Every finding on record at Dpp II Inc

An investigation survey for the incident Intake # 1002365 was initiated on 04/14/2025. Census: Licensed and Certified- 800 Licensed Home Health- 456 Personal Assistance Services- 126 Acronyms: POC- plan of care SOC- start of care SN- skilled nurse SNV’s- skilled nurse visits BKA- below knee amputation ACE- all cotton elastic LVN- licensed vocational nurse RN- registered nurse

Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on record reviews and interviews, the agency failed to assure coordination of services between the Agency and a surgeon involved in the care for 1 (Patient #1) of 3 active patient records reviewed who received wound care services from the agency. This failure meant the agency failed to clarify and share information for the frequency and duration of ongoing wound care. FINDINGS INCLUDE: Patient #1: Record review revealed a POC dated 02/12/2025 to 04/13/2025 with a SOC date 02/13/2025. The patient’s diagnoses included: aftercare following surgical amputation (surgical removal of a limb or part of a limb); Type 2 diabetes mellitus (condition when the body doesn’t produce enough insulin, leading to high blood sugar levels) and Hypertensive chronic kidney disease (kidney damage caused by high blood pressure). The SN frequency was one time a week for one week, twice a week for three weeks and once a week for five weeks. A physician order dated 03/25/2025, signed by the Surgeon, Identifier B, was hand-written on a prescription paper. The order included, “Right BKA wound care by home health Daily with Betadine (antiseptic wound cleaner), cover with non-adherent dressing (wound dressing designed to not stick to the wound) and Kerlix (gauze bandage roll) and ACE (elastic bandage provides compression and support).” Review of the patient’s record revealed SNV’s were done 03/26/2025; 03/29/2025; 03/31/2025 and 04/04/2025 by LVN C and by the Wound Care specialist, Identifier D on 04/02/2025. A transfer form dated 04/05/2025 revealed Patient #1 was admitted to the hospital 04/05/2025. Review of the record revealed no coordination of care with Surgeon B to clarify the order dated 03/25/2025 for frequency or duration of wound care. In a phone interview with LVN C on 04/29/2025 at 10:30 AM, the surveyor reviewed the findings and asked about the physician order from Surgeon B dated 03/25/25. LVN C stated she had taken the picture of the order (from Surgeon B) during the SN visit on 03/26/25. Surveyor stated review of the record showed SN visits were not done daily after 03/26/25 and asked why wound care was not done daily as per Surgeon B’s order? LVN C stated, “I don’t have an answer for you, I’ve never done daily wound care, I’m not sure if the patient’s family was to do that, I really don’t have an answer for you, I turned in the picture of the orders to my supervisor.” Surveyor asked if the LVN had tried to clarify the order with Surgeon B. LVN stated, “No.” In a phone interview with RN E on 04/29/2025 at 10:50 AM, the surveyor reviewed the findings and the physician order from Surgeon B for wound care daily by home health, dated 03/25/25 and asked why SN visits were not done daily as per the surgeon’s order? RN E stated, “oh ok, if we have an order daily, obviously we don’t go daily. If we have family in the home who can understand to do wound care and it was a (family member, Identifier F), we have them do it. I was under the impression we could do that.” Surveyor asked if Surgeon B was contacted to clarify the order. RN E stated, “no.” In an interview with the Administrator/Director of Nurses and Alternate Administrator/Alternate Director of Nurses on 04/29/2025 at 2:00 PM, the surveyor reviewed the findings and asked why the agency did not coordinate care with Surgeon B to clarify the daily wound care order. The Administrator/Director of Nurses stated, “Nursing does wound care typically three times a week and the caregiver does it on the other days if it’s daily wound care, but either the LVN or RN should have contacted the doctor to clarify the order. The order also did not have the duration for how long the wound care would need to be done by the nurse. The agency can perform wound care daily if needed, but that all should have been clarified with the Dr. (Surgeon B). The Alternate Administrator/Alternate Director of Nurses stated, “… the order came from the surgeon and that’s who should have clarified the order.” The surveyor asked how this could affect the patient care if wound care orders were not clarified? The Alternate Administrator/Alternate Director of Nurses stated, “if the orders are clarified, there could be a decrease in the occurrence of infections.” Agency policy, dated 05/01/2024, quoted in part, “Monitoring Patient Care/Coordination of Care, PC. 45, Purpose: To ensure coordination of patient/client care and treatment. Policy: I. The Agency will monitor, evaluate, and report to the patient’s/client’s physician and/or non-physician practitioner regarding the patient’s/client’s progress toward achieving goals established on the plan of care. … Procedure: I. The Agency will: A. Assure effective communication with all physicians and/or non-physician practitioners involved in the plan of care. B. Integrate orders from all physicians and/or non-physician practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient/client. …”

A recertification survey entrance was conducted on 3/3/2025. census: Licensed and Certified Home Health: 1200 The agency met Medicare Conditions of Participation for Emergency Preparedness.

