Every finding on record at Complete Home Health, Inc.

Complete Home Health is in compliance with federal emergency preparedness requirements.

Recertification Survey

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient's written individualized POC (Plan of Care) was followed as evidenced by: 1. the SN (Skilled Nurse) failed to change the patient’s trach (tracheostomy) ties every day as ordered which resulted in the patient sustaining a wound to the left side of her neck; and 2. the SN failed to provide extended care nursing services for the patient as ordered per the POC for 1 (#5) out of 10 sampled patients. Findings: 1. Patient #5. Review of the patient’s clinical records revealed the start of care date was 07/27/2006. The patient’s diagnoses included lennox-gastaut syndrome and tracheostomy. The certification period reviewed was 04/12/2026 to 6/10/2026. Review of the patient’s POC for certification period 04/12/2026 to 06/10/2026 revealed an order for 56 hours of extended nursing care per week which was 8 hours of SN services a day. Further review of the patient’s POC revealed an order “…Change trach ties qd (every day)…” Review of Patient #5’s extended care nursing assessment progress notes dated 04/13/2026 to 04/28/2026 revealed no evidence the SN changed the patient’s trach ties. Review of the patient’s Incident Report dated 04/29/2026 revealed: “Nature of incident (Detailed Description): (caregiver) reported via text message that Patient #5 was admitted to (the hospital)… Caregiver reports area on neck open due to oxygen string was rubbing against her skin and she got a break down.” Review of Patient #5’s ED (emergency department) note dated 04/28/2026 at 23:03 (11:03 p.m.) revealed: “19 year-old female with a history of cerebral palsy, mental impairment, epilepsy, tracheostomy in place on 1.5 L (liters) at baseline presents emergency department for fever, productive sputum output through tracheostomy as well as a wound to her left neck from the trach collar. Mother noted a fever today. Gave 300 mg of Tylenol 4 hours ago… Physical Exam: Vitals & Measurements: T: 38.4 C Rectal (101.12 F); HR 123; RR: 34; BP: 110/51; Sp02: 95%; O2 flow rate: 8; O2 therapy: Trach collar. Alert, mildly distressed, resting in bed. Tracheostomy in place, abrasion/wound to left neck which is rather deep…it is foul-smelling… tachycardic. Assessment Plan: PA (physician assistant) recommends ICU… 3. Tracheostomy dependent 4. Wound, open, neck 5. Sepsis.” On 05/12/2026 at 11:26 a.m., a telephone interview was conducted with S2LPN. S2LPN stated she was the primary nurse providing extended nurse services for Patient #5. S2LPN stated she did not change the patient’s trach ties daily. S2LPN stated that she changed the patient’s trach ties once a week and that she last changed them on 04/22/2026. S2LPN stated she did not know there was an order to change the trach ties daily. S2LPN stated on 04/28/2026, after her shift ended with the patient, the patient’s caregiver had face timed her to inform her that the patient developed an open wound on the left side of her neck which was caused from friction from the trach ties. S2LPN stated she was not aware the patient had developed an open wound on her neck because the trach ties covered the open wound. S2LPN stated Patient #5’s caregiver sent the patient to the hospital because of the open wound on her neck. On 05/12/2026 at 12:23 p.m., an interview was conducted with S1DEHC (Director of Extended Home Care). S1DEHC stated the patient’s aunt called her early on the morning of 04/29/2026. She stated the patient’s aunt told her Patient #5 had a fever and that she noticed the patient had an open wound on the side of her neck. S1DEHC stated S2LPN did not observe and assess the open wound on the patient’s neck. S1DEHC stated she spoke to S2LPN and asked her if she assessed the patient’s neck. S1DEHC stated that she told S2LPN that the patient’s aunt reported to her that she noticed an open wound on the side of the patient’s neck. S1DEHC stated S2LPN responded, “I missed it”. S1DEHC stated that she did not directly ask S2LPN if she changed Patient #5’s trach ties nor did she know if S2LPN was changing the patient’s trach ties daily. S1DEHC confirmed there was an order to change the patient’s trach ties daily and she confirmed that S2LPN should have been changing Patient #5’s trach ties daily as ordered. 2. Review of Patient #5’s clinical records revealed no evidence the patient received SN services on the dates of 04/12/2026 and 04/26/2026. Review of Patient #5’s weekly calendar for the month of April 2026 revealed that on the dates of 04/12/2026 and 04/26/2026 that there was no SN assigned to provide services for those two dates. On 05/11/2026 at 4:00 p.m., an interview was conducted with S1DEHC. S1DEHC reviewed Patient #5’s weekly calendar for the month of April 2026 and stated that the dates where unassigned was written were the dates the patient did not receive SN services. S1DEHC confirmed that no SN services were provided on the dates of 04/12/2026 and 04/26/2026.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the SN (skilled nurse) notified the RN/Physician of changes in the patient’s respiratory status for 1 (#5) out of 10 sampled patients. Findings: Review of S2LPN’s Mandatory Required Reporting form that was signed and dated on 09/18/2025 revealed: “The following items are MANDATORY to report to the office! Failure to report may result in written reprimand and/or termination! *You must report any: … *Plan of Care changes/updates/change in patient condition: (New diagnosis, decrease urinary output, vital signs out of parameters, signs & symptoms of UTI & respiratory distress, seizure activity, equipment, etc) Review of Patient #5’s clinical records revealed the start of care date was 07/27/2006. The patient’s diagnoses included lennox-gastaut syndrome and tracheostomy. The certification period reviewed was 04/12/2026 to 6/10/2026. Review of the patient’s POC (Plan of Care) for certification period 04/12/2026 to 06/10/2026 revealed an order for 56 hours of extended nursing care per week, which was 8 hours of SN services a day. Review of Patient #5’s extended care nursing assessment progress note dated 04/16/2026 revealed the SN suctioned thick, yellow, green phlegm from trach (tracheostomy). There was no evidence the SN notified the RN/MD. Review of Patient #5’s extended care nursing assessment progress note dated 04/18/2026 revealed the SN suctioned thick, yellow, green phlegm from trach. There was no evidence the SN notified the RN/MD. Review of Patient #5’s extended care nursing assessment progress note dated 04/24/2026 revealed the SN suctioned thick, yellow, green phlegm from trach. There was no evidence the SN notified the RN/MD. Review of Patient #5’s extended care nursing assessment progress note dated 04/27/2026 revealed the SN suctioned thick, yellow, green phlegm from trach. There was no evidence the SN notified the RN/MD. Review of the patient’s ED (emergency department) note dated 04/28/2026 at 23:03 (11:03 p.m.) revealed: “19-year-old female with a history of cerebral palsy, mental impairment, epilepsy, tracheostomy in place on 1.5 L (liter) at baseline presents emergency department for fever, productive sputum output through tracheostomy… Mother noted a fever today. Gave 300 mg of Tylenol 4 hours ago. She is concerned about pneumonia. Physical Exam: Vitals & Measurements: T: 38.4 C Rectal (101.1 F); HR 123; RR: 34; BP: 110/51; Sp02: 95%; O2 flow rate: 8; O2 therapy: Trach collar, Alert, mildly distressed, resting in bed. Tracheostomy in place… Purulent sputum from tracheostomy. Rhonchi to all lung fields… tachycardic. Assessment Plan: PA (physician assistant) recommends ICU 1. Pneumonia, Pseudomonas 2. Rhinovirus Infection 3. Tracheostomy dependent 4. Wound, open, neck 5. Sepsis.” On 05/12/2026 at 11:26 a.m., a telephone interview was conducted with S2LPN. S2LPN stated she was the primary nurse providing extended nurse services for Patient #5. S2LPN stated she suctioned the patient’s trach and that sometimes the mucus was thick, yellow, and green. S2LPN confirmed she did not inform the RN or the physician concerning the changes in the patient’s mucus. On 05/12/2026 at 12:50 p.m., an interview was conducted with S1DEHC (Director of Extended Home Care). S1DEHC stated S2LPN did not notify her of the changes in the patient’s mucus and that she should have notified her because that was a change in the patient’s status.

