have a complete patient rights policy places patients at risk for not having agency staff promote and protect all patient rights. The finding is: The agency: "Patient Rights" policy and procedure lacks documented evidence of the right for patients lacking capacity to exercise the rights and the rights to be be represented by an authorized individual or guardian. On May 6, 2010 at 4:05 p.m., the agency Vice President of Home Care was interviewed and did not provide an explanation. 2fice of Health Systems Management I Office of Long Term Care Version NYS 1111712009 -TATE FORM H 232 Responsible Parties: Vice-President and Director of Patient Services oCompleted Corrective action plan: has been policy ratet The LHCSA's Patient Rights tin ent i rve to revised to include documentation related t, the rights of a patient lacking capacity in accordance with 766.1 (c) (attachment # 1) Completion date: Done 465J1 1 Ifcontinuation sheet 4 of 13 PRINTED: 05/24/2010 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDERISUPPLIERICLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION AkBUILDING __________ X3)PDATE SURVEY COMBUITIN LC0523A NAME OF PROVIDER OR SUPPLIER B. WIG STREET ADDRESS. CITY. STATE. ZIP CODE 0510612010 METROPOLITAN JEWISH LICENSED HOME Ci (X4) ID PREFIXi 6323 SEVENTH AVENUE BROOKLYN, NY 11220 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTIONSHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H 404 Continued From page 4 H 40;766.3(b) Plan of care 766.3 Plan of care. The governing authority or operator shall ensure that: S..... (b) a plan of care is established for each patient based on a professional assessment of the patient's needs and includes pertinent diagnosis, prognosis, mental status, frequency of each service to be provided, medications, treatments, diet regimens, functional limitations and i rehabilitation potential.. This Regulation is not met as evidencedby: Based on record reviews and interview the agency failed to develop complete Plans of Care. This was evident for three (3) of tour (4) patient 1care records reviewed (Patients #1.to #3). I H 404 H 404 Responsible Parties: Vice-President and Director of Patient Services Corrective action plan: For patients admitted into the LHCSA, a 485 format will be used for physician orders i (attachment #4) to ensure all pertinent information is included. Charts for LHCSAI patients will be audited on a monthly basis: to ensure physician orders are complete: Completion-date: When patients are admitted to LHCSA N/A I Failure to ensure plans of care are complete places patients at risk for receiving poor care as a J result of not having all needs met. 1The findings are: :1) Patient #1 has a start of care date of "6/10/09" admitted for telemonitoring of blood pressure, pulse and blood glucose. 2) Patient #2 has a start of care date of "7/13/09"; admitted for telemonitoring of blood pressure, pulse and blood glucose. 3) Patient #3 has a start of care date of "4/25/09"; admitted for telemonitoring of blood pressure, pulse and blood glucose. There is no documented evidence of Plans of Care for Patients #1,2 and 3 which include Office of Health Systems Management I Office of Long Term Care STATE FORM Version NYS 11/1712009 465J1 1 continuation sheet S of 13 If . PRINTED: 05124/2010 FORM APPROVED qew York State Department of Health TATEMENT OF DEFICIENCIES ND PLAN OF CORRECTION PROVIDERJSUPPLIERICUA (XI) IDENTIFICATION NUMBER: . (X2) MULTIPLE CONSTRUCTION COMPLEATEDRE COPLEDEN A.BUILDING __0510__2 LC0523A lAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE, ZIP CODE 0510612010 6323 SEVENTH AVENUE BROOKLYN, NY 11220 ID PREFIX. TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCEDTO THE APPROPRLATE DEFICIENCY) COMPLETE DAT, METROPOLITAN JEWISH UCENSED HOME Co (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (XS) H 404 Continued From page 5 pertinent diagnosis, prognosis, mental status,. medications, diet regimens, functional limitations and rehabilitation potential. On May 6, 2010 at 1:30 *p.m..the agency Vice President of Home Care was interviewed and stated: "... we are providing telephonic assessments... we're not going into patients homes." H 5121 766.4(c) Medical Orders H 404 I H 512 Responsible Parties: Vice-President and Director of Patient Services. Corrective action plan: . N/A 766.4 Medical orders. revised as (c) Such orders shall be reviewed and i the needs of the patient dictate but no less frequently than every six months, except where an authorized practitioner, as part of an authorization, orders personal care services for up to one year for a Medicaid patient This Regulation is not met as evidenced by: Based on record reviews and interview, the agency failed to review and revise medical orders This no less frequently than every six months. care was evident for two (2) of four (4) patient Srecords reviewed (Patients #1 and 2). six (6) Failure to obtain medical orders every - For patients admitted into the LHCSA,an electronic reminder/task will be set up for 51/2 months in the future to cue the Coordinator when new orders are due. This will be attached to the patient's record so if the primary Coordinator is out, the covering Coordinator will be cued to obtain the orders and nothing will be missed. Should orders revision at the than 6 months, they require obtained sooner time they are needd. will be " Charts for LHCSA patients will be audited monthly to ensure o.rdeiTs are up to date. months places patients-at risk for receiving .unauthorized care. The findings are: 1) Patient #1 has a start of care date of "6/10/09". and was admitted for telemonitoring of blood pressure, pulse and blood glucose. The patient care record includes a medical order dated "9/29109". Completion date: When patients are admitted to .. ompLHCSA Office of Health Systems Management t Office of Long Term Care Version NYS 1111712009 STATE FORM 465J1 1 Ifcontinuation sheet 8of 13 PRINTED: 0512412010 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION . . . (Xl) PROVIDER/SUPPLIERCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING __________ (X3) DATE SURVEY COMPLETED LC0523A NAME OF' PROVIDER OR SUPPLIER STREET ADDRESS, CITY. STATE, ZIP CODE 0510612010 METROPOLITAN JEWISH LICENSED HOME C) (X4) ID PREFIX TAG 6323 SEVENTH AVENUE BROOKLYN, NY 11220 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE oDEFICIENCY) SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL ' , REGULATORY OR LSC IDENTIFYING INFORMATION) I COMPLETE DATE (X5) H 5121 Continued From page 6 There is no documented evidence of medical orders after "9129109". H 512 i ;admitted for telemonitoring of blood pressure, * pulse and blood glucose. 2) Patient #2 has a start of care date of '713109" The patient care record includes a medical order dated '7/28/09". There is no documented evidence of medical orders after "7/28/09". On May 6, 2010 at 3:00 p.m., the Telehealth Nurse Manager was interviewed and did not provide an explanation. H 514' 766.4(d) Medical orders H 514 Responsible Parties: Vice-President and Director of Patient Services N/A 766.4 Medical orders. (d) Medical orders shall reference all diagnoses, medications, treatments, prognoses, and other I pertinent patient information relevant to the "'agencyplan of care; and 1 swhen shall be authenticated by an authorized (1) practitioner within thirty (30) days after admission to the agency; and .are indicated, orders, including telephone orders, Corrective action plan: For patients admitted into the LHCSA, a 485 . format will be used for physician orders #4) to ensure all pertinent information (attachment is included. For patients admitted into the LHCSA, the verbal order is received, the written order will be faxed the same day to the physician:. The returned copy with signature will be trackdd if it is not received within 3 days (5 days if it includes a weekend), the physician will be contacted 6gain. If it is not received back in another 3-5 days. the (2) when changes'in the patient's medical orders shall be authenticated by the authorized .. practitioner within thirty (30) days.. I This Regulation is not met as evidenced by: Based ort record reviews and interview, the agency failed to have complete medical orders and toensure medical orders are signed by an authorized practitioner within thirty (30) days. Office of Health systems management i Office of Long Term Care . STATE FORM Version NYS 1111712009 699 physician will again be contacted and the order will be re-faxed. This process will be continued until the orders are received back with signature. Contact with the physician and attempts to obtain signed copies will be documented inthe patient's record. 465311 If continuation sheet 7of 13 PRINTED: 05/24/2010 FORM APPROVED -ew York State Departmentof Health TATEMENT OF DEFICIENCIES ND PLAN OF CORRECTION (XI) PROVIDERJSUPPLIERCLIA IDENTIFICATION NUMBER: X MULTIPLE CONSTRUCTION . (X3) DATE SURVEY COMPLETED A. BUILDING LC0523A LAME OF PROVIDER OR SUPPLIER WING . B. STREET ADDRESS. CITY. STATE. ZIP CODE 0510612010 METROPOLITAN JEWISH LICENSED HOME Ci (X4) ID PREFIX 1 TAG 6323 SEVENTH AVENUE -BROOKLYN, NY 11220 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE Y)TO THE APPROpRATE CROSS-REFERENCED (xs) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H514, Continued From page 7 This was evident for four (4) of four (4) patient care records reviewed (Patients #1 to #4). Failure to ensure medical orders are complete and authenticated by the authorized practitioner places the patient at risk for receiving unsafe care. The findings are: 1) Patient #1 has a start of care date of "6110/09' ;admitted for telemonitoring of blood pressure, pulse and blood glucose. The initial medical order dated "6/5/09" lacks documented evidence of diagnoses, medications and prognosis. 2) Patient #2 has a start of care date of '7/13/09"; admitted for telemonitoring of blood pressure, pulse and blood glucose. The initial medical order dated "6/29/09" lacks i documented evidence of diagnoses, medications and prognosis. The medical order initiated on "6/29/09" was signed by the physician past 30 days on "9/22/09". The medical order initiated on "7/13109" was signed by the physician past 30 days on "1019/09". 3) Patient #3 has a start of care date of "4125/09"; admitted for telemonitoring of blood pressure, pulse and blood glucose. The first documented medical orders is dated "6110/09", which is two (2) months after the start Dtfice of Health Systems Management /Office of Long Term Care STATE FORM Version NYS 11/1712009 H 514 Charts for LHCSA patients will be audited monthly to ensure orders are up to date. Completion date: When patients are admitted to LHCSA eas 465JI 1 If continuation sheet 8 of 13 PRINTED: 05/2412010 FORM APPROVED New York State Deartment of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDERJSUPPLIER/CLIA IDENTIFICATION NUMBER: - ... . (X2) MULTIPLE CONSTRUCTION A BUILDINCOMPLETED B.WNG _0__0__2010 (X3) DATE SURVEY LCO523A NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CrTY. STATE, ZIP CODE 05106/2010 METROPOUTAN JEWISHLICENSED HOME Cd . (X4)I PREFIX i TAG 6323 SEVENTH AVENUE BROOKLYN, NY 11220 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE (X5) COMPLETE DTE SUMMARY STATEMENT OF DEFICIENCIES (EAC4 DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H 514 Continued From page 8 of care. There is no documented evidence of initial medical orders which include diagnoses. medications, treatments and prognosis. 