A recertification survey entrance was conducted on 3/3/2025 with complaints, #567148, # 571199, #535653, and #534238. Census: Licensed and Certified Home Health: 1200 The agency met Medicare Conditions of Participation with Standard level deficiencies. Definitions: RN-Registered Nurse DON- Director of Nursing LVN- Licensed Vocational Nurse CM- Case Manager BON- Board of Nursing EMS- Emergency Medical Services PTA- Physical Therapy Assistant COTA- Certified Occupational Therapy Assistant POC- Plan of Care SOC- Start of Care HCP- Home Care Providers

Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This ELEMENT is not met as evidenced by: Based on record review, interview, and observation, an agency nurse, LVN A, neglected 1 (Patient 1) of 3 patients in which LVN A was assigned to provide wound care. LVN A failed to report pertinent changes in wound status to the patient’s family, the RN CM, and physician. The neglect of the agency’s employee, LVN A, to report the changes in wound status on February 17th, 21st, and 24th, prevented Patient 1 from receiving timely wound care treatment by appropriate medical professionals, resulted in the patient’s hospitalization on February 25th with sepsis [life-threatening condition from an infection] from a wound infection, and was followed by a below the knee amputation of the patient’s right leg on 3/4/2025. Findings include: Review of the Consumer Rights and Services Incident Investigation Worksheet included: A date received of 2/27/2025 at 9:21 AM. The report included an allegation of Resident/Patient/Client Neglect. The report read in part: “The reporter first learned of the incident on 2/26/2025, from after agency hours.” The report included Patient 1 was sent to Facility M, on 2/25/2025 due to a sepsis infection. The report read in part: “It should be known that [name] Identifier D has mentioned that if it is determined that the wound caused the sepsis infection then there is talk about possible amputation.” Review of the agency’s Provider Investigation Report, Form 3613, signed and dated by RN B on 2/27/2025, included: “Description of Injury and Assessment” that read in part: “[name] Identifier D called HCP [agency] and reported patient was taken by EMS to [name] Facility M, after [name] Identifier D found patient was delusional and dressing was off foot…. Caller accused [name] LVN A of failing to report wound status change to wound care doctor or notifying family….” The Provider Investigation Report included “Investigation Summary” that read in part: “LVN A stated a wound evaluation during visit on Monday 2/24/2025 did not include any signs or symptoms of infection, nor did patient demonstrate any signs or symptoms of sepsis…. However, [name] Identifier D reported today, 2/28/2025, that patient began acting altered on Monday 2/24/2025.” Identifier D also reported, “the PTA [Identifier W] arrived on Tuesday 2/25/2025 to find patient altered and dressing [wound dressing] removed. PTA W called LVN M and reported the findings….” Review of Patient 1’s POC included in the patient’s clinical record: Patient 1’s POC was signed and dated by RN A on 1/8/2025 and by the patient’s physician on 2/3/2025. The SOC date for the POC was 1/8/2025 and the POC’s certification period, that included the physician’s orders for the 60-day period, was 1/8/2025 to 3/8/2025. The POC indicated RN C was the clinical case manager for the patient. The POC included a primary diagnosis of “Encounter for change or removal of surgical wound dressing,” with additional diagnoses of “Encounter for orthopedic aftercare following surgical amp [amputation],... Acquired absence of other right toes, peripheral vascular angioplasty status with implants and grafts [a procedure to open narrowed or blocked blood vessels with stents placed to keep the blood vessels open] and chronic pain syndrome….” The POC included Physician’s orders for Skilled nursing 2 times a week for 1-week, skilled nursing 3 times a week for 8 weeks, physical therapy and occupational therapy evaluations. The POC included a “Medical Necessity Statement” that included skilled nursing is required for assessment and instruction on diagnosed S/P [status post, meaning after] partial amputation of the right foot and to perform wound care to partially amputated right foot. Physical therapy and Occupational therapy to restore and or maintain physical functioning. The POC included: orders to notify the physician of vital signs outside of the physician’s parameters, skilled nurse to inspect patient’s feet daily and report any skin or nail problems to skilled nurse or physician, skilled nurse to assess and instruct the patient on wound care to the right foot as follows, “Vashe [brand of wound cleanser] or normal saline [a wound cleanser], Iodasorb [an over the counter wound gel], cover wound with ABD pad [thick pad], kerlix [wound care