Complaint #LA105545

Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) The HHA must— (i) Investigate complaints made by a patient, the patient's representative (if any), and the patient's caregivers and family, including, but not limited to, the following topics: (A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; (B) Mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient's injury of unknown source was investigated for 1(#3) out of 3 (#1, #2, and #3) sampled patients. On 04/15/2024, a review of the agency’s policy titled “9.08.1 Identifying and Reporting Possible Victims of Alleged or Suspected Abuse, Neglect, or Exploitation” with a date of 11/03/2017 revealed…..Purpose: To define the process for identifying and reporting possible victims of alleged/suspected abuse, neglect, or exploitation…. Procedure: 2. Criteria to identify abuse include… unexplained injuries or multiple hematomas....6. Staff will immediately report an assessment of patient’s condition and a supervisor will be assigned to assess…. 7. All findings and communication will be documented in the patients’ medical record. Review of the patient’s clinical records revealed the start of care date was 05/16/2016. The patient’s diagnoses included Cerebral Palsy, other abnormal involuntary movements, and Profound Intellectual Disability. The certification period reviewed was 02/04/2024 to 04/03/2024, and 04/04/2024 to 06/02/2024. Review of the patient’s Plan of Care (POC) for certification periods revealed an order for Skilled Nurse Extended Care Services for 72-84 hours per week. Patient’s POC revealed the skilled nurse was to monitor the status of patient’s skin integrity. Patient #3’s was dependent on others for all transfers and activities of daily living and had functional limitation of speech with aphasia. Review of daily extended care progress notes revealed the following: 02/03/2024 at 8:00 a.m. S3LPN (Licensed Practical Nurse) assessed Patient #3’s left eye being red and swollen. There was no documentation that the injury was reported. 02/04/2024 at 2:40 p.m. S4RN (Registered Nurse) assessed Patient #3’s redness to left side of face and around left eye. There was no documentation that the injury was reported. On 04/15/2024 at 1:45 p.m. a home visit was conducted with Patient #3. She was unable to verbalize any details regarding her redness and swelling that occurred to her left eye and face. On 04/15/2024 at 3:20 p.m., a telephone interview was conducted with S3LPN. She confirmed she assessed Patient #3 for redness and swelling to her left eye on 02/03/2024. She acknowledged that she did not notify anyone until she contacted S4RN the following day to assess. On 04/15/2024 at 3:30 p.m., a telephone interview was conducted with S4RN. She confirmed she received notice from S3LPN about Patient #3’s left eye being red and swollen. She was unable to recall if she notified anyone about the incident on that day. On 04/15/2024 at 3:50 p.m., an interview was conducted with S1ECS (Extended Care Supervisor). She confirmed Patient #3 had redness and swelling to her left eye and left side of face that occurred around 02/03/2024. She stated S4RN had notified her about it either over that weekend or possibly on the Monday. She confirmed she was unable to provide evidence that an investigation had been conducted for patient’s injury of unknown source.

