Every finding on record at Apex Home Health Care LLC

An unannounced Complaint survey, #2021016937, was commenced on 03/29/2022 and concluded on 03/30/2022 at Apex Home Health Care LLC Home Health Agency provider. The provider is not in compliance with 42 CFR Part484, Subpart A-C, Conditions of Participation for Home Health Agencies.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on review of the Home Health Agency (HHA)'s documents. record review and interview, the HHA failed to integrate services for 2 of 3 sampled patients (Patient #1 and #3) as evidenced by the failure to ensure a Licensed Practical Nurse (LPN) was not practicing Nursing outside the scope of their practice by administering an Intravenous (IV) antibiotic without a physician's order and having an LPN administer the IV antibiotic via IV "push" (directly into a vein) (Patient #1); failing to coordinate and communicate with the physician regarding a low Hemoglobin test result (Patient #1) and failing to coordinate and communicate with the physician regarding a Vancomycin (Antibiotic) blood level not done as ordered (Patient #3) . The findings included: 1) Review of the HHA's document titled “Clinical Documentation Guidelines for Medicare Reimbursement” provided by the HHA Director of Nursing reveals, “…establish the patient care plan…document and update patient/caregiver response to the plan of care and any changes in the plan of care weekly… Review of the HHA's document titled, “Administration of Medications: General Guidelines” provided by the HHA Director of Nursing reveals, “…obtain a physician’s order for the patient’s medication. It should include the following information: name of patient, name of the medicine, medication dose, route, and frequency of administration…inscribe the physician’s order on the medication record…update record as needed…administer medication according to the HHA policies and stated nurse practice act…keep the medication record current. Obtain written physician’s order for changes in the dosages of medications or for new medications…update the plan of care…” Review of the HHA's document titled, “Antibiotic Therapy: Intermittent Infusion” provided by the HHA's Director of Nursing reveals, “…antibiotic therapy is usually administered through intermittent drug infusion…for approximately 30 minutes…consult with the physician or the home infusion service’s pharmacist regarding serum level monitoring of antibiotics. Electrolyte, liver panel, blood urea nitrogen (BUN) and serum creatinine levels may be required for therapy lasting at least 5 days. In addition, serum peak and through levels are usually monitored for …Vancomycin therapy…antibiotic medication as prescribed by the physician…” Review of Patient #1’s electronic medical record documented a start of care date of 09/28/2021. Review of the patient’s Home Health Certification and Plan of Care (POC) period from 09/28/2021 to 11/26/2021 documented a Primary Diagnosis of Pain due to internal orthopedic prosthesis and a skilled nurse (SN) visit frequency of weekly for two weeks. The POC documented in part the skilled nurse goal as “The patient will have no hospitalizations during the certification period with a target date on 11/26/21. The review revealed a correction to the plan of care dated 11/04/21 with additional diagnoses as S/P (Status Post) Right Conversion Total Hip Replacement, Type 2 Diabetes Mellitus and Skilled Nurse interventions as follows: Skilled nurse to assess/instruct on pressure ulcer prevention measures. Skilled nurse to assess/instruct patient/caregiver in wound characteristics and s/s of infection. Patient/caregiver will be cognizant of home safety, bill of rights, emergency measures, and s/s of complications in 1 visit. Patient/caregiver will verbalize understanding of importance to maintain medical condition in home without hospitalization, visit, or unplanned physician visit within 1 visit. Otherwise frequencies and POC remain unchanged. Review of Patient #1’s laboratory results dated 10/15/21 documented a Hemoglobin (Hgb) of 8.2 with a reference value range between 14.0 to 18.0 indicating that the patient’s Hemoglobin was below normal range. Further review of the patient's Skilled Nurses Notes from 10/15/21 to 11/02/21 reveals no evidence of documentation of any contact with the physician to report the abnormal Hemoglobin test result on 10/15/21. Review of the patient’s Orthopedic Surgeon's order dated 10/04/21 documents, “IV (intravenous)order, Diagnosis-Right Hip Infection” with no further evidence of the physician's order to include additional information as name of the medication, medication dose and frequency of administration as per the HHA's policy. Review of Patient #1’s “Communication