Every finding on record at Diverse Home Care LLC

AMENDED Extended Substantial Allegation Survey Substantial Allegation 71604 An entrance conference was conducted on 08/29/22 with administrative staff. An exit conference was conducted on 09/23/22 with administrative staff. On 09/20/22 at 4:22 PM the Administrator was informed, based on the findings, of a determination of immediate jeopardy existed when the agency failed to provide services that are ordered by the physician as indicated in the plan of care. The Administrator was informed on 09/23/22 at 3:35 PM that based on the agency's Plan of Action and the immediate steps taken, the immediate jeopardy was removed. The following deficiencies were issued as a result of the Extended Substantial Allegation Survey 71604 completed on 09/23/22. Diverse Home Care LLC 369001, is not in compliance with the requirements at 42 CFR Part 484, Subpart B, C for Home Health Agencies. Diverse Home Care LLC is precluded from offering its own aide training and/or competency evaluation program for a period of two years from the exit date of this survey.

Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This CONDITION is not met as evidenced by: Based on medical record review, hospital medical record review and staff interview, the agency failed to provide services that are ordered by the physician or allowed practitioner as indicated in the plan of care (G710). The cumulative effect of these systemic practices resulted in the agency's inability to ensure that the patients' nursing needs would be met.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on medical record review, hospital medical record review and staff interview, the agency failed to provide services that are ordered by the physician or allowed practitioner as indicated in the plan of care for one of four patients reviewed (Patient #1). This could affect all patients receiving services from the agency. The agency's census was 33. Findings include: Review of the medical record for Patient #1 revealed the patient's start of care was 09/28/21 and the primary diagnosis was paraplegia. Other diagnoses were urinary incontinence, chronic pain due to trauma, and mild intermittent asthma. The physician ordered plans of care from admission on 09/28/21 through the current certification period dated 07/25/22 to 09/22/22 included skilled nursing visits three to four times per week for nine weeks and home health aide visits 49 hours per week for nine weeks. According the plan of care, the skilled nursing assessment and evaluation tasks were vital signs, cardiovascular and pulmonary status, pain level and management, skin integrity status, musculoskeletal, mobility status, medication compliance, response, nutrition and hydration status, and therapeutic diet education. The home health aide tasks were: provide/assist with personal care, hygiene and grooming needs and assist with ADL (Activity of Daily Living), and light housekeeping work. Review of the patient's start of care assessment dated 09/28/21 revealed the patient had no observable pressure ulcers, and the integumentary status was good, pink/normal, moist, and warm. Review of the skilled nursing visit notes from 09/28/21 to 08/19/22, 105 total visits, revealed the nurse documented the patient's skin was intact and a physical assessment with no changes was performed. Review of the patient's most recent recertification assessment completed by the Registered Nurse (RN), Staff D, on 07/22/22 revealed the patient had no observable pressure ulcers. The stage of the most problematic unhealed (observable) pressure ulcer/injury that is stageable was left blank. The patient was admitted to the hospital on 08/19/22. The patient's hospital medical record was obtained and reviewed. The patient was admitted to the hospital the afternoon of 08/19/22 by ambulance through the emergency department (ED). The patient was unable to provide any history, and no family was at bedside. The reason for admission was sepsis, wounds and pneumomediastinum (air gets into the upper chest and starts accumulating, usually due to trauma or other illnesses that cause air to leak from the lungs). The hospital diagnoses were severe sepsis, high potassium levels, AKI (acute kidney injury), paralysis of both lower limbs, stage four skin ulcer of sacral region, acute respiratory failure, mediastinal emphysema (pneumomediastinum), substance use disorder, kidney infection, and encounter for palliative care. Review of the ED note, dated 08/19/22, revealed the patient presented with concerns of altered mentation. The history was not obtainable from the patient, as the patient was significantly encephalopathic (broad term for any brain disease that alters brain function or structure). The patient had a history of paraplegia related to prior gun shot wound. The medics had mentioned the patient's home living environment was atrocious. The patient was thought to have had a history of opioid overdose in the past although that was not confirmed. The patient had a significant left foot wound with brown discharge and maggots in the wound. "Addendum: Seems that he/she struggled with opioid abuse, unclear how he/she actually gets opioids as he/she is completely bedbound. Regardless was thought to have used earlier. EMS did arrive and gave Narcan…It