Complete Home Health is in compliance with federal emergency preparedness requirements.

Recertification Survey

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient's written individualized POC (Plan of Care) was followed as evidenced by failing to ensure SN (Skilled Nurse) visits were made per the POC for patient (#1, #3) and failing to ensure PT (Physical Therapy) visits were made per the POC for patient (#3) for 2 out of a total sample of 7 patients. 1. Patient #1. Review of the patient's electronic clinical records revealed the start of care date was 5/12/2023. The patient's diagnoses included Pressure Ulcer Stage 2, Pleural Effusion, Abscess of Lung, and Downs Syndrome. The certification period reviewed was 7/11/2023 to 9/8/2023. Review of the patient's POC (Plan of Care) for certification period 7/11/2023 to 9/8/2023 revealed an order for "SN 3wk9wk, 7 prn: Complications; Beginning during week of 7/11/2023 (skilled nurse visits three times a week for nine weeks, seven skilled nurse visits as needed for complications beginning during the week of 7/11/2023)”. Review of the SN visit notes revealed that there was no evidence 3 SN visits were made as ordered for the week of 7/11/2023. On 7/17/2023 at 4:10 p.m., an interview was conducted with S1DON (Director of Nursing). She reviewed the patient’s electronic clinical record and confirmed that there was no evidence the SN made 3 visits for the week of 7/11/2023 as ordered. 2. Patient #3. Review of the patient’s electronic clinical records revealed the start of care date was 3/25/2023. The patient’s diagnoses included Cerebral Infarction, Paralytic Gait, Aphasia, and Dysphagia. The certification period reviewed was 5/24/2023 to 7/22/2023. Review of the patient’s POC for certification period 5/24/2023 to 7/22/2023 revealed an order for “SN 1wk9wk, 7 prn begin 5/24/2023 (Skilled nurse visit one time a week for nine weeks, seven skilled nurse visits as needed begin 5/24/2023)”. Further review of the POC revealed an order for “PT 2wk9wk begin 5/24/2023 (Physical Therapy visits two times a week for nine weeks begin 5/24/2023)”. Review of the SN visit notes revealed that there was no evidence that a SN visit was made as ordered for the week of 5/24/2023. Review of the PT visit notes revealed that there was no evidence that two PT visits were made as ordered for the week of 5/24/2023. On 7/18/2023 at 1:30 p.m., an interview was conducted with S1DON. She reviewed the patient’s electronic clinical record and confirmed that there was no evidence the SN made a visit for the week of 5/24/2023 as ordered and confirmed that there was no evidence the PT made two visits as ordered for the week of 5/24/2023.

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 observation, record review and interview, the home health agency staff failed to demonstrate that effective coordination of care occurred when the SN (Skilled Nurse) and the external organization’s staff failed to communicate that there was a change in the medication without an order from the physician for 1 (#1) out of 3 (#1, #2, #3) patients seen during a home visit out of a total sample of 7 patients. Review of the agency’s policy and procedure for Coordination of Patient Care revealed, “Policy: (Agency) staff members regularly communicate to ensure that their efforts are coordinated effectively and ultimately support the objectives outlined in the plan of care. Purpose: To ensure that quality services are being provided to patients; to provide a mechanism for representatives from various disciplines to discuss patient care in a group meeting; and to determine eligibility for care… 6. Care will be coordinated with other involved external organizations …community agencies…” Patient #1. Review of the patient's electronic clinical records revealed the start of care date was 5/12/2023. The patient's diagnoses included Pressure Ulcer Stage 2, Pleural Effusion, Abscess of Lung, and Downs Syndrome. The certification period reviewed was 7/11/2023 to 9/8/2023. Review of the patient's POC (Plan of Care) for certification period 7/11/2023 to 9/8/2023 revealed an order for "SN 3wk9wk, 7 prn: Complications; Beginning during week of 7/11/2023 (skilled nurse visits three times a week for nine weeks, seven skilled nurse visits as needed for complications beginning during the week of 7/11/2023)”. Further review of the POC revealed an order for “Clearlax oral powder for reconstitution; Administer 17 gm(s) (grams) orally once a day on Monday, Wednesday, and Friday. Start date: 5/12/2023”. On 7/17/2023 at 12:20 p.m., a home visit was made. During the home visit, S2RN (Registered Nurse) and the patient’s waiver staff were present. S2RN was observed reconciling the patient’s medications. During the reconciling of the medications, S2RN asked about the Clearlax/Polyethylene Glycol (stool softener). The Clearlax was not present with the patient’s other medications. The patient’s waiver staff stated that the patient was not taking the medication and that it was discontinued. The patient was present during the conversation and he stated that he was not taking the Clearlax. The waiver staff stated the nurse at the waiver agency discontinued the Clearlax. S2RN confirmed that the Clearlax was still one of the medications listed on the POC orders and that it was not discontinued. S2RN stated that the home health agency’s main concern was to provide wound care to the patient and that the waiver agency was responsible for the medications. S2RN stated the waiver agency did not communicate to the home health staff the Clearlax was discontinued. On 7/18/2023 at 9:00 a.m., an interview was conducted with S2RN. S2RN stated that she followed up with the nurse at the waiver agency concerning the order to discontinue the Clearlax. S2RN stated that the nurse at the waiver agency told her that there was no order to discontinue the Clearlax. On 7/18/2023 at 10:30 a.m., an interview was conducted with S1DON (Director of Nursing). S1DON confirmed that there was no order to discontinue the Clearlax. S1DON stated that there was no coordination of care between the waiver agency staff and the home health staff to ensure the patient’s medication was administered as ordered.