wrap], and lightly wrap with an ace bandage [brand of elastic bandage], skilled nursing to assess and instruct on interventions to monitor and mitigate pain, including monitoring pain level on a 1-10 scale….and listed a pain goal of 5/10….” Review of the SOC assessment indicated the SOC was conducted by RN D on 1/8/2025 and included the patient’s wound care was provided as ordered. Wound measurements were documented as: 4.5 cm, width: 7 cm, depth, 0.1 cm, and a wound assessment description of moderate amount of serosanguinous [drainage from a wound that is a mix of serum and blood] drainage, pungent odor, and included a photograph of the wound attached to the patient’s clinical record. The surveyor observed the photo included and noted the wound was a large open wound to the top and outer side of the patient’s right foot. The wound bed appeared pink in the color photo. Review of Patient 1’s clinical record included the following skilled nursing notes documented by LVN A from 1/10/2025 to 2/24/2025. Review of LVN A’s skilled nurse visit dated 1/10/2025 LVN A documented the patient’s pain intensity of “10 severe”, on a 1-10 pain scale, location of the pain was the patient’s “Rt [right] foot.” Review of the record did not include evidence LVN A reported the pain level to the family, RN C, or the physician. Wound care was documented as ordered with wound measurements of length: 4.5 cm by width: 7 cm, depth 0.1 cm. There were no changes from the previous visit assessment on 1/8/2025 of the wound measurements and wound bed description. Review of LVN A’s skilled visit dated 1/15/2025 included documentation of wound care as ordered and no changes in the size of the wound. Review of LVN A’s skilled note dated 1/17/2025 LVN A indicated an increase in the wound length from 4.5 to 6.5 cm and an increase in the wound depth from 0.1 to 0.3 cm. Review of the record did not include LVN A reported the increase in the wound size to the family, RN C, or the physician. There was a photo attached the surveyor observed the wound bed appearance as pink in the color photo, it was difficult to determine the size change due to the position of the foot in the color photo. Review of LVN A’s skilled nurse visits from 1/20 to 2/19/2025, included wound care assessments that were unchanged during that period. Review of the record included an agency “missed visit” note by LVN A on Wednesday 2/19/2025 due to inclement weather. The missed visit note included the patient reported having heat, food, and water. There was no documentation that indicated LVN A asked Patient 1 about the wound, or if anyone was able to provide wound care for that day. The note indicated that a doctor was notified by phone but did not list the name of the doctor. There was no indication LVN A notified RN C. Review of the record included an agency “missed visit” note from an occupational therapist that had attempted a visit. The note was dated Friday 2/21/2025 by COTA O. The note read, “therapist attempted to schedule therapy 3 consecutive days, patient reported, “I am feeling very bad and not able to do it.” The missed visit note indicated it was faxed to the patient’s primary care physician. There were no indications the Cota’s findings were reported to the family, LVN A, or RN C. Review of LVN A’s skilled note on Friday 2/21/2025 included a visit note that indicated wound care was provided and included a photo attached with the note. Review of the photo of the wound, the surveyor noted the wound bed changed from the previous pink color to black. The note included a pain intensity of 6 of 10 located in the patient’s right foot. Review of the patient’s record did not include LVN A notify the family, RN C, the patient’s primary care physician, or the patient’s wound care physician of the change in color of the wound bed from pink to black. Review of LVN A’s skilled note on 2/24/2025 included a pain intensity of 7 of 10 to the patient’s right foot. There were no changes noted in the wound measurements and there was no photo taken of the wound. Review of the patient’s clinical record there was no indication LVN A notified the family, RN C, the patient’s primary care physician, or the patient’s wound care physician of the findings from LVN A’s visit on 2/21 of the change in the color of the wound bed and did not notify anyone of the patient’s increased pain level. Review of the clinical record included an agency “missed visit” form signed and dated by PTA W, on 2/25/2025 and indicated patient 1’s physician was faxed the following information: “traveled to patient: yes, attempt made: 13:05 [1:05 PM], Reason: cancellation of care, Comments: As scheduled arrived to pt’s [patient’s] home on 02/25/2025 at 1:05 PM. Pt’s family member [name] Identifier D informed PTA W she will be taking [name] Patient 1 to [name] Facility SW at this hour.” Identifier D said, “Pt is not well