seems that he/she otherwise has poor care at home." Past medical history included anemia, asthma, bladder problem, chronic pain disorder (low back and legs), constipation (on bowel program), depression, gun shot wound (with spinal cord injury/paraplegia), nephrolithiasis (kidney stones), neurogenic bladder (lack of bladder control due to spinal cord injury), neurogenic bowel (lack of bowel control due to spinal cord injury), paraplegic spinal paralysis, peripheral neuropathy, PTSD (post-traumatic stress disorder), pulmonary embolism, pyelonephritis (kidney infection), Vancomycin Resistant Enterococcus (VRE). Past surgical history included debridement decubitus ulcer bilateral ischial pressure ulcers. CT Abdomen/Pelvis showed extensive soft tissue and osseous necrosis involving lower sacrum, only tiny fragments of the coccyx remaining. Started on two liters of crystalloid, pancultured and started on vancomycin, Zosyn and clindamycin. There was maggots in her sacral wound in addition to her left foot. Maggots and bedbugs found in patient’s vagina, buttocks wound, and left heel. The patient had a physician’s consult for surgery for multiple stage four pressure ulcers, and wound care nursing consult was recommended. The patient’s wound measurements upon hospital admission on 08/19/22 were as follows: right ischium - unstageable pressure injury (an ulcer that has full thickness tissue loss but is either covered by extensive necrotic tissue or by dead tissue) – measures 10.5 centimeters (cm) x 3 cm x 0.2 cm; sacrum – stage 4 pressure injury (a deep wound that reaches the muscles, ligaments, or bones) - measures 7 cm x 4.5 cm x 0.3 cm; left upper sacrum – stage 4 pressure injury – measures 2 cm x 1.5 cm with a 0.5 cm tunnel at 10-11 o’clock of 2.5 cm bone palpated; left posterior hip/iliac crest – unstageable pressure injury – measures 7 cm x 5.5 cm x 0.2 cm. Wound bed is 95% dark grey leathery eschar. Peri-wound is denuded; more lateral left hip – unstageable pressure injury – measures 5 cm x 5 cm x 0.1 cm. Wound bed is 95% grey moist eschar. Peri-wound is denuded; left trochanter – unstageable pressure injury – measures 6.5 cm x 6 cm x 0.2 cm. Wound bed is 90% leathery dark grey eschar and 10% pink tissue. Peri-wound is denuded; left ischium – stage 3 pressure injury (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed) – Wound bed is pale pink. Peri-wound is denuded; left toes – unknown etiology wounds; left heel – stage 4 pressure injury – measures 5 cm x 3.5 cm x 0.4 cm. Wound bed is red with bone palpated. Peri-wound is macerated; left lower leg – unknown etiology – measures 1 cm x 1 cm. Wound bed is purple non blanching; right heel – unstageable pressure injury – measures 1 cm x 0.5 cm x 0.1 cm. Wound bed is dried eschar. Peri-wound is scarred. A Physician’s Clinical Note dated 08/23/22 revealed progression of chronic decubitus ulceration and destruction of coccyx and sacrum with no appreciable skin overlying the sacrum region. By report there is gross necrosis tissues over the sacrum with maggots. Staff D, the RN who provided nursing services to Patient #1, was interviewed in person on 08/30/22 at 12:05 PM. She stated that she did not provide wound care and that she was not aware of any pressure sores. She stated the patient was wheelchair bound. The patient was always dressed during nursing visits and did not want to provide too much exposure to the nurse during assessments. The patient did not allow the nurse past the front door to the home to provide care. A second interview with Staff D by phone on 09/20/22 at 12:25 PM. revealed the patient never disclosed she had open areas on her skin or had complaints of pressure sores. Staff D again stated that the patient never let her into the home and that the only time she was in the patient's home was for the initial assessment. She stated she performed the assessments outside the patient's home on a wheelchair ramp. She asked the patient if there were any open areas on her skin or any bruising. When the patient stated "no" she documented the patient's skin was intact. The nurse did not remember the patient having any odor when she saw the patient, but the patient was not exactly very clean. She would have food on her clothes at times. She stated she spoke with the patient's home health aide who told her that the patient would not let the aide undress her for bathing. She said the aide would wheel the patient into the bathroom, and the patient would undress herself before bathing. When the nurse was made aware of the patient's condition upon admission to the hospital she stated she had no idea the patient was in such dire straits and could not understand why the patient would not confide in her. The nurse stated she had worked for the agency for about three to four years and never had a situation like this before. She had never had a patient refuse care or not disclose any issues. She had worked in home health since 2015. When asked what she should do when a patient refused care or if she identified an issue with the patient, she stated that she should probably call the physician. The nurse confirmed that she never reported any of these issues. Staff B was made aware of the findings in an interview on 09/20/22 at 4:22 PM. This deficiency substantiates Substantial Allegation 71604.