Complaint Survey LA00094558

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient's written individualized POC (plan of care) was followed as evidenced by the Skilled Nurse (SN) failing to provide 72-84 hours of extended nursing care services per week as ordered per the POC for 1 (Patient #2) out of 5 (#1- #5) sampled patients. Patient #2. Review of the patient's POC (Plan of Care) revealed that the patient's SOC (start of care) date was 2/9/2006. The certification period reviewed was 11/12/2022 to 1/10/2023. The patient's diagnoses included Obstructive Hydrocephalus, Cerebral Palsy, Epilepsy, Tracheostomy, and Gastrostomy. Review of the patient’s POC for certification period 11/12/2022 to 1/10/2023 revealed orders for Skilled Nursing: Extended Skilled Nursing Services, 72-84 hours/week. Review of the patient's Extended Care Nursing Progress Notes for the week of 11/12/2022 revealed no evidence that the skilled nurse provided services on 11/12/2022 and 11/13/2022. The patient received only 56 hours of service for that week. Review of the agency's Missed Visit note for the week of 11/12/2022, which was dated 11/18/2022 revealed, "LPN (Licensed Practical Nurse) out… for rest of the weekend…" Review of the patient's Extended Care Nursing Progress Notes for the week of 11/14/2022 revealed no evidence that the skilled nurse provided services on 11/14/2022 and 11/20/2022. The patient received only 56 hours of service for that week. Review of the agency's Missed Visit note for the week of 11/14/2022, which was dated 11/22/2022 revealed, "… No LPN (Licensed Practical Nurse) available Sunday…" Review of the patient's Extended Care Nursing Progress Notes for the week of 11/21/2022 revealed no evidence that the skilled nurse provided services on 11/26/2022 and 11/27/2022. The patient received only 56 hours of service for that week. Review of the agency's Missed Visit note for the week of 11/21/2022, which was dated 12/2/2022 revealed, "No LPN available for weekend…” Review of the patient's Extended Care Nursing Progress Notes for the week of 11/28/2022 revealed no evidence that the skilled nurse provided services on 12/2/2022, 12/3/2022, and 12/4/2022. The patient received only 48 hours of service for that week. Review of the agency's Missed Visit note for the week of 11/28/2022, which was dated 12/9/2022 revealed, "No LPN available for weekend-Still looking for staff willing to work in the home…" Review of the patient's Extended Care Nursing Progress Notes for the week of 12/5/2022 revealed no evidence that the skilled nurse provided services on 12/5/2022, 12/10/2022, and 12/11/2022. The patient received only 44 hours of service for that week. Review of the agency's Missed Visit note for the week of 12/5/2022, which was dated 12/16/2022 revealed, "No LPN available for weekend..." On 12/19/2022 at 11:40 am, an interview was conducted with S2DEN (Director of Extended Nursing Care Services). She stated that the patient did not receive the extended nursing care services as ordered per the POC because there was no nursing staff available. On 12/19/2022 at 11:50 am, an interview was conducted with S1DON (Director of Nursing). She stated that the patient did not receive the extended nursing care services as ordered because there was no nursing staff available. On 12/19/2022 at 3:15 pm, a telephone interview was conducted with S3LPN (Licensed Practical Nurse). S3LPN stated that she was the only nurse working on the patient's case. She stated that she worked 12 hour shifts Monday through Thursday, and worked an 8 hour shift on Friday. S3LPN confirmed that there was no nursing staff available to provide extended nursing care services on the weekends.