4) Patient #4 has a start of care date of "3/12110" and was admitted for telemonitoring of blood pressure and pulse. The initial medical order dated "3/4/10" lacks documented evidence of diagnoses, medications and prognosis. I On May 6, 2010 at 3:00 p.m., the Telehealth Nurse Manager was interviewed and did not provide an explanation. H 720 766.6(a)(9) Patient care record 766.6 Patient care record. (a) The agency shall maintain a confidential record for each patient admitted to care to include: ..... o qi(9) documentation of the patients receipt of information regarding his/her Ighis. This Regulation is not met as evidenced by. Based on record reviews and interview, the agency failed to document receipt of information regarding patient rights and advance directives. This was evident for four (4) of four (4) patient care records reviewed (Patients #1 to #4). Failure to document receipt of information regarding patient rights and advance directives places patients at risk for not being able to fully exercise all rights. - H 514 " H 720 Responsible Parties: Vice-President and Director of Patient Services. Corrective action plan: N/A For patients admitted into the LHCSA" we \vill utilize a 2 page Admission Agreement (attachment #3) to document that the patient has received information regarding their rights and advanced directives. Charts for LHCSA patients will be audited monthly to ensure; Admission Agreement has beerf received bAck from patient. Completion date: When patients are admitted to LHCSA Office of Health Systems Management I Office of Long Term Care Version NYS 111172009 STATE FORM os 465.J11 Itcontinuaeiron sheet 9 of 13 PRINTED: 05/24/2010 FORM APPROVED Jew York State Depalment of Health. .......... rATEMENT OF DEFICIENCIES JD PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER! . A. BUILDING WING (X2) MULTIPLE CONSTRUCTION _____ _____ (X) DATE SURVEY COBUETID LCO523A OF A-JMI PROVIDER OR SUPPLIER O510612010 0. NU 623EVNHA EPSTREET ADDRESS, CITY. STATE, ZIP CODE WETROPOLITAN JEWISH LICENSED HOME C1 (X4)ID PR.EFIX I TAG HOME BROOKLYN, NY 11220 ID PREFIX TAG, i 6323 SEVENTH AVENUE PROVIDERS pLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (xs) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H 720! Continued From page 9 The findings are: 1) Patient #1 has a start of care date of "6110t09"; admitted for telemonitoring of blood pressure, pulse and blood glucose. 2) Patient #2 has a start of care date of "7/13/09" admitted for telemonitoring of blood pressure, p ulse and blood glucose. 3) Patient #3 has a start of care date of "4125/09" ; admitted for telemonitoring of blood pressure, pulse and blood glucose. i 4) Patient #4 has a start of care date of "3112110"; admitted for telemonitoring of blood pressure and * pulse. There is no documented evidence of receipt of information regarding patient rights and advance directives for Patient #1, 2, 3 and 4. On May 6, 2010 at 1:30 p.m., the agencyVice President of Home Care was interviewed and stated: "..... we are providing telephonic assessments... we're not going into patients homes." H.100 . 766.9(c) Governing authority Section 766.9 Governing authority. The governing authority or operator, as defined in Part 700 of this Title, of a licensed home care services agency shall: p (c) ensure the development of a written emergency plan whichf is current and includes procedures to be followed to assure health care needs of patients continue to be met in of Long Term Care Office of Health Systems Management 7 Office Version NYS 11117/2009 STATE FORM H 720 H1006 Responsible Parties: Vice-President and .Director Completed of Patient Services GUN 465.11 Ifcontinuatlon sheet 10 of 13 PRINTED: 05/24/2010 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDEPRSUPPLIER/CLiA IDENTIFICATION NUMBER: (X2} MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A.BUILDING B . LC0523A NAME OF PROVIDER OR SUPPLIER 0510612010 STREET ADDRESS, CITY, STATE, ZiP CODE ME=TROPOLITAN JEWISH LICENSED HOME Co (X4) ID PREFIX TAG . 6323 SEVENTH AVENUE BROOKLYN, NY 11220 ID PREFIX TAG PROVIDER'S PLAN OF. CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE (X5l COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES ((EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) -H1 i Continued From page 10 006 i 1emergencies that interfere with delivery of H1006 DEFICIENCYI . The LHCSA, a participating agency of Metropolitan Jewish Health System (MJHS) abides by the MJHS System Emergency Management i services, and orientation of all employees to their responsibilities in carryingout such a plan. esiiseltiens carrnot t This Regulation is not met as evidenced by: Based on record review and interview, the agency failed to develop a complete Emergency Preparedness Plan. This was evident for the agency Emergency and Disaster Preparedness policy, Failure to develop a complete Emergency Preparedness Plan places patients at risk for unsafe care during an emergency. Plan. The Plan applies to patients admitted within the LHCSA. The Emergency Management Plan Policy is further detailed in the Emergency Management Mahual. The Emergency Management Manual is updated annually.. The Plan which isevidence of operational preparedness includes procedures to follow to assure health care needs of. patients continue to be met in emergencies that interfere with delivery of services. The Plan for Emergency Preparedness/ Management addresses the following: #1: Attachment #5: I The findings are: iThe Teagency g IlEmergencyand Disaster Page 2 of emergencyManagement Policy(ldentific~uon of 24/7 emergency contact person and alternate) Page 2 of Emergency Management Manual ldentifi~ation of 24/" emergency contact person and alternate) #2: Attachment #6: Call Down List Pages 8,9, 11-16 from Emergency Management Manual Preparedness" policy lacks documented evidence of the following information as outlined in the Dear Administrator Letter (DAL) dated 'May 10, 2005": .(Contact list of community partners and HPN Policy) Page 1 from Emergency Management Manual (Collaboration with community partners in planning effort) #3: Attachment #7: Attached copy of Emergency 1) ldentificatiOn a 24/7 emergen cntact ef c person and alternate to be contacted in an emergency; Classification Guidelines and procedure from 12/09 and Patient Classification System used prior to 12/09 (Classifications from the Emergency Management Manual and 22) A call down list of agency staff, contact list of community partners and collaboration with " ommunity partners inplanning efforts; c i a r n f 3) A current patient roster containing patient demographics, rapid identification of patients, classification levels'and emergency contact Policy). #4. Attachment #8: Actual implemented Emergency which Management Plan activities Events in Disaster drill for IT which impacts upon electronic data collection and medical record - Home.Based Care Task Force Meetings with OEM- evidence of continuous participation by MJHS leadership numbers of care-givers;. 4)Documentation of participation in disaster drills; 5) How the call down list information will be kept c u rre nt ; Office of Health Systems Management/ Office of Long Term Care STATE FORM Version NYS 11/17/2009 #5. Human Resources maintains list of employees x4hich is kept current. Human Resource updates files with new employee demographics upon hire and upon termir)ation of employment. This list is constantly maintained and nade available to the VP and Director. The Director updates the call down list whenever there are ' agency staffing changes. [] 465JI If ontinuation of sheet 11 13 ew YorkState Department of Health ATEMENT OF DEFICIENCIES 10 PLAN OF CORRECTION " PRINTED: 05124/2011D FORM APPROVED (X2) MULTIPLE CONSTRUCTION . BUILDING (X3) DATE SURVEY COMPLETED XI) PROVMDER/SUPPUERJCLI A IDENTIFICATION NUMBER: LC0523A VME OF PROVIDER OR SUPPLIER. B. 'WING STREET ADDRESS. CITY. STATE. ZIP CODE 05f06(2010. IETROPOLITAN JEWISH LICENSED HOME Ci (X4) ID PREFIX TAG 6323 SEVENTH AVENUE BROOKLYN, NY 11220 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY). (X,) COMPLETE DATE SUMMARY STATEMENT OF DEFICIENCIES {EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H1006! Continued From page 11 6) Annual review and update of the plan and orientation of staff. on May 6, 2010 at 4:07 p.m., the agency Vice President of Home Care was interviewed and did not provide an explanation. H 11421 766.9(o) Governing Authority Section 766.9 Governing authority 1H1006 #6. Attachment #9: Page 3 & 4 of the Emergency Management Policy (Annual review and update, orientation of staff). Completion date: Done H1142 Responsible Parties: Vice-President and Director of Patient Services Corrective action plan: The Director of Patient Services had been I erroneously set up in the HPN as an Adminiistrator. His role has since been corrected in the Directory. The staff person in the role of Emergency Response Coordinator performs thatrole for multiple agencies within Metropolitan Jewish Health System *andshares pertinent information across the system. As such, her access had been granted through anotier MJHS however, she has since been assigned to this 7/9/10 (o) Health Provider Network Access and Reporting Requirements. The governing authority or operator of an agency shall obtain from the Department' s Health Provider.Network (HPN), HPN accounts for each agency that it operates and ensure that sufficient, knowledgeable staff will be available to and Shall maintain and keep current such accounts. At a minimum, twenty-four hour, seven-day a week contacts for emergency communication and alerts, must be designated by each agency in the HPN Communications Directory. A policy defining the agency' s HPN DitorygA oicyenwing the agency' s hurs oagency operation shall be created and reviewed by the agency no less than annually, Maintenance of each agency' s HPN accounts shall consist of, but not be limited to, the following: (1) sufficient designation o' the agency' s HPN coordinator(s) to allow for HPN individual user application; (2) designation .by the governing (r authority or i operator of an agency of sufficient staff users Of the HPN accounts to ensure rapid response to requests for information by the State and/or local Department of Health; OfMic of Health Systems Management I Office of Long Term Care STATE.FORM Version NYS 11/1712009 coverage consistent with the agency's$ hours ofroedeclinteLCA We are awaiting the signed paperWork frown the Governing Board Chairman and will submi his HPN access application by June 9, 2010 The LHCSA has a self perpetuating Board and does not have members, therefore assignment of a Governing Body, Member in HPN does not apply. Completion date: June 9, 2010 465,111 Itcontinuation sheet 12of13 PRINTED: 05/24/2010 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDERJSUPPLIERCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY A.LBUILDING _OMPLETED B. WING LCO523A NAME OF PROVIDER OR SUPPUER STREET ADDRESS, CITY, STATE. ZIP CODE 0510612010 6323 SEVENTH AVENUE BROOKLYN, NY 11220 IPROVIDERS PREFIX TAG PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (XS) COMPLETE DATE METROPOLITAN JEWISH UCENSED HOME C' (X4) IO PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H11421! Continued From page 12 (3) adherence to the requirements of the HPN H1142 user contract and (4) current and complete updates of the Communications Directory reflecting changes that include, but are not limited to, general information and personnel role changes as soon as they occur, and at a minimum, on a monthly basis. This Regulation is not met as evidenced by: Based on record review and interview, the agency failed to maintain a current Health Provider Network (HPN) Communications Directory. Failure to ensure the HPN Communications Directory is current places patients at risk for j-unsafe.care during an. emergent situation. I . - ... . . - o The findings are: A copy of the agency "Contact Information" from the HPN Communications directory was provided. The following roles were unassigned in the * communications directory: Director, Home Care Patient Services; Emergency Response Coordinator;, Governing Body, Chairman/President and Governing Body, Member. On May 6, 2010, the agency Vice President of Home Care was interviewed but did not provide an explanation. Office of Health Systems Management I Office of Long Term Care STATE FORM Version NYS 11117/2009 465Jil f1 contnuation sheet 13of 13 e Richard F. Daines M.D. STATE OF NEW YORK . DEPARTMENT OF HEALTH . NY 10007 Metropolitan Area Regional Office 90 Church Street, New York, James W. Clyne, Jr. Executive Deputy Commissioner Commissioner August 2, 2010 Metrocare Givers Inc. Attn: Camille M. Singer, RN Director of Patient Services 325 Gold Street, 3 rd Floor Brooklyn,NY 11201 / Re: Response to Plan of Correction Provider: #9773L001 Survey Date: 6/9/2010 Dear Ms. Singer: - State Re-licensure Please be advised that the Plan of Correction relating to the recent Survey of your agency have been reviewed by this office. implement this plan All items were found to be acceptable and it is expected that you will will be conducted to within the time frames that were submitted. A post approval review verify the correction of deficiencies. at (212) 427-4921. If you have any questions. regarding this matter, please call our office Sincerely, Cheryl Phoenix-Tannis, RN, MSN, CS Regional Program Director Bureau of Home.Health Care and Hospices Services Metropolitan Area Regional Offices /Ijt FORM APPRO! New York State Department of Health TATEMENT OF DEFICIENCIES ,ND PLAN OF CORRECTION ".:".... :" " (X1) PROVIDERISUPPLIER/CLIA (Xl) "(X3) (X2) MLJLTIPLE CONSTRUCTION DATE SU.:RVEY" IDENTIFICATION NUMBER: ."A. " AODGLETED BUILDING B. WING "_" COMPLETED LC0718A JAMEOF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE. ZIP CODE. 06109/2010 325 GOLD STREET, 3RD FLOOR BROOKLYN, NY 11201 ID PREFIX TAG PROVDER'S PLAN OF CORRECTION SHUL. (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED 1O THE APPROPRIATE .BE (X:. COMPI DA1 METROCARE GIVERS INC "X4)i: PREFIX TAG . TAG " SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) REGU Y OR I N IDEFICIENCY) H.0001 InItial Comments A State re-icensure survey was conducted at .,Metro are Givers, Inc. on June 9, 2010. . .. H 000 " I 766.5 (b)(l) Clinical Supervision Five (5) Patient Care Records were reviewed and are identified as Patients #1 to 5. Six (6) Personnel Records were reviewed and are identified as Employees #1 to 6. The DPS reviewed the records of the two patients (patients #1& 2) to ensure'current visits were completed. Patient # I was last seen on 4/19/2010 with the next visit due on 7/19/2010. Patient #2 was last seen on 5/10/2010 with the next visit due on .... The.agency Policy and Procedure Manual, Complaint Log and Quality Improvement Committee Meeting Minutes were reviewed. - .