Every finding on record at Amazing Care Home Health Services LLC

A survey prompted by CO #116552 was completed on 8/6/25. One deficiency was cited.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure skilled professional services communicated with all the physicians involved in the plan of care for 1 of 3 active patients reviewed (Patient #5). Findings include: 1. The clinical record for Patient #5 was reviewed on 8/5/25. The plan of care (POC) for the certification period dated 4/27/25 to 6/25/25, revealed a start of care (SOC) date of 7/17/21; diagnoses included complications of gastrostomy, type 2 diabetes mellitus, gastroparesis, unspecified protein-calorie malnutrition, gastrostomy status, malignant neoplasm of prostate, and Barrett's esophagus without dysplasia. POC orders included skilled nursing (SN) services once a week for 60 days for medication management, diabetic skin checks, monitor and mitigate pain, and gastrointestinal tube (G-tube) monitoring; and home health aide visits two times a week for 60 days for hygiene, showering, grooming, and activities of daily living. The POC dated 6/26/25 to 8/24/25 revealed a SOC date of 7/17/21; diagnoses included Type 2 diabetes mellitus, gastroparesis, unspecified protein-calorie malnutrition, gastrostomy status, malignant neoplasm of prostate, and Barrett's esophagus without dysplasia. POC orders included SN services once a week for 60 days for medication management, diabetic skin checks, monitor and mitigate pain, and (G-tube) monitoring; and home health aide visits two times a week for 60 days for hygiene, showering, grooming, and activities of daily living. POC mental assessment shows status as oriented and forgetful. a) The agency failed to coordinate with the physician regarding increased pain, fluid leakage, and skin changes surrounding Patient #5’s G-tube. A Review of the comprehensive assessment dated 4/24/25 for the certification period dated 4/27/25 to 6/25/25 revealed Patient #5 required medication management services for medication compliance, pain assessment, and G-tube site monitoring for signs or symptoms of infection. The assessment of Patient #5’s G-tube revealed no signs of infection. Patient #5 reported tube leaking and occasional pain at the site as manageable. Additional review indicated Patient #5 reported no recent medication changes, Emergency Room (ER) visits, or infections. The POC assessment showed the mental status of Patient #5 as oriented and forgetful. Review of SN visit note completed on 5/15/25, revealed Patient #5 self-reported visiting the ER on 5/14/25 for severe pain and leakage at the G-tube site. RN #2’s visit note stated Patient #5 was well-versed and independent in notifying his primary care physician (PCP) regarding issues with his G-tube. Additional review revealed an intervention for the SN to notify the PCP of any signs or symptoms of infection or any other gastrointestinal abnormalities. Review of SN visit note dated 5/22/25, showed Patient #5 reported pain 7 out of 10 on the pain scale. Additional review noted an appointment for Patient #5 with his PCP the week before. Patient #5 continued to report leakage. RN #2 noted Patient #5 as independent in notifying his PCP. The review failed to reveal care coordination. Additional review of SN visit notes dated 5/29/25, 6/5/25, 6//13/25, and 6/19/25 showed similar findings of pain and leakage of the G-tube. Review of Patient #5’s coordination notes failed to reveal documented coordination of care notes during the certification period dated 4/27/25 to 6/25/25. Record review revealed RN #2 completed a comprehensive assessment on 6/26/25. The assessment summary revealed Patient #5’s mental status as oriented and forgetful. RN #2 reported Patient #5 had experienced pain and leakage from the G-tube site. The site was described as red and irritated. Patient #5 reported G-tube site pain as 7 of 10 on the pain scale. Review of additional SN visit notes between 7/3/25 and 7/30/25 showed Patient #5 continued to report pain and leakage of the G-tube site. The record review failed to reveal care coordination for Patient #5 from 6/26/25 to 8/4/25. During an interview on 8/5/25 at 4:31 p.m., RN #2 reported she did not communicate with Patient #5’s PCP, surgeon, or other providers. According to the RN, the patient could manage his appointments, orders, and G-tube. The RN admitted that the pain, leakage, and skin issues should have been discussed with the patient’s PCP. The RN acknowledged failure to coordinate care for Patient #5. An interview with the branch’s Director of Nursing (DON) on 8/6/25 at 2:02 p.m. stated she was unaware of the lack of coordination with Patient #5’s PCP.