Record” documents, on 10/05/21, “Spoke with Pharmacy regarding IV Rocephin arrangement. Pharmacy will make the arrangement for PICC (a venous access) line access. First dose is to be given at Outpatient Radiology or M.D. (physician) office. Expected treatment is daily for 6 weeks…” Review of Patient #1's Staff A's, RN (Registered Nurse) “RN IV” Note dated 10/06/21 documents, “Ceftriaxone 2 grams IV(intravenous) daily, patient response: no complaint. Plan for next visit as per POC…” Review of Staff A's, “RN IV” Note dated 10/11/21 to 10/20/21 documents, “Ceftriaxone (Rocephin) 2 grams IV daily, patient response: no complaint. Plan for next visit as per POC…” Review of Staff A's, “RN IV” Note dated 10/27/21 to 11/02/21 documents, “Ceftriaxone 2 grams IV daily, patient response: no complaint. Plan for next visit as per POC…” Further review of Staff A's "RN IV" Notes lack evidence of documentation of coordination of care with Patient #1’ s physician for clarification of the IV order and for reporting of the Hemoglobin test results of 8.2 on 10/15/21. Review of Patient #1's” Staff B's Licensed Practical Nurse (LPN) Note dated 10/07/21 documents, “Ceftriaxone 2 grams IV daily, patient response: tolerates well…IV line located on patients left arm…SN administered Ceftriaxone 2 grams via IV push…” Review of Staff B's LPN Note dated 10/08/21 documents, “Ceftriaxone 2 grams IV daily, patient response: tolerated well…” Review of Staff B's LPN Note dated 10/09/21 documents, “Ceftriaxone 2 grams IV daily, patient response: tolerated well…IV line located on patients left arm…SN administered Ceftriaxone 2 grams via IV push…” Review of Staff B's LPN Note dated 10/10/21 documents, “…IV line located on patients left arm…SN administered Ceftriaxone 2 grams via IV push…” Review of Staff B's LPN Note dated 10/21/21 documents, “Ceftriaxone 2 grams IV daily, patient response: tolerates well…” Review of Staff B's LPN Note dated 10/22/21 documents, “…IV line located on patients left arm…SN administered Ceftriaxone 2 grams via IV push…” Review of Staff B's LPN Note dated 10/23/21 documents, “…IV line located on patients left arm…SN administered Ceftriaxone 2 grams via IV push…” Review of Staff B's LPN Note dated 10/24/21, 10/25/21 and 10/26/21 documents, “Ceftriaxone 2 grams IV daily, patient response: tolerates well…” Further review of Staff B's LPN Notes lack evidence of documentation of coordination of care with Patient #1’s physician for clarification of the IV orders and reporting of the Hemoglobin test results of 8.2 on 10/15/21. On 03/29/22 at 2:25 PM, an interview was conducted with the HHA 's Administrative Assistant (AA) who stated that the HHA has had many Directors of Nursing (DONs) within a year and the DON was responsible for the laboratory results; to upload the result in the patient's electronic medical record; stated that she will contact the Laboratory for Patient’s #1’s test result. On 03/29/2022 at 2:37 PM, a side-by-side review of Patient #1’s electronic medical record was conducted with the HHA's Director of Nursing (DON) who confirmed the administration of the IV antibiotic by Staff A and Staff B; confirmed a physician's order dated 10/04/21 for an IV with no additional information as to the medication name or the frequency; the DON stated she will expect the nurses to call the physician to clarify the IV order, she would have scheduled a "Follow Up OASIS (Home Health Agency Assessment) Assessment" that would verify the physician's orders; stated previous OASIS Assessments did not capture the diagnosis for the antibiotic; stated that completing the "Follow Up OASIS" would allow them to document the goals and interventions for the IV orders; added that a "Follow Up OASIS Assessment" would include sections to reconcile the medication profile and to submit any changes or medications, if done, it would have given the clinician the opportunity to document new medications; stated there was not an update to the patient's "Medication Profile" for 10/06/22 when the IV medication was started; added an addendum POC was not generated because a "Follow Up OASIS Assessment was completed; confirmed that Staff A and Staff B provided administration of an IV without a physician's order; stated that the nurses do not draw blood, the HHA will have a "Mobile Phlebotomy Group" draw the blood to send to the laboratory for the patient; confirmed Patient’s #1’s Laboratory test result dated 10/15/21 of a low Hemoglobin; confirmed that there was no evidence of documentation related to communicating to the physician the patient’s low Hemoglobin result and added that Patient #1’s low Hemoglobin was not addressed. A side-by-side review of the patient’s "Communication Record by Staff A dated 11/04/21 documents, “Patient