- t 614' 766.5(b)(1) Clinical supervision H 766.5 Clinical supervision. The governing H 614 . for visit frequency to maintain that visits were current, and the next visit & aide supervision was scheduled according to the Plan of Care. 100% of the existing patient 8/10/2010. Responsibl ps D ReCo Complete Date: 6/10/2010 were reviewed All existing patient records authority shall ensure for all health care services visits'were found to be current as of o and the next visits including aide supervisions were scheduled according to the , patient's Planperson: DPS Responsible of Care. that. , -6/15/2010, -b) all staff delivering care in patient homes are adequately supervised. The department shall of considerthe following factorsas evidence Ronle adequate supervision: ('1)staff regularly provide services at the times and.frequencies-specified in the patient's plan of care:and in accordance with the policies and procedures of their respective services. This Regulation is not met as evidenced by: 1a3sed on record reviews and interview, the agency failed to ensure patients receive services Complete Date: 6/15/2010 An additional Registered Nurse was hired on 5/18/2010 to assist with patient visits and aide supervisions. The DPS reviewed the ' pe: D50 process for schedulng and tracking visits The DPS in-serviced the nursing staff in the process for scheduling and tracking visits. The DPS will review the patient visit schedules on a daily basis to ensure nursing visits and aide supervisions are assigned and completed according to the Plan of Care. acc rding to the frequency on the Plan of Tretei:.etent. This was evident for two (2) of five ':;',".,i.5)paint care records reviewed (Patients #1 rt paietarrcd Responsible person: DPS Complete Date: 7/8/2010 ' ~d 2 ~ " ' ' The DPS will perform a quarterly audit of 100% of all patient records on a quarterly basis to ensure services are pro dd- :: 'kL 1:'. according to the Plan of Care. The results Failure to provide services as ordered in the Plan of Treatment places patients at risk for receiving p r.care and unsafe care. ce~f.Heaith Systems Managemen 1 Office of Long Term Care /0.-SI [-, o:~~b K.._ will be reported to the Quality Assurance C: ' //~ .-o Committee on a quarterly basis and forwarded to the Governing Authority. Respurrsible peisona DPS /29/2019 (date of next PI), Complete Dqi and ongoing (x5) DA / BOR ORY;DIRECTOR'S OR PROVIDER/SU&IER REPRESENTATIVE'S SIGNATURF a g7/",, ' ATE FORM Version NYS 11/17/2009 6%15C.C)R1I Ifcontinuation she PRINTED: 06/24/201C FORM APPROVED New York State Department of Health STATEMENT OFPDVFICEENCES AND PLAN OF CORRECTION RIDEISUPPLIERCUA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY LC0718A NAME OF PROVIDER OR SUPPLIER B. WING________ ___ 06/09/2010 STREET ADDRESS, CITY, STATE, ZIP CODE METROCARE GIVERS INC !: PREFIX P 325 GOLD STREET, 3RD FLOOR "BROOKLYN, NY 11201 ID PREFIX (EACH CORRECTIVE CSSRFRNDTOTEAPPITE ACTION SHOULD BE. RTAG PROVIDER'S PLAN OF CORRECTION (X5) COMPLETE DATE TO THE APPROPRIATE (X4) ID TAG - (EACH DEFICIENCY MUST BE PRECEDED BY FULL SUMMARY STATEMENT OF DEFICIENCIES I REGULATORY OR LSC IDENTIFYING INFORMATION) R R OR C TDEFICIENCY) H 614 Continued From page 1 The findings are: 1) Patient #1 has a start of care date of "6/2/09" with diagnoses which include: Parkinson's Disease and Glaucoma. The agency: "Plan of Treatment" dated "12/2/09 to 612/10" documents: "RN (Registered Nurse): Every 3 months for patient reassessment, aide teaching and supervision ... The patient care record documents nursing visits and aide supervision on "11/30/09" and "4/19/10". The nursing visits and aide supervision are not, completed every 3 months as ordered on the Plan of Treatment. . H 614 2) Patient #2 has a start of care date of "12/3/09" 'with diagnoses which include: Insulin Dependent Diabetes Mellitus, Hypertension, Glaucoma. The agency: "Plan of Treatment" dated "12/3/09 to 6/3/10" documents the foli6wing information: "RN (Registered Nurse): Every 3 months for patient reassessment, aide teaching and supervision . . The patient care record documents nursing visits and aide supervision on "12/3/09" and "5/7/10". The nursing visits and aide supervision are not completed every 3 months as ordered on the Plan of Treatment. he-ag ency.=-On,. e ,_2010.atitl56:atm .Tt , ...... ... I-. Director of Patient Services was interviewed and stated: "Iknow... that's why we hired someone else." I_ _ _ __ _ _ __ ___'_ . ..... _ __ _ _ _ _ Office of Health Systems Management / Office of Long Term Care Version NYS 11/17/2009 STATE FORM 499 9COR1 1 If continuation sheet 2 of'9 pg2 I-Nfl L. .1. ttUat.ttJ FORM APPRO New York State. Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDERISUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A BUILDING B. WING _________ __________ M (X DATE SURVEY COMPLEDED LC0718A NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE 0610912010 METIROCARE GIVERS INC X4)lID PREFIx TAG SUMMARY STATEMENT OF DEFICIENCIES 325 GOLD STREET, 3RD FLOOR BROOKLYN, NY 11201 ID *PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) K. (X5 cOMPI DAT (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H1006:1 766.9(c) Governing authority SSection 766.9 Governing authority. The governing authority or operator, as defined in "Part 700 of this Title, of a licensed home care services agency shall: . -..... ensure the development of a written I(c) emergency plan which is current and includes procedures to be followed to assure health care needs of patients continue to be met in iemergencies that interfere with delivery of Lservices, and orientation of all employees to their ,reSl0nsibillties in carrying out such a.plan. This Regulation is not met as evidenced by: .Based on record review and interview, the .Goernin Authrity ailed to revise the agency's i .Governing Authority fi . Emergency Operation Plan. Failure to have an updated Emergency Operation Plan places patients at risk for unsafe care during an emergency situation. -The findings are: , . . H1006 1')There is no documented evidence of a patient rostericontaining patient demographics.and pridority classification levels (Levels 1, 2 and 3)to facilitate rapid identification of patients and the emergency contact numbers of care givers for :.current patients. 2).,There is no documented evidence of agency aboration with community partners in planning oi."6 . efforts. - -. - ... , . . ' . o~dc'0rnen~d vidnceof acureht ~ Ttereis calldown list of agency staff and the procedure to maintain the call-down list, Health Systems Management f Office of Long Term Care Offfice of NYS 11/17/2009 FORM ,Version '1patienit .STATE . . . I 766.9(c) Governing Authority The agency's patient roster was updated to include patient demographics and priority classification levels. The agency's staff roster I was updated. Both current patient and staff rosters were printed and made available to the office staff and a copy filed in the on-call binder on 7/2/2010. The agency call-down list was updated with current employees and 1 all their contact information on 6/10/2010. The DPS is completing the Emergency Operations Resource List to include the names and phon6 numbers of all the agency's community resources including the agency's community partners. Responsible person DPS Complete Date: 7/15/20 10 A process was developed and implemented to .: ensure a current Emergency Operations Plan. The patient and staff rosters will beupdated on a weekly basis, printed, made available to the office staff and a copy will be filed in the on call binder. The call-down list will be reviewed minimally on a quarterly basis but updated as an employee's status changes. The I Emergency Operations Resource List will be maintained by the DPS and a copy kept inall office sites as well as in the on-call book. I Responsible person DPS Complete Date: 7/8/2010 & ongoing All agency staff will be in-serviced in the I process and their, responsibility in updating I patient & staff rosters, the call-down list: and the Emergency Operations Resource List. Responsible person: DPS i Complete Date: 7/8/10 The DPS will perform a quarterly audit of the o s.x that nn . EmergenpyQperationsP & staff roster " Emergency Operations Resource List are current and up to date. The results will be reported to the Quality Assurance Committee i quuitcly bdis nd forwarded to the u a,, Ifconifinualion shei Authority. 9 &9ycrning Responsible person: DPS Complete Datel 9/29/2019 (date of next PI), and ongoing - r Pg3 PRINTED: 06/24/ FORM APPRC New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF-CORRECTION (X1) PROVIDEPJSUPPLIERJCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING B. (X3) DATE SURVEY COMPLETED _ _ _ WING _ _ _ _ _ _ _ LC0718A NAME OF PROVIDER OR SUPPLIER " STREET ADDRESS, CITY, STATE, ZIP CODE 06/092010 325 GOLD STREET, 3RD FLOOR BROOKLYN, NY 11201 ID L PREFIX PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE TO THE APPROPRIATE DEFICIENCY) (X! COMPI METROCARE GIVERS INC (X4) ID PREFIX SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST-BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H1006. Continued From page 3 The agency call-down list of agency staff documents the name of a nurse not currently employed with the agencyThe agency call-down list of agency staff documents the name of a nurse hired by the agency on "5/18/2010". There is no documentation of the nurse's phone number. The agency contact list of Home Health Aides. and Personal Care Aide's included in the Emergency Operation Plan documents a print out * dateof "September 19,.2008". - H1006 - " - . 4) There is no documented evidence of a contact list of community partners as documented in the ager.cy "Emergency Operation Plan" and the procedure to maintain the contact list. The agency "Emergency Operation Plan" documents: "A readily accessible and current Emergency Operations Resource List with name and telephone and includes: fire, police, Red * Cross, area emergency relief services, will be :maintained at all office sites, and in the on-call -bObk." - - " " , o ' There is.no documentation of the "Emergency Operations Resource List". On June 9, 2010 at 3:20 p.m., the agency Director of Patient Services was interviewed and did not provide an explanation766.9(o) Governing Authority H 142:, :. " , . . H1142 766.9(o) Governing Authority The agpncyad inistator 'eipe, d t. . Secii76.696-- ng auth nty . (o)Health Provider Network Access and " Reporting Requirements. The-governing authority "Office of Health Systems Management I Office of Long Term Care Version NYS 11117/2009 FORM .STATE clarified and an additional person was assigned-----o as coordinator. The HPN Communications the current IDirectory was updated to reflect - users of theagency's-HPNe.