Home health aide services CFR(s): 484.80 Condition of participation: Home health aide services. All home health aide services must be provided by individuals who meet the personnel requirements specified in paragraph (a) of this section. This CONDITION is not met as evidenced by: This Condition is not met as evidenced by: Based on medical record review and staff interview, the agency failed to ensure home health aides provided services that are included in the plan of care (G800). The cumulative effect of these systemic practices resulted in the agency's inability to ensure that the patients' home health aide needs would be met.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on medical record review and staff interview, the agency failed to ensure home health aides provided services that are included in the plan of care for one of four patients reviewed (Patient #1). This could affect all patients receiving services from this agency. The agency's census was 33. Findings include: Review of the medical record for Patient #1 revealed a start of care on 09/28/21 and the primary diagnosis was paraplegia. Other diagnoses were urinary incontinence, chronic pain due to trauma, and mild intermittent asthma. The plan of care from admission on 09/28/21 through the current certification period dated 07/25/22 to 09/22/22 included skilled nursing visits three to four times per week for nine weeks and home health aide visits 49 hours per week for nine weeks. According the plan of care the home health aide tasks were to provide/assist with personal care, hygiene and grooming needs and assist with ADL (Activities of Daily Living), and light housekeeping work. The home health aide care plan revealed the patient was to receive daily skin care, assist with dressing, bed making, light housekeeping, meal preparation, fluid encouragement, partial bath, medication reminder, and wheelchair assistance. The patient was to receive weekly foot care, nail care, light laundry, bed linen change, dusting, sweeping, vacuuming, taking out the trash, and showering. Special instructions were to report to office any change in client condition or ability to carry out plan as written. Home health aide time sheets were reviewed for the dates of 07/03/22 to 08/06/22. The home health aide services were provided by Staff C, who was also the patient's aunt and who was also listed as the patient's emergency contact. The time sheets consistently had 49 hours of services documented by the aide. The time sheets dated 07/03/22 to 07/09/22 daily in the morning revealed shower/tub bed/partial/complete, hair care, assist with dressing, transfer, medication reminder, meal preparation, and encourage fluid. The time sheets dated 07/03/22 to 07/09/22 daily in the evening revealed assist with dressing, clean/file nails, foot care, skin care/moisturize, exercise/ROM, meal preparation, encourage fluids, light housekeeping, laundry, make bed/change linens, and shopping. The time sheets dated 07/10/22 to 07/16/22 daily in the morning revealed shower/tub bed/partial/complete, hair care, assist with dressing, transfer, medication reminder, meal preparation, and encourage fluid. The time sheets dated 07/10/22 to 07/16/22 daily in the evening revealed assist with dressing, clean/file nails, foot care, skin care/moisturize, exercise/ROM, meal preparation, encourage fluids, light housekeeping, laundry, make bed/change linens, and shopping. The time sheets dated 07/17/22 to 07/23/22 daily in the morning revealed shower/tub bed/partial/complete, hair care, assist with dressing, transfer, medication reminder, meal preparation, and encourage fluid. The time sheets dated 07/17/22 to 07/23/22 daily in the evening revealed assist with dressing, clean/file nails, foot care, skin care/moisturize, exercise/ROM, meal preparation, encourage fluids, light housekeeping, laundry, make bed/change linens, and shopping. The time sheets dated 07/24/22 to 07/30/22 daily in the morning revealed shower/tub bed/partial/complete, hair care, assist with dressing, transfer, medication reminder, meal preparation, and encourage fluid. The time sheets dated 07/24/22 to 07/30/22 daily in the evening revealed assist with dressing, clean/file nails, foot care, skin care/moisturize, exercise/ROM, meal preparation, encourage fluids, light housekeeping, laundry, make bed/change linens, and shopping. The time sheets dated 07/31/22 to 08/06/22 daily in the morning revealed shower/tub bed/partial/complete, hair care, assist with dressing, transfer, medication reminder, meal preparation, and encourage fluid. The time sheets dated 07/31/22 to 08/06/22 daily in the evening revealed assist with dressing, clean/file nails, foot care, skin care/moisturize, exercise/ROM, meal preparation, encourage fluids, light housekeeping, laundry, make bed/change linens, and shopping. The patient was admitted to the hospital on 08/19/22. The patient's hospital medical record was obtained and reviewed. The patient was admitted to the hospital the afternoon of 08/19/22 by ambulance through the emergency department (ED). The patient was unable to provide any history, and no family was at bedside. The reason for admission was sepsis, wounds and pneumomediastinum (air gets into the upper chest and starts accumulating, usually due to trauma or other illnesses that cause air to leak from the lungs). The hospital diagnoses were severe sepsis, high potassium levels, AKI (acute kidney injury), paralysis of both lower limbs, stage four skin ulcer of sacral region, acute respiratory failure, mediastinal emphysema (pneumomediastinum), substance use disorder, kidney infection, and encounter for palliative care. Review of the ED note, dated 