to .. (local hospital's name) after MD visit on 11/03 reviewed bloodwork and Hemoglobin 8.5” On 03/29/2022 at 3:09 PM, during the review and interview, the DON was asked to call Staff A; A telephone call was made to Staff A with no answer after several rings; the DON was asked, regarding Laboratory tests for patients receiving Antibiotic therapy and stated the standard is to check the patient’s kidney function and a blood count; On 03/29/21, at 3:10 PM, an interview was conducted with the HHA Administrative Assistant who stated that Staff A and Staff B no longer work for the HHA. The DON was asked to provide the HHA's "Policy and Procedures" related to physician's orders, coordination of care, nursing documentation and Laboratory Test result follow up. Subsequently, a side-by-side review of the HHA's binder labeled, "Policy and Procedure" was conducted with the DON to reveal the binder did not include any of the policies requested. The AA provided a binder labeled, “Nursing Procedure” On 03/30/2022 at 1:52 PM, a telephone call was made to the HHA’s DON who was asked regarding the Policies and Procedure requested on 03/29/22; stated she was still going through the book/binder and added that the “Nursing Procedure” binder was more like for office procedures. On 03/30/22 at 3:15 PM, a telephone call was made to the HHA’s DON who was asked if an LPN could do IV antibiotic push; stated that she did not want to give a straight answer and added it depend on the "State" and the LPN's experience; the DON was informed that "The Florida- Nurse Practice Act- Chapter 64B9-12.003 Aspects of IV therapy outside the scope of practice of the LPN and IV pushes except heparin and saline flushes, shall not be performed or initiated by an LPN unless under the direct supervision of RN or physician;" the DON was apprised that Staff B, an LPN documented that he administered Patient #1's IV antibiotic as an "IV push" during his Skilled Nurse visit to Patient #1; the DON stated they should have never assigned Staff B to Patient #1; added that the LPN can’t do IV antibiotic "push" in the home and confirmed that Staff B was practicing nursing outside his scope of practice. 2) Review of Patient #3’s electronic medical record documented a start of care date of 12/20/21. Review of the patient’s Home Health Certification and Plan of Care (POC) period from 12/20/21 to 02/17/22 documented a Primary Diagnosis of Cellulitis of Right Lower Limb; the POC medication list included Vancomycin intravenous 1000 mg. (milligrams) in 200 ml. (millimeters) daily; the Skilled Nurse frequency was written as daily for 8 weeks and the Skilled Nurse interventions included to administer Vancomycin (antibiotic) 1 gram IV every 24 hours via PICC line…labs (laboratory) to be obtained and fax results to physician. Review of Patient #3’s Registered Nurse (RN)'s Skilled Nurse Note (Staff C), dated 12/21/21 to 12/31/21 documents Vancomycin IV antibiotic administered via PICC daily from 12/21/21 through 12/31/21. Review of the patient’s additional physician's order dated 12/21/21 documents, “Vancomycin trough (blood level) to be drawn on 12/22/21”. Review of the patient’s Communication Record, dated 12/23/21 documents, “Patient was scheduled to have Vancomycin trough level to be done on 12/22/21 by (local lab name), received phone call from patient's’ spouse that no labs were done…(local Lab name) stated the lab tech (technician) did go out to see the patient and the spouse refused to let them in. Spouse said they did not come. Spoke with (local lab name) again and they stated they did go and is closed on 12/24. Called (patient’s Drs. name) office left message on voicemail...”. Further review reveals no evidence of follow up documentation on the patient's Vancomycin through level not done as ordered. Review of the patient’s Skilled Nurse visit by Staff C, from 12/22/21 to 12/31/21 reveals no evidence of documentation related to the physician's verbal order dated 12/21/22 for Vancomycin trough (blood work) to be done on 12/22/22. Further review revealed no evidence of documentation of coordination or notification to the patient’s physician related to the Vancomycin trough not being done as per the physician's orders. On 03/29/22 at 2:15 PM, a side-by-side review of Patient’s #3’s electronic clinical record was conducted with the DON. who confirmed that the physician ordered a Vancomycin through level on 12/22/21 and that the laboratory "closed the case;" added that she did not see any follow up documentation/communication/coordination with the patient’s physician related to the Vancomycin trough level not done on 12/22/21 and stated there was no evidence of confirmation about the physician receiving the message that it was not done.