-ltRbI6 w Rensible person Administrator .nmplete Date: 7/6/2010 "nnuaion s" . . pg4 PRINTED: 06/24, FORM APPRC New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDERISUPPLIERICLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A BUILDING B. WING__ __________ _ _ _ _ _ _ _ _ _ (X3) DATE SURVEY COMPLETED LC0718A NAME OF PROVIDER OR SUPPLIER E STREET ADDRESS. CITY, STATE. ZIP CODE 061091201( METROCARE GIVERS INC (X) ID PREFIX TAG 325 GOLD STREET, 3RD FLOOR BROOKLYN, NY 11201 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) p COMI DI SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ' H1142: Continued From page14 or operator of an agency shall obtain from the Department' s Health Provider Network (HPN), HPN accounts for each agency that it operates and ensure that sufficient, knowledgeable staff will be available to and shall maintain and keep current such accounts. At a minimum, twenty-four hour, seven-day a week contacts for emergency communication and alerts, must be designated by each agency in the HPN Communications Directory. A policy defining the agency' s HPN o coverage consistent with the agency' s hours of operation shall be created and reviewed by the agency no less than annually. Maintenance of each agency' s HPN accounts shall consist of,' but not be limited to, the following: ' " .(1) sufficient designation of the agency' s HPN coordinator(s) to allow for HPN individual user application; (2) designation by the governing authority or operator of an agency of sufficient staff users of .the HPN accounts to ensure rapid response to .requests for information by the State and/or local DearmetofHelt;Complete :Department of Health; Hl142. The agency administrator reviewed the agency's HPN policy and updated it to ensure that the HPN Communications Directory is maintained and changed, as roles are assigned/re-assigned. A log will be maintained by theHPN coordinator to reflect review of the HPN Communications Directory minimally on a monthly basis, and changes as they occur. Amsr Ress per a Complete Date: 7/6/2010 All agency staffwere in-serviced in the updated HPN policy, andtheir role mnthe HPN& maintenance of the HPN Communications Directory. Responsible person: Administrator Complete Date: 7/6/10 perform a quarterly The Administrator will audit of the HPN Communications Directory and the log to ensure that the directory is current and changes are made as they occur. i The results will be reported to the Quality and forwarded to the on a quarterly basis Assurance CommitteeGoverning Authority.o" i ,. and Responsible person: Administrator next P), (date of ex P , I) . Date: 9/29/2019 n non o' and ongoing -.3) adherence to the requirements of the HPN ( .userlcontract; a-d (4) current and complete updates of the Communications Directory:reflecting changes thatiinclde, but'are not limited to, general infdrmation and personnel role changes as soon as they occur, and at a minimum, on a monthly basis% * This Regulation is not met as evidenced by: Based on record review and interview, the agency failed to maintain a current Health Provider ftsq 9CDR 11 If continualion'si . Offi6e of Heath Systems Management I Office of Long Term Care Version NYS 11117/2009 STATE FORM Pigs PRINTED: 061z4 FORM APPR( New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X) PROVIDER/SUPPLIERJCUA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION .. A BUILDING __________ ___ (X3) DATE SURVEY cOMPLETED. LCO718A NAME OF PROVIDER OR SUPPLIER B. WING_______ W 06/091201( STREET ADDRESS, CITY, STATE, ZIP CODE .METROCARE GIVERS INC (X4) ID PREFIX TAG 325 GOLD STREET, 3RD FLOOR BROOKLYN, NY 11201 ID PREFIX TAG PROVIDER'S.PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE 'DEFICIENCY) COMI DA SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H1142. Continued From page 5 Network (HPN) Communications Directory. Failure to ensure the HPN Communications. DireCtory is current places patients at risk for unsafe care during an emergent situation. "The findings is: The agency HPN Communications Directory docufnents thefollowing roles as unassigned: I Dirie tor Home Care Patient Services and Governing Body, Chairman/President. The Director of Patient Services (DPS) was interviewed and'did not provide an explanation. H1142 j . . " (g) Personnel The employee (employee #1) was removed direct patient care until an annual health assessment and Mantoux/PPD are completd, began 7/6/10 and which will be completed by 7/8/2010 when the Mantoux/PPD testing is read. Employee # 1 Iwas scheduled for in-home obsevation visit on6/8/2010 Patients seen by this employee were observed and oemployment monitored for signs & symptom of T1B. The patients have remained free from. signs & symptoms of TB and will continue: to be monitored. Documentation for this in-home was located and filed in the . . employee's personal file. An overall assessment of performance wasconpleted on 7/7/2010 and filed in the employee's record. The employee (employee #2) was removed from direct patient care until two (2)reference checks were verified which was conpleted.by. " 61( es e.766.11 H13381 76& 11 (g) Personnel 76.1 Pfrom P1 ersonnel. Twhich the governing authority or operator shal ensure ofor all health care personnel: (g) that personnel records include verifications of history and qualifications for the " 'ddtie ssigned and, as appropriate, signed and i; dated >!pplications foi.ernployment; records of professionaI licenses and registrations; records of examinat ions~andhealth status '" .. iphysical iassessments; performance evaluations; dates of .emp'oyment, resignations, dismissals, and other pertinent data provided that all documentation and information.pertaining to an employee's .. H1338 .observation medical condition or health status, including such r . ordsof physical examinations and health re . ,at - .etat seos~srrent~s.=hallem{rnta.-d record." ro te non-medicalp .pa 'informationand shall be afforded the same i confidential treatment given patient medical records under section 766.6 of this Part. . .-. 7/8/2010 . .'Z, . Responsible person: DPS Complete Date: 7/8/2010 The DPS will perform an audit of 100% of the employees' records to .9COR11 . Office of Health Systems Marnagement I Office of Long Term Care Version NYS 1l117/2009 STATE FORM if-continuation shiee Pg6 PRINTED: 06/2d FORMIAPPR New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDERISUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING __________ (X3) DATE SURVEY COMPLETED LC0718A NAME OF PROVIDER OR SUPPLIER B. WING ___________ 061091201 STREET ADDRESS, CITY. STATE, ZIP CODE R325 TG METROGARE GIVERS INC (X4) ID PREFIX i TAG GOLD STREET, 3RD FLOOR BROOKLYN,. NY 11201 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COiN c SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H1338 Continued From page 6 This Regulation is not met as evidenced by: Based on record reviews and interview, the agency failed to maintain complete personnel records. This was evident for two (2) of five (5) personnel records reviewed (Employees #1 and 2). Failure to maintain complete. personnel records places patients at risk for receiving care from potentially unqualified employees. ThI .. o.1n ' "oComplete 1) Employee #1 isa Registered Nurse hired by theagency on "5/6/02". There is no documented evidence of an annual health assessment and Mantoux/PPD testing for the-year 2008. There is no documented evidence of an in-home Observation for the year 2008. There is no documented evidence of an annual evaluation and in-home observation for the year t iensure H1338 complete personnel records are maintained including two (2) verified reference checks, an annual performance assessment, annual in home supervisory visits , to observe performance, and annual health assessments & Mantoux/PPD. The health records are maintained in a separate folder apart from the personnel record. All noncompliant employees will be removed from direct patient care until all-missing components are scheduled, completed and filed in the employee's personnel record. Responsible person DPS Date: 7/15/2010 The DPS reviewed the agency's policy and process for ensuring compliance with verification of reference checks, annual assessments including the in-home supervisory visit and annual health assessments & MantouxlPPDs. The scheduling and tracking process was also reviewed. The DPS in-serviced all agency staff in the agency's process for scheduling and tracking personal compliance. Responsible person: DPS Complete Date: 7/8/10 :2009. . The DPS will perform aquarterly audit of " 100% of all personnel records for one-yea,': I. then quarterly audit of 25% of all personnel oho 6/18/records thereafter. The results will be reported to the Quality Assurance Committee. on a quarterly basis and forwarded to the Governing Authority. : Responsible person: DPS Complete Date: 9/29/2010 (date of next PI) and ongoing . ... " 2) Employee #2 is a Registered Nurse hired by "There is no documented evidence of two (2) o verified reference checks. On June 9, 2010 at 1:50 p.m., the agency . :pirector of Patient Services was interviewed and r. ,~. a ... . .... prvxplap In~. . o Previously Cited 10/24/07. Office of.Health Systerns Management / Office of Long Term Care Version NYS 11/17/2009 STATEFORM I cortinualion If9COR11 st pgl PRINTED: 061241. FORM APPRO New York State Department.of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIERCLIA IDENTIFICATION NUMBERI (X2).MULTIPLE CONSTRUCTION A BUILDING ___________ (X3) DATESURVEY COMPLETED LC0718A NAME OF PROVIDER OR SUPPLIER 8 WING STREET ADDRESS. CITY, STATE. ZIP CODE 0610912010 METROCAREGIVERS INC (X4).ID PREFIX TAG 325 GOLD STREET, 3RD FLOOR BROOKLYN, NY 11201 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (Xi COMPI DAI SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H1342: Continued From page 7 jH13421 766.11(i) H1342 H1342 Personnel 7661 Persn766.1 "" .for all health care personnel: cae for ll ealt pesonel: ,The governing authority or operator shall ensure .. (i) that all personnel receive orientation to the policies and procedures of the home care i eucat to " operation and in-service services-agency ' educasionneiesay peminrrm hisheemployee Ato responsibiities: At a minimum: ii.....) : { :ome healtha)iides must participate in 12 h "")....eealh adesustparicpte 12agency's l(l)(]) Personnel 1 The employee (employee #1)was scheduled for and attended in-services on Standard Precautions and HIV confidentiality on 12/18/2008 and again on 12/29/2009. Documentation of attendance at these inservices was locatedand filed in the and still in orientation at the time ofthe survey. This employee completed the. orientation including orientation to .,theagency's policy and procedures, specific the agency's emergency operations plan, HIV Confidentiality and Standard . !employee (employee #2) was a new epoe epoe 2 a e - employee's personal file on 6/10/2010. The tlo~r-f in-service education per year; and hours oduties, o i ." : :. *. " " (2) personal care aides must participate in six hoursPrecautions hius oRe cedation ispnotm etrevideed bcompletion Based on record reviews and interview, the agency failed to a t~ document orientation to agency . .-.. . 1,plicy'and procedures;.specific duties; eiiergency disaster plan and required annual training for,employees. This was evident for two (2) of siX (6).personnel records reviewed 'Emdplees #1 and 2). Failure to document required orientation and. o annual traiing,for:employees places patients at. .. Pleatin Conf identialitan a r on 6/10/2010. Evidence of the orientation was filed in the employee's personal file on 6/10/2010. Responsible person: Comple De: 1/ DPS 1 The DPS willIperform an audit oflOO0/cof::: T pl er an1audi1of 100 the employee's records to ensure .4 " ri.. eceiving poor care from potentially s fr. unqualified personnel. Thefindings are: . 