Complaint Survey #LA71911.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient's written individualized POC (plan of care) was followed as evidenced by the Skilled Nurse (SN) failing to provide 60 hours of extended care nursing services per week as ordered per the POC and physician’s orders for 1 (patient #2) out of 5 sampled patients. Patient #2. Review of the patient's clinical record revealed the start of care date was 3/12/2015. The patient's diagnoses included Degenerative Diseases of Nervous System, Epilepsy, and Quadriplegia. The certification period reviewed was 8/2/2022 to 9/30/2022. Review of the patient's POC for certification period 8/2/2022 to 9/30/2022 revealed an order for SN: Extended Care Services, 50-60 hours per week to provide total patient care. Further review of the patient’s clinical record revealed the patient’s physician’s visit notes dated 4/8/2022 that read, “ …Nursing duties include, but are not limited to: G-tube feedings and site care as ordered by MD; Administration of medication per G-tube as ordered by MD; Seizure precautions and administration of rectal Diastat (seizure medication) for lengthy seizure or cluster seizure activity; ROM (range of motion) to all extremities; maintenance of bowel program to prevent constipation. Due to the progressive degenerative nature of this disease process, I am ordering the continuation of Extended Care Nursing services, 60 hours/week to help ensure the health and safety of this increasingly fragile child.” Review of the Client Visit Notes dated 6/27/2022 to 10/5/2022 revealed that on 6/29/2022, 7/1/2022, 7/4/2022, 7/5/2022, 7/9/2022, 7/12/2022, 7/15/2022, 7/23/2022, 7/26/2022, 7/28/2022, 8/1/2022, 8/3/2022, 8/4/2022, 8/6/2022, 8/30/2022, 9/1/2022, 9/3/2022, 9/6/2022, 9/8/2022, 9/15/2022, 9/17/2022, 9/20/2022, 9/22/2022, 9/23/2022, 9/29/2022, 9/30/2022, and 10/1/2022 there was no nurse available to provide extended care nursing services for those dates. Review of the patient’s Extended Care Nursing Progress Notes for the week of 8/2/2022 revealed that the patient received 20 hours of extended care nursing for that week. The patient was short 40 hours of extended care nursing services for the week of 8/2/2022. Review of the agency’s Missed Visit note dated 8/11/2022 revealed for the week of 8/2/2022, the patient missed 40 hours of extended care nursing services. Further review of the note revealed that the reason was “Need another LPN for case…” Review of the patient’s Extended Care Nursing Progress Notes for the week of 8/8/2022 revealed that the patient received 42.25 hours of extended care nursing for that week. The patient was short 17.75 hours of extended care nursing services for the week of 8/8/2022. Review of the agency’s Missed Visit note dated 8/18/2022 revealed for the week of 8/8/2022, the patient missed 17.75 hours of extended care nursing services. Further review of the note revealed that the reason was “Need another LPN for case…” Review of the patient’s Extended Care Nursing Progress Notes for the week of 8/15/2022 revealed that the patient received 29 hours of extended care nursing for that week. The patient was short 31 hours of extended care nursing services for the week of 8/15/2022. Review of the agency’s Missed Visit note dated 8/24/2022 revealed for the week of 8/15/2022, the patient missed 31 hours of extended care nursing services. Further review of the note revealed that the reason was “Need another LPN for case…” Review of the patient’s Extended Care Nursing Progress Notes for the week of 8/22/2022 revealed that the patient received 40 hours of extended care nursing for that week. The patient was short 20 hours of extended care nursing services for the week of 8/22/2022. Review of the agency’s Missed Visit note dated 8/31/2022 revealed for the week of 8/22/2022, the patient missed 20 hours of extended care nursing services. Further review of the note revealed that the reason was “No LPN available Tuesday and Thursday…” Review of the patient’s Extended Care Nursing Progress Notes for the week of 8/29/2022 revealed that the patient received 20 hours of extended care nursing for that week. The patient was short 40 hours of extended care nursing services for the week of 8/29/2022. Review of the agency’s Missed Visit note dated 9/8/2022 revealed that the for the week of 8/29/2022, the patient missed 40 hours of extended care nursing services. Further review of the note revealed that the reason was “Still looking for another LPN for case…” Review of the patient’s Extended Care Nursing Progress Notes for the week of 9/5/2022 revealed that the patient received 40 hours of extended care nursing for that week. The patient was short 20 hours of extended care nursing services for the week of 9/5/2022. Review of the agency’s Missed Visit note dated 9/15/2022 revealed for the week of 9/5/2022, the patient missed 20 hours of extended care nursing services. Further review of the note revealed that the reason was “No LPN available Tuesday and Thursday- Still looking for LPN at this time…” Review of the patient’s Extended Care Nursing Progress Notes for the week of 9/12/2022 revealed that the patient received 40 hours of extended care nursing for that week. The patient was short 20 hours of extended care nursing services for the week of 9/12/2022. Review of the agency’s Missed Visit note dated 9/22/2022 revealed for the week of 9/12/2022, the patient missed 20 hours of extended care nursing services. Further review of the note revealed that the reason was “No LPN available Thursday and Saturday-We are still looking for a nurse for case…” Review of the patient’s Extended Care Nursing Progress Notes for the week of 9/19/2022 revealed that the patient received 30 hours of extended care nursing for that week. The patient was short 30 hours of extended care nursing services for the week of 9/19/2022. Review of the agency’s Missed Visit note dated 9/29/2022 revealed for the week of 9/19/2022, the patient missed 30 hours of extended care nursing services. Further review of the note revealed that the reason was “Still looking for another LPN for case…” On 10/3/2022 at 3:18 pm, an interview was conducted with S2DON (Director of Nursing). She stated that the patient’s family moved and they lived further away and that it was difficult to provide nursing staff for the patient. S1DON confirmed the patient was not receiving 60 hours of extended care nursing services per week as ordered by the physician. On 10/4/2022 at 11:43 am, an interview was conducted with S3DEN (Director of Extended Nursing Services). She stated that the patient was approved for 60 hours a week and the range for 50-60 hours a week was if the patient had appointments in the week, that minimum hours was 50 hours a week. S3DEN stated that the patient was not getting the approved 60 hours of extended care nursing services a week because there was a nursing shortage and where the patient lives was an issue for the nursing staff to drive to the home. S3DEN stated that the agency just does not have the nursing staff to provide the 60 hours of extended care nursing services in the week. On 10/4/2022 at 1:18 pm, a telephone interview was conducted with S4SC (Staffing Coordinator). She stated that the nurses do not want to work full time with the patient because of the drive. S4SC stated that the patient lives too far out which makes it hard to staff nurses to provide the 60 hours of extended care nursing services. On 10/5/2022 at 10:55 am, an interview was conducted with S1Admin (Administrator). She stated that the agency has pulled nurses from patient #2 when there have been last minute call-ins for other patients that live alone and does not have natural support. S1Admin confirmed that the agency is short on nursing staff and that the extended care nursing service hours that the patients are approved for were not being provided.