and having memory issues. She [patient] had several falls and has been removing dressings on amputated foot but had no recollections of doing so.” PTA W continued documentation in the comments, “via phone call at 1:07 PM with LVN A, nurse reported on her arrival yesterday [2/24/2025] the dressing was removed, and the pt having difficulty understanding verbal instructions to transfer from commode to recliner.” Review of LVN A’s skilled note on 2/24/2025 did not indicate LVN A notified the family or RN C of the patient having difficulty understanding instructions, and the dressing was off the amputated foot. Review of Patient 1’s clinical record included an agency form titled “Patient Communication” signed and dated by PTA W, on 2/25/2025. The communication included documentation regarding the patient’s hospitalization on 2/25/2025 and read in part: “… date hospitalized: 2/25/2025.” Also included was documentation PTA W reported he received a text message from “Patient 1.” The text message read in part: “… admitted to [name] Facility M…foot was infected, and stent stopped flowing blood to her foot…” Another “Patient Communication” signed and dated by RN C on 2/26/2025 indicated RN C notified Patient 1’s wound care physician of the patient’s hospitalization on 2/25/2025. Interviews: Family: In a phone interview with Identifier D and Identifier L on 3/4/2025, they reported Patient 1 was at Facility SW, for surgery to amputate patient 1’s leg below the knee. Identifier D said Patient 1 was living with Identifier D since being discharged from a rehabilitation facility on 1/8/2025. Identifier D and Identifier L said they noticed Patient 1 was becoming confused and disoriented around Sunday 2/23/2025. Identifier D said LVN A did not mention to anyone in the family that on 2/21/2025 Patient 1’s wound had turned black and said they did not think LVN A notified the agency because no one came to the home to check on Patient 1. They said LVN A visited Patient 1 on Monday 2/24/2025 and did not report any changes to Identifier D. Identifier D said on Tuesday the therapist PTA W, came to the home, cancelled the therapy visit when Identifier D told him she was taking Patient to the hospital because she was not feeling well, had fallen several times, and was not answering questions appropriately. Identifier D said PTA W called LVN A to report that he found the wound dressing was off when he arrived at the home PTA W reported to Identifier D that LVN A said the dressing was off the patient’s foot when she did her visit yesterday (2/24/2025), and that Patient 1 had a hard time transferring from the commode to the chair. LVN A reported Patient 1 had trouble understanding instructions. Identifier D said PTA W was told to cover the wound and she (LVN A) would be there tomorrow. Identifier D said LVN A never mentioned any of that to her on 2/24/225, and said she was at home when LVN A did the visit. Identifier D said Patient 1’s doctor told her they would not be able to turn the wound around this time with antibiotics, and would have to amputate, said the gangrene infection was too deep. Identifier D said the surgeon that did the previous surgery told Identifier D that after the 3rd and 4th toes were amputated, he was hoping to heal the wound enough to do a skin graft. Identifier D and Identifier L said they felt like this was neglect by LVN A for not communicating to the family or the physician about the wound and said they felt this could have been prevented if they had known sooner. The surveyor made another phone call to Identifier D on 3/14/2025 and Identifier D said they were moving Patient 1 to a rehabilitation facility today. The surveyor told Identifier D she would call her back on 3/17/2025. The surveyor received a call from Identifier D and Identifier L on 3/17/2025 at 12:32. They said Patient 1 was recovering well and was going to be in the rehab facility for a while. A phone interview was conducted with LVN A on 3/17/2025 at 3:26 PM. Surveyor asked LVN A why she did not report the changes in Patient 1’s wound on 2/10, 2/17, 2/21, and 2/24 to her supervisor RN C, and the patient’s physician. LVN A said, “everything was about the same from day 1” and said, “the patient really never had any questions or concerns.” LVN A said she “thought the patient was seeing a doctor every week and only recently found out it was every 3-4 weeks.” LVN A said, “she [Patient 1] always had pain every visit and sometimes it was very high.” The surveyor asked why LVN A did not report to the physician when the patient had a high intensity of pain in her foot. LVN A said, “she [Patient 1] always had pain every visit and sometimes it was very high,” LVN A said, “I should have reported the pain and the changes in the patient’s wound.” LVN A said, “I am so sorry, I have learned my lesson and I’m so sorry. LVN A said, “I really should have