A complaint survey, prompted by #CO93958 was completed on 10/26/22 Three deficiencies were cited.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure drugs and treatments were administered by agency staff only as ordered by a physician for 1 of 1 patient records reviewed who required a resumption of care (Patient #4), and 1 of 2 discharged patients (Patient #3). Findings include: AGENCY POLICY According to the policy titled Physician or Allowed Practitioner Orders, revised 2/23/21; "All medications, treatments and services provided to clients must be ordered by a Physician or Allowed Practitioner." According to the policy titled Plan of Care, revised 2/23/21; “An individualized Plan of Care/485 signed by a Physician or Allowed Practitioner shall be required for each client receiving home health and personal care services.” 1. The clinical record for pediatric Patient #4 was reviewed on 10/24/22. The Plan of Care for the certification period, dated 7/24/22 to 9/21/22, revealed a start of care date of 9/4/14; diagnoses included congenital malformation, unspecified. Plan of Care orders included private duty nursing (PDN) visits 8 to 24 hours per day for 60 days to provide gastrostomy (g) tube care, change g-tube every 1 to 3 months and as needed (PRN), change tracheostomy every 2 weeks, and monitor and maintain Trilogy ventilator continuously; and certified nurse aide (CNA) visits 2 to 10 times per month for two months to provide care and assist with activities of daily living (ADLs). a) Clinical record review showed the SN failed to obtain adequate and specific physician orders prior to proceeding with patient care. Clinical record review showed Patient #4 was transferred to an inpatient facility on 8/23/22. Review of a ROC [Resumption of care] order dated 8/1/22 completed by registered nurse (RN #3) showed a W/O [Written Order] requested by the RN to the physician to resume Patient #4’s care after hospitalization. Specifically, the order read “effective 8/1/22 at 1600 PM resume skilled nursing, CNA [certified nurse's aide], and ST [speech therapy] services as the patient was discharged from the hospital and returned back to her home…” Review showed the written order request which was not a verbal order was granted by the physician as evidenced by the physician’s signature on 8/12/22, 11 days after the order was written. However, record review showed nursing visits were provided without orders by various agency clinicians between 8/1/22 and 8/12/22, 11 days before the physician authorized the request for resumption of care orders. During an interview on 10/24/22 beginning at 3:01 p.m., RN #3 confirmed she did not talk to the physician or the physician's office, and this was a request. When asked if this was a practice with this physician, RN #3 said yes. She stated this physician’s office would not take verbal orders or take calls. "They would not give orders so we sent written requests." 2. The clinical record for pediatric Patient #3 was reviewed on 10/21/22. The Plan of Care for the certification period, dated 8/13/22 to 10/11/22, revealed a start of care date of 4/15/22; diagnoses included spastic quadriplegic cerebral palsy. Plan of Care orders included PDN visits 16 to 24 hours per day for 60 days to provide continuous enteral feeding, perform cough assist, apply average volume-assured pressure support (AVAPS) mask via Trilogy ventilator at bedtime and while taking naps, and evaluate the patient for complications and obtain medical and emergency assistance if required. a) Clinical record review showed the agency failed to obtain adequate physician orders for Patient #3’s care. Review of a Recert Request Order dated 8/8/22 showed RN #4 had completed a physician verbal order to authorize the recertification of Patient #3 for the certification period dated 8/13/22 to 10/11/22. The verbal order was never signed by the physician. However, record review showed PDN visits were provided by RN #5 from 8/13/22 through 9/10/22 when Patient #3 passed away, without obtaining a physician’s signature on the verbal order to authorize care and the subsequent plan of care which was implemented for the certification period dated 8/13/22 to 10/11/22. On 10/24/22 at 12:23 p.m., the surveyor requested signed physician orders for Patient #3. During an interview on 10/24/22, beginning at 1:08 p.m., the PDN director stated the agency had difficulties in obtaining physicians’ signatures and having orders signed by some physicians’ offices/clinics. She expressed they had difficulties obtaining signatures on some orders, but stated they developed a follow up process to ensure verbal orders and plans of care were signed timely. She then confirmed Patient #3's orders and plans of care were not signed. On 10/26/22 at 2:08 p.m., the surveyors received an email from the PDN director, stating “We do have the verbal Recertification order for episode 8/13/22-10/11/22, but it is not signed. This is the Special Care Clinic, the clinic we discussed yesterday that we are in the process of escalating our unsigned orders. His [Patient #3] plan of care from this episode is also unsigned.”