Complaint Survey LA00057869

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient's written individualized POC (plan of care) was followed as evidenced by the LPN (Licensed Practical Nurse) failing to notify the agency's RN (Registered Nurse) and/or the patient's physician of abnormal findings when identified for 1 (Patient #1) out of 5 sampled patients. Findings: Patient #1 was admitted to the agency on 2/19/2004 with a principle diagnosis of Cerebral Palsy. The certification period reviewed was 3/21/2021 to 5/19/2021. Review of the patient's plan of care for the certification period reviewed revealed an order to notify MD/RN (medical doctor/registered nurse) of abnormal findings... Review of Patient #1's nurse's notes dated 4/2/2021 by S4LPN revealed the following: 9:30 am - transferred client to w/c (wheelchair) via lifter. In transferring client from bed to w/c while in sling noted Rt (right) leg turned out more so than usually is - had to position to put in chair. Client's legs do turn out and do have to position properly when putting down but more so today ...wheeled to living room. Informed dad that I thought something was different. Dad assessed as well. States "we'll just have to watch it"... slight warmth to rt knee, a bit of swelling noted to knee underneath kneecap and bit to thigh area. Did not note in am care... 10:30 AM - client very fussy this am ...Questioned once again if leg hurts nods head "yes" this time. Sitting with dad in living room. Dad states "we will watch it. I guess if we go we will x-ray it." "we will wait and see". Informed dad that I see a difference and I feel like something is not right". 12N - wheeled to BR (bedroom) and carefully put to bed with lifter. When put down in bed and sling removed did note rt leg turned inward, felt a bit awkward - very loose when carefully handling it. Before moved anymore and removed sling, summoned dad in room to assess with me. Carefully removed sling without turning. Dad said " ...his daughter is coming visit in a little while he will talk to her about it" 1:30 pm - ...sister here - ..I informed sister I thought his leg did not look/feel right but only way to tell is if we take him in to be assessed ...will take client to (emergency room) ... 4:30 pm - x-ray done ...x-ray showed a fracture to femur 5 pm - in hospital ...shift complete. Review of incident report dated 4/3/21 revealed the following: Employee reporting incident: S4LPN Area of incident: patient home Witness: S4LPN Description: (S1DON) received phone call from (S4LPN) after her shift reporting that (Patient #1) had gone to ER and was found to have a femur fx (fracture). (S4LPN) says that at 9:30 am, she noticed that (Patient #1) right leg seemed turned out of place. She reported it to dad who assessed it and said he wanted to continue to watch him before taking him in. They went to ER around 3 PM for x-ray ... Further review of Patient #1's nurse's notes revealed the following entries: 4/24/2021 12:00 pm by S5LPN - showed father a picture of wound on R. (right) buttocks and patient's informed him how it has gotten so much worse since yesterday. Dad instructed this nurse to not put MOM (Milk of Magnesia) anymore this weekend in case pt (patient) had a reaction to it. There was no evidence that S5LPN had informed the RN or MD concerning the patient's wound being worse since yesterday and that Milk of Magnesia would not be used for the patient's wound care. 4/25/2021 9:40 am by S5LPN - ...R buttock has open wound with wound bed red. Surrounded by some ecchymosis and maceration. Excoriation noted. Cleaned are with wound cleanser. MOM not applied per dad instructions ...will call wound care in the AM tomorrow to report worsening & receive new orders ... 4/26/2021 5:00 pm by S4LPN - Late entry for 8:45 am ...Call was put in to inform that MOM as previously ordered seemed to make wound worse ... On 6/2/2021 at 3:00 pm, a telephone interview was conducted with S4LPN. She stated that she got the patient up for his bath around 9 AM using the sling. She stated when she transferred the patient from bed to shower the sling was mostly flat and didn't notice anything different at that time. She reported that he usually took nap after his bath and medications. She stated that after he woke up she transferred him from the bed to the wheel chair. This time the sling was more curved into a sitting position and that's when she really noticed that maybe something was not right with his leg. She called the dad to come look at it and he wanted to just watch it and wait for his daughter to arrive. Once daughter got there then they agreed to take him to the emergency room. She stated that she should have called the agency RN immediately upon noticing the change. On 6/3/2021 at 9:45 am, an interview was conducted with S2DEN (Director of Extended Nurse). She stated that changes in a patient's condition should be reported at the time they are observed. Parents of extended care patients sometime directed care of the patients, but the LPN caring for the patient still should have reported the change upon noticing it to the RN at a minimum. The change in the patient's wound occurred on the weekend when the wound care clinic was closed. She verified that is an RN on call on the weekend and the LPN should have reported the change when it was noticed.