called about the wound being black, I didn’t have experience with the wound medication. When I researched the medication, it read that the medication was supposed to dry the wound, so I thought the wound was responding to the medication. I thought the wound needed to be debrided [scraped by a wound specialist] by the doctor.” The surveyor asked if PTA W called her on Tuesday 2/25/2025. LVN A said, “He called and told me the wound dressing was off and I asked him if he or the family could cover it and she would be there the next day.” LVN A said, “the wound was off the patient’s foot when she arrived to her visit [Monday 2/24/2025] and the patient was in her gown and on the commode when she arrived.” LVN A said, “she [patient] had a hard time transferring from the commode to the chair and seemed tired on this visit.” LVN A said she did not report this to anyone because she just seemed tired during the visit and the patient’s vital signs were normal. Review of LVN A’s personnel record: The personnel record included LVN A’s agency application dated 5/17/2024 and listed LVN A’s work experience included on LVA’s resume. LVN A’s work experience included wound care experience listed while working at another agency from 2022 to current. Agency’s training and competency listed a hire date of 5/27/2024 and included wound care education and competency 5/29/24 and 3/12/2025. LVN a signed and dated an agency job description on 5/17/2024 that included: “1. Furnishes service in accordance with agency policy and procedure, and acceptable standards of practice under the supervision of a RN. 9. Engages in effective interchange, reporting, and coordination of care regarding the client under the supervision of the RN. The application included a signed and dated document titled Employee Acknowledge on 5/17/25 by LVN A. The Employee acknowledgement included Abuse, Neglect, and Exploitation. The surveyor made 3 phone calls to PTA W and left 3 voicemails, with no return calls. Calls were made on: 3/10/2025 at 1:38 PM, 3/172025 at 3:59 PM, and 3/26/2025 at 10:30 AM. An exit conference was conducted on 3/18/2025 at 3:30 PM and included: the Administrator/ DON, RN A, the Alternate Administrator/ Alternate DON, RN B, and an agency Regional RN Case Manager, RN C. The surveyor conducted an interview with RN C during the exit interview. RN C said she was the RN case manager for Patient 1 and LVN A’s supervisor. The surveyor asked RN C if LVN A ever called and reported any of the wound changes or any concerns about Patient 1 during any of LVN A’s visits. RN C replied, “No”. RN C said she does a supervisory visit with agency LVNs every 60 days and more often if she is aware of and health issues with a patient. During the exit conference the surveyor asked the agency’s Alternate Administrator/ Alternate DON, RN B, why she reported the incident to HHSC. RN B said when the patient’s family contacted the agency, and said they felt LVN A neglected the patient, by not telling the family or doctor about the changes in Patient 1’s wound status, RN B immediately reported the allegation to HHSC. RN B said after the agency investigated the patient’s clinical record and LVN A’s skilled notes it was determined a PEER Review wound need to be conducted by the agency with LVN A. The PEER review would be conducted on 4/4/2025 and a determination would be made regarding a BON referral. During the exit conference the Administrator/ DON, RN A, said LVN A had been oriented to the agency policies and the policy to report changes in a patient’s health status immediately to the RN CM and the doctor. RN A said LVN A had been informed of the Peer review and had been required to do re-education on the agency’s policy regarding reporting patient health status to the agency’s clinical supervisors. RN A said LVN A’s failure to report the changes in Patient 1’s health status did not meet the agency’s policy or the regulation standards. A second exit interview was conducted on 3/21/2025 at 3:30 PM, regarding another intake that was received on 3/18/25, after the first exit, before the surveyor left the agency. The surveyor was required to continue the survey to conduct an investigation on Intake #571199. During the second exit interview the surveyor informed the Administrator Intake #571199 was unsubstantiated. Agency Policies: Abuse/ Neglect/ Exploitation PC.20, with a review date of 02/22/24 "...An agency employee, representative, or contractor suspected of... neglect... will be suspended immediately, and an investigation will be conducted by the agency. If there is cause to believe... neglect of the patient/ client has occurred by an agency employee, the incident will be reported to the appropriate authorities.... B. Neglect means failure to provide for one's self the goods or services, including medical, which are necessary to avoid physical or emotional harm...."