08/19/22, revealed the patient presented with concerns of altered mentation. The history was not obtainable from the patient, as the patient was significantly encephalopathic (broad term for any brain disease that alters brain function or structure). The patient had a history of paraplegia related to prior gun shot wound. The medics had mentioned the patient's home living environment was atrocious. The patient was thought to have had a history of opioid overdose in the past although that was not confirmed. The patient had a significant left foot wound with brown discharge and maggots in the wound. "Addendum: Seems that he/she struggled with opioid abuse, unclear how he/she actually gets opioids as he/she is completely bedbound. Regardless was thought to have used earlier. EMS did arrive and gave Narcan…It seems that he/she otherwise has poor care at home." Past medical history included anemia, asthma, bladder problem, chronic pain disorder (low back and legs), constipation (on bowel program), depression, gun shot wound (with spinal cord injury/paraplegia), nephrolithiasis (kidney stones), neurogenic bladder (lack of bladder control due to spinal cord injury), neurogenic bowel (lack of bowel control due to spinal cord injury), paraplegic spinal paralysis, peripheral neuropathy, PTSD (post-traumatic stress disorder), pulmonary embolism, pyelonephritis (kidney infection), Vancomycin Resistant Enterococcus (VRE). Past surgical history included debridement decubitus ulcer bilateral ischial pressure ulcers. CT Abdomen/Pelvis showed extensive soft tissue and osseous necrosis involving lower sacrum, only tiny fragments of the coccyx remaining. Started on two liters of crystalloid, pancultured and started on vancomycin, Zosyn and clindamycin. There was maggots in her sacral wound in addition to her left foot. Maggots and bedbugs found in patient’s vagina, buttocks wound, and left heel. The patient had a physician’s consult for surgery for multiple stage four pressure ulcers, and wound care nursing consult was recommended. The patient’s wound measurements upon hospital admission on 08/19/22 were as follows: right ischium - unstageable pressure injury (an ulcer that has full thickness tissue loss but is either covered by extensive necrotic tissue or by dead tissue) – measures 10.5 centimeters (cm) x 3 cm x 0.2 cm; sacrum – stage 4 pressure injury (a deep wound that reaches the muscles, ligaments, or bones) - measures 7 cm x 4.5 cm x 0.3 cm; left upper sacrum – stage 4 pressure injury – measures 2 cm x 1.5 cm with a 0.5 cm tunnel at 10-11 o’clock of 2.5 cm bone palpated; left posterior hip/iliac crest – unstageable pressure injury – measures 7 cm x 5.5 cm x 0.2 cm. Wound bed is 95% dark grey leathery eschar. Peri-wound is denuded; more lateral left hip – unstageable pressure injury – measures 5 cm x 5 cm x 0.1 cm. Wound bed is 95% grey moist eschar. Peri-wound is denuded; left trochanter – unstageable pressure injury – measures 6.5 cm x 6 cm x 0.2 cm. Wound bed is 90% leathery dark grey eschar and 10% pink tissue. Peri-wound is denuded; left ischium – stage 3 pressure injury (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed) – Wound bed is pale pink. Peri-wound is denuded; left toes – unknown etiology wounds; left heel – stage 4 pressure injury – measures 5 cm x 3.5 cm x 0.4 cm. Wound bed is red with bone palpated. Peri-wound is macerated; left lower leg – unknown etiology – measures 1 cm x 1 cm. Wound bed is purple non blanching; right heel – unstageable pressure injury – measures 1 cm x 0.5 cm x 0.1 cm. Wound bed is dried eschar. Peri-wound is scarred. A Physician’s Clinical Note dated 08/23/22 revealed progression of chronic decubitus ulceration and destruction of coccyx and sacrum with no appreciable skin overlying the sacrum region. By report there is gross necrosis tissues over the sacrum with maggots. Interview with the Administrator on 09/20/22 at 2:00 PM revealed Staff C never made mention of the patient's condition so the agency was unaware of any serious issues with the patient. The agency was told by the aide that the patient was “doing fine now” the last time the patient was discussed. The aide was currently inactive due to the patient being in the hospital. In the past when dropping off time sheets, the aide never communicated regarding the patient's status. An interview was conducted via phone with Staff C on 09/20/22 at 2:15 PM. Staff C stated that she stopped seeing the patient because the patient was not going to the doctor to be seen, or letting the aide and nurse provide the proper care. "She wouldn't let us do anything." She also stated the patient's house was "a mess." Staff C stated her duties when it came to housekeeping were light duties, not heavy duties. When asked why she did not report the issues to the agency, she stated that she did not have to report anything to the agency because the patient was the aide's niece. She stated that the home health agency was not going to be able to do anything for the patient that she (Staff C) could not do herself. She stated that getting the doctor involved could not have helped anything. When asked about the services she was to provide per the home health aide plan of care, she stated she did document all of the care she provided. When asked about providing daily skin care, she stated the patient would not undress in front of her so she would wheel the patient into the bathroom and the patient would undress herself. She confirmed that she did not report any of these issues to the agency. The agency was made aware during an interview with the Administrator on 09/20/22 at 4:22 PM of the deficient practices. This deficiency substantiates Substantial Allegation 71604.