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to provide evidence that the RN (Registered Nurse) ensured that the LPN received orientation and training prior to providing patient care and services for 1 (patient #2) out of 5 sampled patients. (#2) Findings: Patient #2. Review of the patient's clinical records revealed the start of care date was 4/1/2019. The patient's diagnoses included Spastic Quadriplegic Cerebral Palsy. The certification period reviewed was 3/21/2021 to 5/19/2021. Review of the patient's POC (plan of care) for certification period 3/21/2021 to 5/19/2021 revealed an order for skilled nurse 48-56 hours per week to provide total patient care. The POC revealed that the patient continues to require skilled nursing services to administer gastrostomy feedings/care, administer medications, transfer from bed to wheelchair via lift per request, administer nebulizer treatments, provide chest CPT (Chest Percussion/Physiotherapy) following nebulizer treatments, checking CBG (Capillary Blood Glucose) qd (everyday) and prn (as needed) and to provide assessment/evaluation in patient's status to prevent complications/exacerbations. Review of the patient's Extended Care Nursing Progress Notes dated 4/24/2021 revealed that S3LPN (Licensed Practical Nurse) reported on duty on 4/24/2021 at 8:00 am and that she received report from the patient's mother. Further review of the progress note dated 4/24/2021 at 4:00 pm revealed that S3LPN documented that she reported off duty to the patient's mother. Review of the patient's Extended Care Nursing Progress Notes dated 4/25/2021 revealed that S3LPN reported on duty on 4/25/2021 at 8:00 am and received report from the patient's mother. S3LPN documented that she reported off duty to sitter. On 6/2/2021 at 2:20 pm, a telephone interview was conducted with S3LPN. S3LPN stated that it was her first time meeting the patient and his family on 4/24/2021. S3LPN stated that she did not receive specific training or orientation prior to working with the patient on the weekend of 4/24/2021 and 4/25/2021. S3LPN stated that since it was her first time working with the patient, the patient's mother told her to keep him in bed and not to get him up out of bed that weekend. S3LPN stated that before she left at the end of her shift, that she reported off to the patient's sister, who was a DSW for another agency. On 6/3/2021 at 8:53 am, S2DEN (Director of Extended Nursing Services) stated that S3LPN was working with the patient on the weekend of 4/24/2021 and 4/25/2021. S2DEN stated that to her knowledge that it was the first time S3LPN had worked with the patient. S2DEN stated that she does not know if S3LPN had specific training or orientation prior to working with the patient on that weekend. On 6/3/2021 at 9:47 am, S1DON (Director of Nurses) stated that all nurses working with a patient for the first time should receive training prior to working with that new patient. On 6/3/2021 at 10:30 am, S1DON stated that S3LPN did not receive training prior to working with the patient. S1DON confirmed that to her knowledge that was the first time S3LPN worked with the patient. Review of S3LPN's employee record revealed there was no evidence that she received orientation or specific training with the patient prior to working with him. Review of the agency's policy and procedure titled "Extended Care Guidelines" revealed, " ...Orientation *Usually four (4) hours with a caregiver on the case. *No charting is required, nurse on duty will chart ..."