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to coordinate care delivery to meet the patient's needs for 1 of 2 discharged patients' records reviewed who received private duty nursing (Patient #1). Findings include: AGENCY POLICY According to the policy titled Coordination of Client Services, revised 2/21/19; “All personnel providing services shall maintain a liaison to assure that their efforts are coordinated effectively and support the objectives outlined in the Plan of Care. This may be done through formal care conferences; maintaining complete, current Care Plans; and written and verbal interaction. The Administrator and the Director of Clinical Services of the parent office will work with the Director of Nursing Services from the branch to ensure compliance with this policy. "To ensure services are coordinated between members of the interdisciplinary team. To ensure appropriate, quality care is being provided to clients. "To establish effective interchange, reporting, and coordination of client care.” 1. The clinical record for pediatric Patient #1 was reviewed on 10/20/22. The Plan of Care for the certification periods dated 6/27/22 to 8/25/22 and 8/26/22 to 10/24/22 revealed a start of care date of 11/4/2020; diagnoses included spastic quadriplegic cerebral palsy, dependence on supplemental oxygen, and hypothermia, not associated with low environmental temperature. Patient #1 was ventilator dependent. Plan of Care orders included private duty nursing (PDN) visits 16 to 24 hours per day for 60 days to monitor patient for seizure activity, provide continuous line-of-sight supervision and proper nursing actions/interventions, provide tracheostomy care, perform cough assist, and monitor and maintain ventilator settings and functioning; and certified nurse aide (CNA) visits 4 to 6 times per day for 60 days to provide care and assist with activities of daily living (ADLs). a) The agency failed to provide oversight and coordination to ensure collaboration of care and services meet the patient's needs. In an occurrence report dated 10/1/22 filed by the agency with the State Agency (SA), it was indicated “the family had just moved into their new home the previous day.” During an interview on 10/24/22 beginning at 10:42 a.m., RN #1 who was also the mother of the child (MOC) and on duty during Patient #1’s death was asked about the move to the new home and how she ensured the patient’s equipment was functioning correctly after the move. She stated she had moved Patient #1 as she always did, with all physician visits or travels using a portable Trilogy ventilator, a battery packed oxygen concentrator that fed through the ventilator and a pulse oximeter probe that remained on the patient's fingers or toes. She said the alarms on the ventilator, pulse oximeter and oxygen concentrator could be heard throughout the new home because they had a baby monitor they carried around to hear any noises while the child slept. She said she had two of each piece of equipment including a suction machine because her child could not live for long without the life saving equipment. According to RN #1, Patient #1 stayed in a makeshift bed on the living room floor on the day of the move until his bed and the other Trilogy ventilator transported by the mover were set up in Patient #1’s room in the new home. The patient was then moved from the makeshift bed to the bed in the patient's bedroom and connected to the oxygen concentrator and Trilogy ventilator that had been moved by the movers. When asked if the durable medical equipment (DME) company was available to help to ensure the equipment was functioning well, she stated it was just plugged into the wall and everything worked well. She stated the DME company was not available to check on the equipment because they stopped servicing the patient. She said the new company did not offer to inspect the equipment after the move. She stated she usually set up the equipment since she was trained by Childrens' Hospital. During continued interview on 10/24/22 beginning at 1:03 p.m., when RN #1 was asked about the last time the equipment was serviced by the DME company, she stated it was in August 2022. She explained the DME company had dropped the patient from service. She stated she had complained and reported to the DME company that she was not receiving her supplies she requested and the DME representative, a respiratory therapist (RT) coming out to the home was giving nurses a hard time. She stated it had been more than 5 to 6 weeks since Patient #1 had a DME company come to the home to service the equipment. She said she was instructed by Childrens' Hospital to report DME problems to them. The nurse from Childrens' Hospital gave her numbers to call other DME companies to resume services. She said she reported to the nurse at Childrens' Hospital on numerous occasions expressing her fear of not getting services resumed in a timely manner. She expressed surprise “a person dependent on oxygen and vent and who needed equipment serviced every month would be dropped from service.” She said she reported the DME concern to the nurses that worked with her son but did not receive guidance from them on what to do to get services restarted faster. RN #1 said that on the day of her son's death, the ventilator equipment showed he was breathing normally, yet when she looked at his skin it was pale and gray. She said she knew he was in distress but did not realize at the time what the concern was until she went to turn up the volume of oxygen on the concentrator, but it would not adjust. She said the alarm on the concentrator did not sound which was unusual since any interruption in flow would cause the alarm to sound. She said she did not know how long he was without oxygen. She had by this time connected an ambu-bag to the patient's trach to intubate. She said this was a normal process to follow when he needed extra oxygen. She said this would happen when his temperature dropped. She said she had to get the oxygen tank to connect to the ambu-bag to provide supplemental oxygen to her son. She noticed the pulse oximeter was reading normal levels of 98%, which she understood could not be accurate since her son was pale and gray in color. She said she removed the pulse oximeter and noticed it was registering a normal range even when not being connected to a person's finger. She confirmed the malfunctioning ventilator and oxygen concentrator were moved by the movers and not her. She said the pulse oximeter was always on the child's fingers or toes. During an interview on 10/24/22 at 2:50 p.m., registered nurse/case manager (RN/CM) was asked if she was informed of the difficulties RN #1 (MOC) had with the DME company. She stated yes, and explained, RN #1 had several issues with one employee and was in the process of switching over to another company, but was not sure where she was in that process. RNCM stated the DME company was not responsive to her needs, brought wrong supplies and told her to keep them. When the RNCM was asked about the last time DME was in the home for service. She stated she did not know. Asked if the situation in the home with the DME was communicated to a supervisor to intervene, she stated she had sent a note to her boss about inappropriate in-home interactions with the RT and wrong supplies. RNCM added RN #1 (MOC) might not have communicated with the supervisor and/or office about the DME. During an interview on 10/24/22 at 3:04 p.m., the RN/Supervisor was asked about the DME situation in the home, she said she had a conversation about it with RNCM and had instructed her to contact the DME company to explain what was happening and report to them that the RT had been rude and inappropriately aggressive. But when asked if she knew that the DME company had dropped services to the patient 5 to 6 weeks prior to his death and had not had the equipment checked, she said she did not know. She also stated she did not report the issues shared with her by RNCM with the agency leadership group. During an interview on 10/26/22 beginning at 10:25 a.m., the agency PDN director, PDN assistant director of nursing (ADON), the director of clinical services (DOCS), and clinical educator (CE) all stated they were not aware of the DME situation in the home as it had not been reported to them. They also stated the current agency policy held the DME company responsible for the maintenance of equipment and if any issues came up, the DME was to be notified. They added that education would be provided to managers and supervisors on reporting expectations to the agency leadership group.