1) Employee #1 is a Registered Nurse hired by aqency u 5/6/02" There is no documented evidence of annual Universal Precautions training for the years 2008 9COR 11 " , ': .and 2009. '.:'; IfContiiuatiofn sheet 'fic& of Health Systemffs Management I Office of.Long Term Care STATE FORM: VersioriNYS 11/17/2009 Pg8 PRINTED: 06/2, FORM APPP New York State Department of Health STATEMENT OF DEFIIENCIES - AND PLAN OF CORRECTION (XI) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A . A. BUILDING ___________ B. WING___________ . (X3) DATE o SURVEY -. COMPLETED. LC0718A NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE 06/091201 SG R I325 METROCARE GIVERS INC (X4) ID PREFIX TAG GOLD STREET, 3RD FLOOR BROOKLYN, NY 11201 IC PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) CON 1 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) H1342 Continued From page 8 2) Employee #2 is a Registered Nurse hired by the agency on "5/18/10". There. is no documented evidence of orientation to agency policy and procedures, specific duties and emergency disaster plan.. There is no documented evidence of HIV Confidentiality training and Universal Precautions training at the time of hire. On June 9, 2010 at 1:50 p.m., the.agency Director of Patient.Services was interviewed and did: not provide an explanation. H1342 and attendance at an in-service on Standard Precautions and HIV confidentiality at the time of hire and on an annual basis. All noncompliant employees will be removed from direct patient care until the-employee attends . orientation and an inservice on Standard Precautions & HIV confidentiality, and proof of attendance is filed the employee's personnel record. In-services are scheduled every Tuesday for the remainder of 20 1 Responsible person: DPS o Complete Date: 7/15/2010. The DPS reviewed the agency's policy and. process for ensuring compliance with initial I orientation and Standard Precautions & HIV confidentiality in-services. The DPS in-. serviced all agency staff in agency's policy and process for scheduling and tracking initial orientation and Standard Precautions & HIV. . confidentiality in-services. Responsible person: DPS Complete Date: 7/8/2010 The DPS will perform a quarterly audit of .K,. 100% of all new personnel records for: compliance to initial orientation and Standard Precautions & HIV confidentiality in-services.': The results will be reported to~the Quality. IAssurance . . Committee on a quarterly basis and :forwarded to the Govemrig Authority Responsible person: DPS . Complete Date: 9/29/20 10 (date of next PI) and ongoing .: I - 7: Office.of Health Systems Management / Office of Long Term Care STATEFORM Version NYS 11/1712009. 0899 9COR11 ... Ifcontinuationsh Pg9 STATE OF NEW YORK DEPARTMENT OF HEALTH Richard F. Daines M.D. Commissioner Metropolitan Area Regional Office 90 Church Street, New York, NY 10007 James W.Clyne, Jr. Executive Deputy Commissioner August 25, 2010 Premier Home Health Care Services, Inc. Attn: Donna Duggan, RN Director of Clinical Services 9202 Fifth Avenue Brooklyn, NY 11209 Re: Response to Plan of Correction License: 1665L003 Survey Date: 6/10/2010 Dear Ms. Duggan: Please be advised that the Plan of Correction relating to the recent State Re-licensure Survey of your agency have been reviewed by this office. All items were found to be acceptable and it is expected that you will implement this plan within the time frames that were submitted. A post approval review will be conducted to verify the correction of deficiencies. If you have any questions regarding this matter, please call our office at (212) 417-4921. Sincerely, Cheryl Phoenix-Tannis, RN, MSN, CS Regional Program Director Bureau of Home Health Care and' Hospices Services Metropolitan Area Regional Offices Ijt PRINTED: 06125/2010 FORM APPROVED New York State Department of Health. DE...E STATEMENT OF CECI(X2) AND PLAN OF CORRECTION "CIS l) PROVIDEJSUPPLIEIJCUA IDENTIFICATION NUMBER (E C MUPLE CONSTRUCTION _ _ _ _ _ _ _ _ _ (X3) DATE SURVEY COMPLETED A BUILDING B. WING _ _ LC0681D NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CIY, STATE ZIP CODFE 061012010 9202 5TH AVE BROOKLYN, NY 11209 ID PREFIX TAG PROVIDEES pLAN OF CORRECTION (EACH CORRECTIE ACTION SHOULD BE CROSS-REFERENCEDTO THE APPROPRIATE DEFICIENCY) (5) PREMIER HOME HEALTH CARE SERVICES IN' (X4) ID PREFIX TAG i SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) COMPLETE DATE H 000 Initial Comments A State re-licensure survey was conducted at "Premier Home Health Care Services, lnc". (1665L003).( formerly known asPatient. Carel147LO03) on June 10, 2010. Four (4) Patient Care Records were reviewed and are identified as Patients #1 to 4. Seven (7) Personnel Records were reviewed and are identified as Employees #1 to 7. The agency Policy and Procedure Manual, Complaint Log and Quality Improvement Committee Meeting Minutes were reviewed. .1 514 766.4(d) Medical orders H 000 H514 L H 514 Corrctiv action for those . patients found to be affected by the deficient practice: 766.4 Medical orders. 1. Patient#l FNS was reeducated on obtaining signed and dated (d) Medical orders shall reference all diagnoses, medications, treatments, prognoses, and other pertinent patient information relevant to the agency plan of care; and. (1) shall be authenticated by an authorized ,-regulations. practitioner within thirty (30). days after admission to the agency;, and -1. (2) when changes in the patients medical orders are indicated, orders, including telephone orders, shall be authenticated by the authorized practitioner within thirty (30) days. This Regulation is not met as evidenced by: Based on record reviews and interview, the agency failed to ensure medical orders are signed within 30 days by an authorized practitioner. This was evident for two (2) of four (4) patient care records reviewed (Patients #1. and #2). Office of Heakth Systems Management I O L MD orders within 30 days as per agency policy and state patient #2 FNS was reeducated on obtaining signed M) orders as per agency policy and state 9/30/2010 Identification of other patients having the potential to be affected by the deficiency and wbat corrective action will be taken: All case managed cases have the potential to be affected by the deficient practice1. The agency will perform 100% audit of the current population of case managed cases " " " . (X6) DATE ATORY DIRECTORS OfROVIDERJSUPPLUER REPRESENTATIVES SIGNATURE Version NYS 11/17/2009 STATE FORM .k Otri&Aj of Long Term Care Cohtf MBSQ L2 . Ifcontinuation sheet lof 8 PRINTLU: Uo./zolu u FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES ANn PLAN OF CORRECTION (X) PROVIDERSUPPLIERICLIA IDENTIFICATION NUMBER- (X2) MULTIPLE CONSTRUCTION A. BUILDING __________ (X3) DATE SURVEY COMPLETED LCO68ID NAME OF PROVIDER OR SUPPLIER B.WING STREET ADDRESS. CITY, STATE, ZIP CODE 0611012010 PREMIER HOME HEALTH CARE SERVICES INi PREFIX TAG (X4) ID 9202 5TH AVE. BROOKLYN, NY 11209 ID pREFIX TAG PROVDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERNCED TO THE APPROPRIATE DEFICIENCY) SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) L "Y o I COMPLETE DATE H 5141 Continued From page I o"- H 514 1I3 Measures Mat will be ptin place to ensure that the deficient practice will not Failure to ensure medical orders are signed within 30 days places patients at risk for unsafe and unauthorized care. The findings are: deiriecr: 1. The Regional Director of Patient of"W14/08" 1) Ptiet#1 asastar ofcaredat and a diagnosis of Hypertension. The patient care record documents a medical order initated on "10/16/09" and signed by the authorized practitioner on " /19/09". 2) Patient #2 has a start of care date of "11/28/08" and a diagnosis of Hypertension. The patient care record documents medical orders intated on "03105/09", "09/05/09" and I "03/05/10". There is no documented evidence of the date the physician signed the orders. .On June 10, 2010 at 4:50 p.m., the . I Services will be responsible for overseeing the audit process and then the Office Administrator moving forward. a ae FNS's re-educated on completion of POT, inclusive of identification of services medications, and procedures for 1Sr-dctdo 9130/20310 " - provided, diagnoses matching obtaining signed M) orders within 30 days as per agency IV. policy and state regulations. Bow will te corrective action be monitored to ensure the deficent practice will not reoccur? As is company practice, random quarterly chart audit will continue to ensure compliance with completion of plan of . Director of treatment and Patient Services was interviewed and stated: "I can't get the MD's signatures." Previously cited on 11/08/07 H101 D 766.9(e) Governing authority .i I Section 766.9 Governing authonty. I3. MD signature within 30 days. Persons responsible for ongoing compliance: 1. FN~S 2. Office Administrator PDPS s t H 10.d The goVeming authority or operator, as defined in Part 700 of this T'rtle, of a licensed home care services agency shall: (e) make available to the public information concerning the services which it offers, the Office of Health Systems Management I Office of Long Term Care F -- Te FORM Version NYS 1111712009. am MSSQ11 If Cotfinuation sheet 2 o 1-u. + - rfll~l' vu,./.. v u" FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PROVIDERISUPPLIERJCUIA IDENTIFICATION NUMBER (X2) MULTIPLE CONSTRUCTION A BUILDING ABUILDNG__________ N B VVI G COMPLETED LCO681D NAME OF PROVIDER OR SUPPUER : ADDRESS, CITY, STATE ZIP CODE STREET 06/1012010 PREMIER HOME HEALTH CARE SERVICES IN' (X4)ID PREFIX TAG I SUMMARY STATEMENT OF. DEFICIENCIES. 9202 5TH AVE BROOKLYN, NY 11209 11) PREFIX TAG PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE TO THE APPROPRIATE R EP .SDEFICIENCY) (x5) COMPLETE DATE (EACH DEFICIENCY MUST BE PRECEDED BY FULL REG.ULATORY OR LSC IDENTIFYING INFORMATION) H1010 Continued From page 2. geographic area in which these services are made available, the charges for the various types of service and the payment mechanisms which may be available for such services. This Regulation is not met as evidenced by. Based on record review and interview, the agency failed to provide the public with correct information about the services which it offers. This was evident for the agency admission, packet and "Scope of Services" policy and procedure., Failure to provide the public with accurate information places patients at risk for receiving services that are not authorized, The findings are: H10i0 H.101V Corrective action for those patients found to be affected by, I the deficient practice: No patients were affected by L i I the deficient practice 1. Consent for treatment forms will be amended to exclude physical therapy services. ii. Identification of other patients having the potential to be affected by the deficiency and what corrective action will be taken: The agency operating license documents the agency is authorized to provide the following Pesoa ~~I~~r~hav services: "Nursing, Home Health Aide, Personal Care, Homemaker and Housekeeper ". ' The agency:. "Consent for Treatment form included in the admission packet documents the, Services which may be following information: ".... therapists". rendered by...physical AD caw managed cases have the potential to poealtha their~r be affected by this deficient practice 1. Consent for treatment forms will be amended to exclude physical therapy services. The agency is not authorized to provide Physical ITherapy Ty M. Measures that will be put in place to ensure that the deficient practice will not reoccur: The agency: "Client Service Agreement" form included in the admission packet documents the following services: "Companion" and "Escort". The agency: "Scope of Services" policy and procedure documents the agency offers "Companion" services. -. "new . 1. Upon receipt of amended form, all admission packets will be updated with new form that states accurately authorized services. 