Complaint Survey LA00056928

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient's individualized written plan of care was followed and services was provided as evidenced by no evidence found that the agency provided 48-56 hours of skilled nurse (SN) services for Patient #2 and #5 out of a sample of 5 (1-5) sampled patients. Findings: 1. Patient #2. The patient was admitted to the facility on 8/7/2014 with the diagnoses that included the following: Quadriplegia, Retention of Urine, Anxiety Disorder, Major Depressive Disorder with Psychotic Features, and Encounter For Fitting and Adjustment of Urinary Device. The certification periods reviewed were 11/3/2020 to 1/1/2021 and 1/2/2021 to 3/2/2021. The Plan of Care (POC) was reviewed and the Skilled Nurse (SN) was to provide 48-56 hours per week of services. The POC dated 11/3/2020 to 1/1/2021 and POC dated 1/2/2021 to 3/2/2021 were reviewed and the SN was to assist with medication administration, bathing/hygiene, meal preparations, feeding & all daily living tasks & to assess/evaluate patient's overall status for changes to prevent complication/exacerbations. ... .... Assess for signs and symptoms of Urinary Tract Infection, Impaction, Bowel program every (Q) day (D), Position on left side; insert suppository, wait 30-60 minutes, then perform digital stimulation. If no BM in 72 hours notify nurse. Provided Foley catheter per protocol until dc'd when Foley has been dc'd provide in & out catherizations Q8 hours and prn retention or per pt's request. Provide cath care q shift. ....provide Passive Range of Motion (PROM) exercises as set-up by rehab therapist, provide wound care/skin care per doctor's orders, position change every 2 hours, and transfer from bed to wheelchair per caregiver's request. Clean burn areas with soap & water & apply Silverdene cream. Apply foam dressing to high risk areas prn for protection... Documentation provided of missed visit dated 1/10/2021 discipline (s) - SN ....due to LPN availability for shift - patient aware & ok. Missed visit dated 1/14/2021 discipline (s) - SN ...Parent is aware there is no LPN Available for this shift. Missed visit dated 1/12- 1/24/2021 discipline (s) - SN ...No LPN available for shifts - Parent is aware no replacement. There was no evidence found that the agency provided the nursing services for the following dates and times: 11/3/2020 from 7:00 am to 3:00 pm 11/9/2020 from 11:00 am to 3:00 pm 11/22/2020 from 7:00 am to 3:00 pm 11/26/2020 from 7:00 am to 3:00 pm 11/27/2020 from 7:00 am to 3:00 pm 11/30/2020 - 12/2/2020 from 7:00 am to 3:00 pm 12/4/2020 from 7:00 am to 3:00 pm 12/8/2020 -12/9/2020 from 7:00 am to 3:00 pm 12/11/2020- 12/14/2020 from 7:00 am to 3:00 pm 12/19/2020 from 11:15 am to 3:00 pm 12/22/2020 from 7:00 am to 3:00 pm 12/25/2020- 12/26/2020 from 7:00 am to 3:00 pm 1/10/2021 from 7:00 am to 11:00 am 1/14/2021 from 7:00 am to 3:00 pm 1/22/2021- 1/24/2021 from 7:00 am to 3:00 pm 2/3/2021 from 7:00 am to 3:00 pm. On 2/2/2021 at 2:55 pm, S3Staffer was interviewed and she stated she will send the schedules out weekly to the patients. The patient's schedules were reviewed with S3Staffer and for the months of November 2020 to February 2021 there were multiple days where there was no staff to work the shifts. (dates listed above) S3Staffer stated that the agency does not have nurses to go into the patient's home to work the shifts. S3Staffer verified the agency did not staff the shifts on her calendar with the patient. On 2/3/2020 at 10:00 am, an interview was conducted with S1Administrator and she stated recently the agency has no nurses willing to work with the patient. S1Administrator stated the nurses will work one shift and refuse to go back to the home. She stated there is no one to work with the patient today (2/3/2021) because they can't find nurses to work with the patient and the previous nurse will not go back into the home. S1Administrator stated because of the 4 dogs in the house, the smell of the environment, the way the patient treats the nurses, the urine and feces on the floor in the room, the nurses don't want to work with the patient. S1Administrator stated with all the animals in the room it is very hard for the nurses to do the wound care, her bowel program and the nurse will sit in the home for 8 hours and not eat lunch because of the odors in the home. S1Administrator stated the family fight a lot in the home and it makes for a difficult environment. The patient's schedule was reviewed with S1Administrator and she verified there were several days on the certification periods that no staff was provided for the patient. S1Administrator stated the agency does not have the nurses and the current employees refuse to go into the home. 2. Patient #5. The patient was admitted to the agency on 4/13/2008 with the diagnoses that included the following - Cerebral Palsy, Epilepsy, Chronic Obstructive Pulmonary Disease, and Congenital Malformations of Larynx. The Certification period reviewed was from 11/15/2020 to 1/23/2021 and 1/24/2021 to 3/24/2021. The Plan of Care (POC) reviewed and the Skilled Nurse (SN) was to provide 48-56 hrs/wk of services. The POC reviewed dated 11/25/2021 revealed the SN was to provide the following services - Administer feedings and medications via PEG tube, provided PEG care as ordered, transfer from bed to wheelchair per caregivers request with assistance, Provided PROM exercises daily, turn/reposition q 2 hours, and keep logs of seizure activity. For the certification period 11/25/2020 to 1/23/2021, for the week of 11/16/2020 - 42 hours was provided, for the week 11/23/2020 - 31 hours was provided, for the week of 11/30/2020 - 39 hours were provided, for the week of 12/7/2020 - 34 hours was provided, for the week of 12/14/2020 - 45.75 hours was provided, for the week of 12/21/2020 - 32 hours was provided, for the week of 12/28/2020 - 14 hours was provided. Documentation found that on 12/30/2020 the nurse had s/s of COVID 19 was tested and it was positive. Mother did not want workers in the home due to quarantining her home. Services resumed on 1/11/2020. For the week of 1/18/2021 there was no services provided on 1/22/2021 due to no staff available to staff the patient. Documentation found revealed that the agency did not have staff available to staff the following dates. 11/8/2020 from 1:00 pm to 4:00 pm, 11/19/2020 from 1:00 pm to 4:00 pm, 11/20/2020 from 8:00 am to 4:00 pm, 11/26/2020 from 8:00 am to 4:00 pm, 11/28/2020 form 8:00 am to 4:00 pm, 12/1/2020 from 8:00 am to 4:00 pm, 12/2/2020 from 1:00 pm to 4:00 pm, 12/3/2020 from 1:15 pm to 4:00 pm, 12/8/2020 from 8:00 am to 4:00 pm, 12/9/2020 from 1:15 pm to 4:00 pm, 12/13/2020 from 8:00 am to 4:00 pm, 12/16/2020 from 1:00 pm to 4:00 pm, 12/17/2020 from 8:00 am to 9:45 am and 1:15 pm to 4:00 pm, 12/21/2020 from 8:00 am to 4:00 pm, 12/24/2020 from 8:00 am to 4:00 pm, 12/25/2020 from 8:00 am to 4:00 pm, 12/29/2020 from 3:15 pm to 4:00 pm, and on 12/30/2020 from 8:00 am to 4:00 pm. On 2/1/2021 at 10:55 am, an interview was conducted with S3Staffer and she stated she is the staffer for all of the patients in the extended care side of the agency. S3Staffer stated after a review of the certification periods that she did not have nurses to staff the missing shifts during the certification period and she stated she could not find a worker to work the holidays. On 2/1/2021 at 11:10 am, an interview was conducted with S1Administrator and she stated that the patient's mother was difficult. S1Administrator verified the agency did not provide the hours according to the patient's POC.