Contents of clinical record CFR(s): 484.110(a) Standard: Contents of clinical record. The record must include: This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure clinical records contained complete documentation of pertinent past and current findings in accordance with accepted professional standards for 1 of 2 discharged patients record reviewed who received private duty nursing (Patient #1). Findings include: 1. The clinical record for pediatric Patient #1 was reviewed on 10/20/22. The Plan of Care for the certification periods dated 6/27/22 to 8/25/22 and 8/26/22 to 10/24/22 revealed a start of care date of 11/4/20; diagnoses included spastic quadriplegic cerebral palsy, dependence on supplemental oxygen, and hypothermia, not associated with low environmental temperature. Patient #1 was ventilator dependent. Plan of Care orders included private duty nursing (PDN) visits 16 to 24 hours per day for 60 days to monitor patient for seizure activity, provide continuous line-of-sight supervision and proper nursing actions/interventions, provide trach care, perform cough assist, and monitor and maintain ventilator settings and functioning; and certified nurse aide (CNA) visits 4 to 6 times per day for 60 days to provide care and assist with activities of daily living (ADLs). a) The agency failed to ensure the registered nurse (RN) documented current findings of Patient #1's equipment. Review of the Plan of Care for the certification periods dated 6/27/22 to 8/25/22 and 8/26/22 to 10/24/22 revealed the SN was “to monitor and maintain Trilogy ventilator settings and functioning continuous during the daytime and continuous overnight.” During an interview on 10/24/22 beginning at 10:25 a.m., the PDN director stated the agency identified in May and early June 2022 that there was more the agency could do in regards to agency staff monitoring ventilator dependent patients. As a result, the agency created a ventilator sub-form in the electronic medical record (EMR) so clinicians could document observations they made in their continuous monitoring of the patient and patients' equipment throughout their shifts of patient care. She stated the expectation for the clinicians was to document the live numbers every 2 hours. During the same interview, The PDN assistant director of nursing (PDN/ADON) explained the clinicians were taught to monitor the patient by observing the patients’ rising and lowering of the chest and capturing through documentation, live numbers displayed on the machines ensuring there was proper connection of the equipment and no alarms were off. However, clinical record review of SN Notes for the certification periods dated 6/27/22 to 8/25/22 and 8/26/22 to 10/24/22 (over more than 120 days or 4 months), completed by RN #1 who was also the mother of the child (MOC), showed RN #1 failed to document and complete the flowsheets to record the functioning of the ventilator during her shifts. During an interview on 10/24/22 beginning at 11:42 a.m., RN #1 (MOC) stated she received four hours of care/training for the care of Patient #1, so she did not document. She stated the numbers on the vent changed all the time so by the time she wrote it down the readings had changed. According to RN #1, the settings were not changed because the pulmonologist or respiratory therapist (RT) did it once a month. She further stated her job was to address if any of the numbers was too low or the patient’s trach was too loose or tight. She then stated the agency’s policy for wanting these live numbers documented every two hours on flowsheets did not make sense. During an interview on 10/24/22 beginning at 10:22 a.m., the director of clinical services (DOCS) acknowledged RN #1 had refused to follow the documentation process. She reiterated RN #1 was not following the standards for maintaining and monitoring the functioning of the equipment. She stated she had marked on the report provided to State Agency (SA) on Patient #1’s occurrence report of sudden death, that RN #1 (MOC) did not follow the required documentation of patient care. The DOCS also stated the not-too-clear circumstances of the patient’s death had led the agency to notify police, the coroner, and other entities. Although RN #1 had refused to provide complete patient's care documentation for Patient #1, findings in RN #1’s personnel record review showed the agency had scored her as “exceeding expectation” during the annual performance review dated 8/7/22.