2. All staff will be educated on form The agency is not authorized to provide Office of Health Systems Management /Office of Long Term Care Version NYS 11/17/2009 STATE FORM M8SQ1I .If continuation sheet 3of8 ." PRINTED: 06125/2010 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDERISUFPLIERJCUA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION N k BUILDING COMPLETED LO6 NAME OF PROVIDER OR SUPPUER WING STREET ADDRESS, CITY. STATE. ZIP CODE 06110/2010 PREMIER ft0ME HEALTH CARE SERVICES IN' (X4) ID PREFIX TAG 'E 9225HAVE BROOKLN NY 11209 ID PREFIX TAG NYA11209ECIO BROOKLYNS OF SUMMARY STATEMENT E(A DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL o REGULATORY OR LSC IDENTIFYING INFORMATION) OTH"PRPIT PROVIDER'S PLAN OF CORRECTION H EFRNE SHOULD BE (EAH CORRECTIVE ACTION APPROPRIATE CROSS-REFERENCEDTOTHE DEFICIENCY) i DAPLTE (5) DATE H1010 Continued From page.3 "Companion" and "Escort" services. H1010 On June 10, 2010 at 5:55 pm, the Director of Patient Services Was interviewed.and did not , provide o IV. ~be monitored to ensure flow will the corrective action be onite torre not reoccur? - thi deficient practice will Quarterly audits will be conducted to ensure and reviewed at the quarterly QI meetings an explanation. H1020 H1020 766.9(j) Governing authority Section 766.9 Governing authority. The governing authority oroperator, as defined in Part 700 of this Title, of a licensed home care services agency shall: HI I6 G n acompliance Persons responsible: 1. FNS 2 Branch Administrator 3 RDPS 4 Director of Clinical Services U) ensure the development and implementation I of a patient complaint procedure to include: * j (1) documentation of receipt, investigation and resolution of any complaint, including the I maintenance of a complaint log indicating the dates of receipt and resolution of all complaints received by the agency; (2) review of each complaint with a written response to all written complaints and to oral complaints, if requested by the individuals making the oral complaint "". (i) explaining the complaint investigation findings and the decisions rendered to date by the agency within 15 days of receipt of such complaint;, and (ii) advising the complainant of the right to appeal the outcome of the agency's complaint investigation and the appeal procedure to be * H1020 I. Corretive action for those patients found to be affected by the deficient practice: No patients were affected by the deficient practice. Identification of other patients having the potential to be affected by the deficiency and what corrective action will be taken: All case managed patients have the potential to be affected by this deficient practice. 1. Complnt logs will be reviewed to ensure that all complaints have been 11102 Sfollowed; (3) an appeals process with review by a member or committee of the governing authority within 30 days of receipt of the appeal; and Office of Health Systems Management I Office of Long Term Care Version NYS 11/17/2009 STATE FORM am resolved. The log will be updated to reflect date of resolution. 9/30/2010 MSSQ11 If continuablon sheet 4 of 8 PRINTED: 06/2512010 FORM APPROVED New York State Department of Health STATEMENT OF DEFICIENCIES -AND PLAN OF CORRECTION (Xi) PROVIDERISUPPLIER/CLIA IDENTIFICATION NUMBER: (2) M A C S ILCBUILDING (X3)DATE SURVE ACOMPLETED C LC068 D NAME OF PROVIDER OR SUPPLIER B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 0611012010 W PREMIER HOME HEALTH CAR E SERVICES I1 (X4) ID PREFIX TAG BROOKLYN, NY 11209 [I PREFIX TAG PROMIDER'S PLAN OF CORRECTION) ACTION SHOULD BE (EACH CORRECIVE TO THE APPROPRIATE CROSS-REFERENCED COMPLETE DATE 9202 5TH AVE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL " ~DEFCIENCY), REGULATORY OR LSC IDENTIFYING INFORMATION), H1020 Continued From page4 (4) notification to the patient or his or her designee that if the patient is not satisfied by the agency's response, the patient may complain to H1020 l1I.Measuresthat will be put in place to.ensure that the deficient practice will not reoccur: 1.All staff will be in serviced on proper completion of complaint logs, including date of resolution, as per agency policy and procedure. the Department of Health's Office of Health Systems Management. This Regulation is not met as evidenced by: . 9/30/2010 Based on record review and interview, the agency failed to maintain a log to document the receipt, This investigation and resolution of complaints. log. was evident for the agency complaint Failure to maintain a complaint log places the patents at risk for poor care as a result oftimely agency not responding to complaints in a manner.o 2. Office AdrinistratorlOperations will review ogs weekly to Manager enasure that resolution has been obtained and documented. IV. How will the corrective action be monitored to ensure the deficient practice will not reoccur? As is company practice, complaint logs will be reviewed at quarterly branch QI meetings to ensure that complaints are reported and resolved timely. Persons responsible for ongoing The findings are: The agency complaint log documents Complaints received on "02/08/10"" 03/02/10", "11/11/09", "11/02/09", "11/19/09", "11130109" and 07/13/09. compliance 1l. FNS There is no documented evidence of the dates of resolution for the complaints. On June 10, 2010 at 5:52 p.m., the Director of Patient Services was interviewed and did not provide an explanation. Previously cited on 11/08/07. -11421 766.9(o) Governing Authority Section 766.9 Governing authority (o) Health Provider Network Access and Reporting Requirements. The governing authority or operator of an agency shall obtain from the Office of Health Systems Management I Office of Long Term Care Version NYS 11/1712009 STATE FORM 89 2. Office Administrator 3. Regional DPS H1 142 M8SQ11 -If continuaion sheet 5 of -FORM PRINTED: 06125/2010 APPROVED New York State Department of-Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDER/SUPPUER/CLIA IDENTIFICATION NUMBER: (x2) MULTIPLECONSTRUCTION A. BUILDING B. WING ____/__12010 SURVEY (X3)COMPLETED COMPLETED LC0681D NAME OF PROVIDER OR SUPPLIER STREET,ADDRESS,.CITY, STATE, ZIP CODE 0611012010 PREMIER HOME HEALTH CARE SERVICES IN, (X4) ID PREFIX TAG 9202 5TH AVE BROOKLYN, NY 11209 PREFIX TAG j SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PROVDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (x5) COMPLETE DATE H1142 Continued From page 5 Department's Health Provider Network (HPN), HPN accounts for each agency that it operates and ensure that sufficient, knowledgeable staff will be available to and shall maintain and keep' current such accounts. At a minimum, twenty-four H1142 H1142 I. Corrective action for those patients - hour, seven-day a week contacts for emergency communication and alerts, must be designated by each agency in the HPN Conmunications Directory. A policy defining the agency s HPN coverage consistent with the agency 's hours of operation shall be created and reviewed by the ' agency no less than annually. Maintenance of each agency.' s HPN accounts shall consist of, but not be limited to, the following: (1) sufficient designation of the agency' s HPN coriao~)to allow for .HPN individual user coordinator(s) application; (2) designation by the governing authority or operator of an agency of sufficient staff users of the HPN accounts to ensure rapid response to requests for information by the State and/or local Department of Health; (3) adherence to the requirements of the HPN user contract; and (4) current and complete updates of the found to be affected by the deficient practice: There were no pati s foundto beaffected by this regulation ]]L Identification of other patients having the potential to be affected by the deficiency and what corrective action will be taken: 1. The agency policy and procedure defines the necessary roles within the organization and the function of the HPN coordinator. 2. As is agency practice, the policies and procedures are reviewed anniall-Y. 3. Designatedepoyewilbasgedt Office of the role of:. 24/7 Facility Contact, the Administrator, Criminal History Record Chairmaner member. be authorized person, Governing Body ident Governing Body. (usetrLat t deicimt Pracieewill not reoccu r. Communications Directory reflecting changes that include, but are not limited to, general. basis. t. As is a,*=acypnticc, the policies an 1vivftd annuaflproceduam wiube 2- An m f t taR I information and personnel role changes as soon o as they occur, and at a minimum, on a monthly o c tt me cmired acni tow#rdn-,m e desi QI of I iftltc ~lnl~ aotolO oet&i. -at .f qmmw* C(1po This Regulation is not met as evidenced by-. Based on record review and interview, the i governing authority failed tomaintain a current Health Provider Network (HPN) Communications. Office of Health Systems Management I Office of Long Term Care Version NYS 11/17/2009 STATE FORM 68" MSSQll f continuation sheet 6 of 8 PRIN 1 -U: UIbrZ5/2)1 U New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDERSUPPUER/CuA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING FORM APPROVED (X3) DATE SURVEY COMPLETED LC0681D NAME OF PROVIDER OR SUPPUER PREMIER HOME HEALTH CARE SERVICES IN, (X4) ID PREFIX TAG . & WING STREET ADDRESS, CITY, STATE. ZIP CODE 9202 5TH AVE BROOKLYN, NY 11209 ID PREFIX TAG 06110120i0 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) . PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) I COMPEE DATE. _ ) H1142 Continued From page6 Directory. H1142 V. ow will the corrective action be monitored to ensure not reoccur? Quarterly audits will be conducted to ensure compliance and reviewed at the quarterly QI meetings I I Failure to have an HPN account for each agency and have staff to maintain a current HPN the deficient practice will Communications Directory places patients at risk for unsafe care during an emergent situation, The findings are: On June 10, 2010 at 4:00 p.m., a computer print out of the agency HPN Communications Directory was provided for review. The following roles are unassigned: Facility Contact! and '.'Office of the I Administrator'.. Persons responsible: 2 Branch Administrator aS 3 RD '24 by 7 On June 10, 2010 at 4:58 p.m., the Director of Patient Services was interviewed and did not provide an explanation. . H1342 766.11 (i) Personnel 766.11 Personnel. I The governing authority or operator shall ensure for all health care personnel: "deficiency for ahahabe H1342 111342 L Corrective action for those patients found to be affected by the deficient practice: There were no patients foundto be affected by the deficient practice. H1. Identification of other patients having H1342 the potential to be affected by the taken: - and what corrective action will (i) that all personnel receive orientation to the policies and procedures of the home care services agency operation and in-service All patients have the potential to be affected by the deficient practice. 1. The agency policy and education necessary to perform his/her responsibilities. At a minimum: (1) home health aides must participate in 12 hours of in-service education per year, and (2) personal care aides must participate in six I hours of in-service education per year. . This Regulation is not met as evidenced by. *Office of Health Systems Management/ Office of Long Term Care STATE FORM Version NYS 11117/2009 g procedure requires that all employees receive annual HJV 2. confidentiality to ensure there is no breach in confidentiality. lThe agency policy requires all employees receive annual training in universal precautions to reduce therisk of exposure.to andtransissionofinf___ions.____ MSSQ11 Ifcontinuation sheet 7 cf 8 tK r I nItxi..I'-Jt.JE New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION I) PROviDERJSUIPLERCLIA IDENTIFICATION NUMBER (X2) MULTIPLECONSTRUCTnON : A. FORM APPROVED (X3) DATE SURVEY COMPLETED BUILDING __________ LCO681D NAME OF PROVIDER OR SUPPLIER B. NG STREET ADDRESS, CITY, STATE, ZIP CODE 06110/2010 PREMIER HOME HEALTH CARE SERVICES INi (X4) ID, PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES BROOKLYN, NY -11209 ID PREFIX TAG I 9202 5TH AVE - - PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE (x5) COMPLETE DATE I (EACH DEFICIENCY MUST BE PRECEDED BY FULL. REGULATORY OR LSC IDENTIFYING INFORMATION) __"_"____-DEFICIENCY) H1342 Continued From page 7 Based on record review and interview the agency failed to ensure employees receive HIV Confidentiality and Universal PrecaUtions training annually. This was evident for two (2) of seven (7) personnel records reviewed (Employees #6 and H1342 Ill.Measures that will be put in place to ensure that the deficient practice will not. reoccur: ) - 1. The Office Administrator will monitor that all staff attend annual mandatory training. 2. Evidence of attendance will be "documented and placed in the employee file. IV. How will the corrective action be Failure to ensure ahnual training in HIV .Confidentiality and Universal Precautions places employees and patients atrisk for breach of confidential information and exposure to infection. The findings are. 1) Employee #6 is a Registered Nurse hired by ". o [the agency on "12/04/07. There is no documented evidence of annual HIV! Confidentiality and Universal Precautions training for the years 200aand 2009. On June 10, 2010; at 5:06 p.m., the Director of, Patient Services was interviewed and stated: "Per the HR (Human Resources) Coordinator, the HIV Confidentiality and Universal Precautions training is not present in the file." 2) Employee #7 is a Registered Nurse and Director of Patient Services hired by the agency monitored to ensure the deficient practice will not reoccur?, 1. The agency will document annual V confdentiality and h nul:[~oniefaiy n universal precautions training policy and state regulation. 2. ')oc mentation of training will be placed in the employee 3. o "reviewed record. Compliance reports will be monthly to ensure on all employees as per agency 4 compliance with agency policy rn r ie for ongoing compliance: 1. Office Administrator 2. FiS on " 1/1 4/0". 3. RDPS 4.Compliance"sipervisor There is no documented evidence of annual HIV Confidentiality and Universal Precautions training for the year 2008. On June 10, 2010 at 4:45 p.m., the Director of Patient Services was interviewed and did not provide an explanation. Office of Health Systems Management I Office of Long Term Care STATE FORM Version NYS 11117/2009 M8SQ1 Ifcontinuation sheet 8 of 8 _ STATE OF NEW YORK DEPARTMENT OF HEALTHMetropolitan Area Fegional Office 90 Church Street, New York, NY 10007 James W. Clyne, Jr. Executive Deputy Commissioner Richard F. Daines.M.D. Commissioner August 25, 2010 Americare 'fNe-W York City Attn: Nancy Hahn Administrator 3044 Coney Island Avenue Brooklyn,.NY 11235 Re: Response to Plan of Correction License: 9190L001 Survey Date:, 7/15/2010 Dear Ms. Hahn: Please be advised that the Plan of Correction relating to the recent State Re-Licensure Survey of your agency have been reviewed by this office. All items were found to be acceptable and it is expected that you will implement this plan within the time frames that were submitted. A post approval review will be conducted to verify the correction of deficiencies. If you have any questions regarding this matter, please call our office at (212) 417-4921. Sincerely, Cheryl Phoenix-Tannis, RN, MSN, CS Regional ProgramDirector Bureau of Home Health Care and Hospices Services Metropolitan Aiea Regional Offices /jt americare a tradition of caring August 6, 2010 Ms. Cheryl Phoenix-Tannis, RN, MSN, CS Regional Program Director New York State Department of Health Home Health Care and Hospice Services Metropolitan Area Regional Office 90 Church Street New York, New York 10007 Re: Re-Licensure Survey License: 9190L001 Survey Date: July 15, 2010 Dear Ms. Phoenix-Tannis: Please find enclosed Americare Inc.'s Plans of Correction in response to the Statements. of Deficiency issued by your office dated July 30,.2010 resulting from the re-licensure survey of our agency conducted on July 15, .2010. Should you have questions, please contact me at 718-434-5100 extension 3114. Thank you. Sincerely, Nancy Hahn Administrator New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDERISUPPLIER/CLIA IDENTIFICATION NUMBER: LC 0423B .07/15/2010 PRINTED: 07/29/2010 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING FORM APPROVED (X3)-DATE SURVEY COMPLETED NAME OF PROVIDER OR SUPPLIER AMERICARE OF NEW YORK CITY (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFECIENCIES (EACH DEFECIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG STREET ADDRESS, CITY, STATE, ZIP CODE 3044 CONEY ISLAND AVENUE BROOKLYN, NY 11235 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFECIENCY) ((5) COMPLETE DATE H 000 Initial Comments A State re-licensure survey was conducted at Americare of New York City on July 15, 2010. Five (5) Patient Care Records were reviewed and are identified as Patients #1 to 5. Five (5) Personnel Records were reviewed and are identified as Employees #1 to 5. The agency Policy and Procedure Manual, Complaint Log and Quality Improvement Committee Meeting Minutes were reviewed. H 000 H 224 766.1(a)(9) Patient rights Section 766.1 Patient rights. (a) The governing authority shall establish written policies regarding the rights of the patient and shall ensure the development of procedures implementing such policies. These rights, policies and procedures shall afford each patient the right to: (9) submit patient complaints about the care and services provided or not provided and complaints concerning lack of respect for property by anyone furnishing service on behalf of the agency, to be informed of the procedure for filing such complaints, and to have the agency investigate such complaints in accordance with the provisions of subdivision (j) of section 766.9 of this Part. The agency is also responsible that if the for notifying the patient or his/her designee patient is not satisfied by the response the patient may complain to the Department of Health's Office of Health Systems Management' This Regulation is not met as evidenced by: Based on record review and interview, the agency H 224 r r I -.. Office of Health Systems Management / Office of Long Term Care LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SEGNATURE STATE FORM Version NYS I1/17/2009 6899 UDFKI I TITLE L./DL / Z"IL/t If continuation sh{et I of 5 ' New Ybrk State Department of Health STATEMENT OF DEFICIENCIES -AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: LC 0423B NAME OF PROVIDER OR SUPPLIER AMERICARE OF NEW YORK,CITY (X4) ID PREFIX "TAG SUMMARY STATEMENT OF DEFECIENCIES (EACH DEFECIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PRINTED: 07/29/2010 (X2)-MULTIPLE CONSTRUCTION A.- BUILDING B. WING FORM APPROVED (X3) DATE SURVEY COMPLETED 07/15/2010 STREET ADDRESS, CITY, STATE, ZIP CODE 3044 CONEY ISLAND AVENUE BROOKLYN, NY 11235 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFECIENCY) (X5) COMPLETE DATE H 224 Continued From page 1 did not provide patients complete information about the agency procedures for investigating complaints. This was evident for the agency "Complaint Procedure" included in the admission Packet. Failure to provide patients complete written complaint information places patients at risk for not being able to fully exercise rights. The findings are: 1) There is no documented evidence of informing patients the agency has within 15 days to explain the complaint investigation findings and the decision rendered, 2) There is no documented evidence of informing patients of an appeals process and the appeal must be reviewed by a member or committee of the governing body within 30 days of receipt of the appeal. On July 15, 2010 at 4:30 pm., the agency Director of Patient Services and Administrator were interviewed and did-not provide an explanation. H 224 Plan for Allegedly Affected Patients: The Director of Patient Services will assign a Nurse to re-visit patients #1, #2, #3 to explain and provide each a copy of Americare Inc.'s revised Complaint Procedure outlined in the Patient Bill of Rights. (attachment #1) 8/9/2010 Plan to Identify other Potentially Affected Patients: 8/9/2010 The Director of Patient Services will send all curren patients the following documents 1. 1 Cover Letter (attachment #2) 2. Amended Patient Bill of Rights 3. Acknowledgment of Receipt (attachment #3) Measures and Systems The Director of Patient Services will meet with all the nurses to: 1. ReviewAmericare Inc.'s existing "Patient Grievance Complaint Procedure." (attachment #4) 2. Review the amended Patient Bill of Rights 3. Review the nurses' responsibility in ensuring that the amended Bill of Rights is included in the admission packet before given to patients 4. Review the nurses' responsibility in ensuring Patient Rights are fully explained to patient and or their representatives. H 722 8/11/201 0 H 722 766.6(a)(10) Patient care record 766.6 Patient care record, (a) The agency shall maintain a confidential record for each patient admitted to care to include: (10) a discharge summary when the patient is discharged from the agency including: (i) documentation of discharge planning 8/9/2010 .. Monitoring Systems On-going A dedicated staff will-be assigned to randomly check 20 admission folders per month to ensure that revised and updated Patient Bill of Rights is included in the folder. 8/9/2010 Newly admitted patients will be contacted by On-going their assigned coordinators to ensure of Rights. they have received the Patient Bill Information obtained from monitoring of admission 9/8/2010 On-going folders and patient contact will be prepared and provided at the.Professional Advisory Committee Meeting every quarter. TITLE Ld - Office of Health.Systems Management/ Office of Long Term Care LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SEGNATURE UDFKI I 6899 Version NYS 11/17/2009 STATE FORM o// If continuation sheet 2 of 5 New York State Department of Health STATEMENT OF DEFICIENCIES (XI) PROVIDER/SUPPLIERJCLIA (X2) MULTIPLE CONSTRUCTION PRINTED: 07/29/2 ' 0 FORM APPROVED (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIF CATION NUMBER: LC 0423B A. BUILDING ...... B. WING ....-... COMPLETED NAME OF PROVIDER OR SUPPLIER AMERICARE OF NEW YORK CITY (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFECIENCIES (EACH DEFECIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG 07/15/2010 CITY, STATE, ZIP CODE STREET ADDRESS, 3044 CONEY ISLAND AVENUE BROOKLYN, NY 11235 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFECIENCY) (X5) COMPLETE DATE 722 Continued From page 2 preparation; . H 722 (ii) notification-to the patient's authorized practitioner; (iii) reasons for discharge and date of discharge; (iv) summary of care given and patient's. progress; .Director (v) patient status upon discharge including a description of any remaining needs for patient care and supportive services; (vi) patient or family ability to self-manage in relation to any remaining problems; and (vii) recommendations and referral for any follow-up care, if needed. This Regulation is not met as evidenced by: Based on record reviews and interview, the agency did not document a discharge summary, including notifying the authorized practitioner,. when patients are discharged from the agency. This was evident for two (2) of two (2) discharged patient care records reviewed (Patients #4 and 5). Failure to document a discharge summary places patients at risk for potentially unsafe and.poor continuity of care. The findings are: 1) Patient #4 has a start of care date of "11/25/09" and a discharge date of "6/26/10". There is no documented evidence of a discharge summary and notification to the patient's authorized practitioner. Plan for Allegedly Affected Patients The Director of Patient Services will contact patients #4 and #5 to determine and identify whether they have remaining health care needs and or any follow-up/ referral needs, and whether their physicians have been informed of their discharge from Americare Inc. Should these patients request assistance with referral or with any remaining needs, The Director of Patient Services will assist them as appropriate. The of Patient Services shall document the outcome of these contacts and actions 'taken to address patients' expressed needs. Plan to Identify Other Potentially Affected Patients The Director of Patient Services and four Registered Nurses will conduct a 100% review of cases to identify those patients.that have been discharged from Americare Inc. within the last seven months. Utilizing the Discharge Summary Form (attachment 5), each nurse shall identify remaining needs and request for assistance. Each nurseshall document findings and actions taken to address the patient's expressed needs on the form. 8/16/2010 8/30/2010 Measures and Systems 8/18/2010 The Director of Patient Services shall meet with the to: Registered Nurses andthe Coordinators 1. Train and in-service staff on discharge planning requirements. (see attachment #6). 2. The Director of Patient Services shall emphasize staffs role as referral sources for patient and family obtaining follow-up support services. 3. Identified problems through the discharge plannin, process shalhbe referred to the Quality Management Department. 4. Train and in-service staff on the proper documentation and utilization of the Discharge Summary Form. 5. Reinforcement of departmental. standards and requirements will be discussed. TITLEJ6) DATE If continuation sheet 3 of 5 Officeof Health Systems Management /Office of Long Term Care LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SEGNATURE UDFKI I 6899 Version NYS 11/17/2009 STATE FORM N~w Yqrk State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:. LC 0423B NAME OF PROVIDER OR SUPPLIER AMERICARE OF NEW YORK CITY (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFECIENCIES (EACH DEFECIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PRINTED: 07/29/2010 (X2) MULTIPLE CONSTRUCTION _ A.- BUILDING _ B. WING FORM APPROVED (X3) DATE SURVEY COMPLETED 07/15/2010 STATE, ZIP CODE STREET ADDRESS, CITY, 3044 CONEY ISLAND AVENUE BROOKLYN, NY 11235 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFECIENCY) (X5) COMPLETE DATE H 722 Continued From page 3 of "2/12/10" 2) Patient #5 has a start of care date and discharge date "6/30/10". There is no documented evidence of a discharge summary and notification to the patient's authorized practitioner. On July 15,.2010 at 1:00 pm., the agency Director of Patient Services (DPS) was No Interviewed and stated: ..... we don't have it summary). We have to start doing it." (discharge The DPS further stated: "No, we don't do it for our private paying patients (notifying the authorized practitioner of a patient's discharge." H 722 H 1006 766.9(c) Governing authority Section 766.9 Governing authority. The governing authority or operator, as defined in Part 700 of this Title, of a licensed home care services agency shall: (c) ensure the development of a written emergency plan which is current and includes procedures to be followed to assure health care needs of patients continue to be met in emergencies that interfere with delivery of services, and orientation of all employees to their responsibilities in carrying out such a plan. This Regulation is not met as evidenced by: Based on record review and interview, the agency failed to develop a complete Emergency Disaster Preparedness Plan. Failure to have a complete Emergency Disaster Preparedness Plan places patients at risk for unsafe care during an emergency situation. Office of Health Systems Management / Office of Long Term Care H 1006 LAABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SEGNATURE STATE FORM Version NYS 11/17/2009 6899 TL 7,t211) UDFKI I If continuation sheet 4 of 5 New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION -. (Xl) PROVIDERISUPPLIER/CLIA IDENTIFICATION NUMBER:. LC 0423B NAME OF PROVIDER OR SUPPLIER AMERICARE OF NEW YORK CITY (X4) [D PREFIX TAG SUMMARY STATEMENT OF DEFECIENCIES (EACH DEFECIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) CI M D T E E C ID PREFIX TAG PRINTED: 02/29/2010 (X2) MULTIPLE CONSTRUCTION A. BUILDING __..____ _ _ B. WING_ _ FORM APPROVED (X3) DATE SURVEY COMPLETED 07/15/2010 ADDRESS, CITY, STATE, ZIP CODE STREET 3044 CONEY ISLAND AVENUE BROOKLYN, NY 11235 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFECLENCY) (X5) COMPLETE DATE H 1006 Continued From page 4 The findings are: The agency: "Emergency Preparedness" and "Emergency Disaster Plan" policies lack documented evidence of the following: 1) Procedures for maintaining a current agency call down list of agency staff. 2) Procedures for maintaining a current contact list of community partners. 3) Procedures for how the agency will respond to requests for information by community partners in an emergency. 4) Procedures for orientation of staff. -. On July 15, 2010 at 3:30 p.m., the agency Director of Quality Management was interviewed i an o rvde an explanation."' H 1006 Americare Inc.'s Emergency Preparedness Plan was revised in response to the findings of the survey that took place on July 15, 2010 to include the following: 1. Procedures for maintaining a current agency call down list. 2. Procedures for maintaining a current contact list of community partners. 3. Procedures for how the agency will respond to requests for information by community partners in an emergency. 4. Procedures for orientation of staff. 7/20/2010 8/16/2010 Staff will be in-serviced on the amended The first Emergency Preparedness Plan annually. In-service will be completed by 8/30/2010 Copies of the Plan will be distributed to staff at the time of the in-service. On-going agency's New employees will be oriented to the Emergency Preparedness Plan by their respective Supervisors. (attachment # 7) Office of Health Systems Management / Office of Long Term Care SEGNATURE LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S UDFK1 I 6899 Version NYS 11/17/2009 STATE FORM TITLE . . 6 6DATE If continuation sheet of 5 New York State Department of Health 07/29/2010I . STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PRINTEE FORM APPROVED -(Xl) PROVIDER/SUPPLIERICLIA IDENTIFICATION NUMBER: .(X2) MULTIPLE CONSTRUCTION .... A. BUILDING (X3).DATE SURVEY COMPLETED B. WING LC 0423B NAME OF PROVIDER OR SUPPLIER AMERICARE OF NEW YORK CITY (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFECIENCIES (EACH DEFECIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG 07/15/2010 STREET ADDRESS, CITY, STATE, ZIP CODE 3044 CONEY ISLAND AVENUE BROOKLYN, NY 11235 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFECIENCY) (X5) COMPLETE DATE R 722 402.6(d) Criminal History Record Check Process Section 402.6 Criminal History Record Check Process. .be (d) A provider may temporarily approve a prospective employee while the results of the criminal history record check are pending. The provider shall implement the supervision requirements identified in section 402.4 of this Part, applicable to the provider, during the period of temporary employment, This Regulation is not met as evidenced by: Based on record review and interview, the agency failed to provide in-home supervision during the first week of temporary employment for employees undergoing a Criminal History Record Check (CHRC). This was evident for one (1) of four (4) Home Health Aide personnel records reviewed (Employee #2). Failure to provide in-home supervision during the first week of temporary employment while awaiting the CHRC results places patients at risk for unsafe care. The finding is: Employee #2 is a Home Health Aide hired by agency on "4/1 0/09". The agency "Employee Work Schedule" documents Employee #2 first day worked was "4/14/09" and also worked on "6/3/09, 6/5/09, 6/8/09, 6/9/09, 6/10/09, 6/11/09, 6/12/09, 6/15/09 and 6/16/09." There is no documented evidence of in-home supervision during the first week of temporary Employment until "6/16/09". R 722 Plan for Allegedly Affected Personnel Review of the employee's personnel record was conducted. The review revealed satisfactory annual performance evaluation. A field staff will assigned to check on the aide utilizing the field visit indicator (see attachment #8). Plan to Identify Potentially Affected Personnel The Administrator will convene a meeting with staff to review the statement of deficiencies related to the supervision of the home health aides awaiting results of the Criminal History Record Check. Dedicated staff will be assigned to check the agency's CHRC database weekly to keep current with those employees due for initial visit or telephone contact. 8/9/2010 8/9/2010 Measures and Systems The Director of Quality Management will hold 8/9/2010 weekly meetings with the clerical staff whose and onresponsibilities are to monitor and assign going supervisory visits for the paraprofessionals awaiting results of the CHRC. The purposes of this meeting will include but not be limited to: 1. Obtain updates on the number of paraprofessionals who require supervisory visits. 2. Identify those RN and Field staff available to perform the supervisory visits 3. Plan /schedule the supervisory visits Monitoring of Systems The Director of Quality Management will review th( 8/9/2010 and computer printout of weekly visits that have been performed as well as the number of visits that have on-going been conducted. Report will be provided to the Administrator of Americare Inc. Office of Health Systems Management / Office of Long Term Care LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SEGNATURE STATE FORM Version NYS 11/17/2009 6899 TTLE7 UDFKI I If continuation sh'eet I of 3 New York State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: LC 0423B NAME OF PROVIDER OR SUPPLIER AMERICARE OF NEW YORK CITY SUMMARY STATEMENT OF DEFECIENCLES (X4) 1ID PREFIX (EACH DEFECIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) TAG 11) PREFIX TAG (X2) MULTIPLE CONSTRUCTION A. BUILDING _ __ B. WING__ __ PRINTED: 07/29/2010 FORM APPROVED (X3) DATE SURVEY COMPLETED 07/15/2010 STREET ADDRESS, CITY, STATE, ZIP CODE 3044 CONEY ISLAND AVENUE BROOKLYN, NY 11235 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFECIENCY) (X5) COMPLETE DATE R 722 Continued From page 1 On July 15, 2010 at 4:30 pm, the agency Administrator and Director of Patient Services were interviewed and did not provide an explanation. -R-722 R 1034 402.9(d) Responsibilities of Providers; Required Notif Section 402.9 Responsibilities of Providers; Required Notifications. ....... (d) Policies and procedures. Each provider subject to the provisions of this Part shall have policies and procedures designed to implement the personnel policies and procedures to reflect these new requirements is sufficient compliance with this subdivision, This Regulation is not met as evidenced by: Based on record review and interview, the agency failed to revise Criminal History Record Check (CHRC) policies and procedures. This was evident for the agency Policy and Procedure Manual. Failure to revise Criminal History Record Check policies and procedures fails to ensure agency employees are implementing the CHRC according to regulations, which can result in poor patient care. The findings are: The agency: "Criminal History Record Check Policies and Procedures" lacks documented Evidence of the following: 1) All required responsibilities of providers and Office of Health Systems Management / Office of Long Term Care R 1034 Americare Inc.'s endeavors to comply, with the New York State Department of Health's Criminal History Record Check. It has always been the practice of Americare Inc. not to charge potential employees for obtaining fingerprints for criminal history record check. It is Americare Inc.'s current practice to act upon CHRC information in a timely manner. At the time of the surveillance visit, the surveyor found evidence of compliance with the requirements. Americare Inc.'s CHRC policy and procedure was amended to reflect our on-going implementation of the New York State Department of Health CHRC requirements. (See attachment 9) 7/15/2010 REPRESENTATIVE'S SEGNATURE LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER UDFKII 6899 Version NYS 11/17/2009 STATE FORM TITLE /Ei/IT) j If continuation sheet 2 of 3 New, York State Department of Health STATEMENT OF DEFICIENCIES (X 1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION .. IDENTIFICATIONNUMBER: - . LC 0423B NAME OF PROVIDER OR SUPPLIER AMERICARE OF NEW YORK CITY (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFECIENCIES (EACH DEFECIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PRINTED: 07/29/2010 (X2) MULTIPLE CONSTRUCTION A. -BUILDING ... .... B. WING FORM APPROVED (X3) DATE SURVEY COMPLETED 07/15/2010 STREET ADDRESS, CITY, STATE, ZIP CODE o3044 CONEY ISLAND AVENUE BROOKLYN, NY 11235 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE _DEFECIENCY) (X5) COMPLETE DATE R 1034 Continued From page 2 required notifications (402.9); 2) Prohibiting the charging of employees for a criminal history record check; 3) Requesting, receiving, reviewing and acting upon CHRC information in a timely manneIr (402.4)(a)(1). On July 15, 2010 at 3:30 p.m., the agency Director of Quality Management was interviewed and did not provide an explanation. R 1034 Office of Health Systems Management / Office of Long Term Care LABORATORY DIRECTOR'S OR PROVIDERISUPPLIER REPRESENTATIVE'S SEGNATURE T&TLE1 STATEFORM Version NYS 11/17/2009 6899 UDFKI I tE If continuation shedt 3 of 3 '