Every finding on record at Excel Complete Home Health & Therapy Services LLC

A recertification and complaint investigation (# 294309) survey entrance conference was conducted on 01/23/23. Census: 40 Licensed & Certified - 40 Licensed Home Health - 0 Personal Assistance Services – 0 The agency was in substantial compliance with 42 CRF Park 484.102, Emergency Preparedness Requirements for Home Health Agencies.

A recertification and complaint investigation (# 294309) survey entrance conference was conducted on 01/23/23. Census: 40 Licensed & Certified - 40 Licensed Home Health - 0 Personal Assistance Services – 0 Acronyms used: POC – plan of care RN – registered nurse

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the plan of care contained patient specific interventions and safety measures to protect against injury for 1 of 7 patients reviewed for plans of care. (Patient #4) This failure could place patients at risk of injury to a dialysis access site, leading to complications and hospitalization. Findings included: Record review of Patient #4’s POC dated 12/15/22 to 02/12/23 indicated she was 55 years old with diagnoses including end stage renal disease (final stage of kidney failure). The POC indicated Patient #4 was ordered skilled nursing visits one time a week for 9 weeks. The POC narrative indicated Patient #4 went to dialysis (treatment that removes waste and toxins from blood) 3 times a week. Skilled nurse interventions included to assess for signs and symptoms of end stage renal disease exacerbation and instruct patient as needed. The POC did not include orders to assess the patient’s dialysis access site (access to reach the blood for dialysis) and it did not address the location, safety measures, or care interventions for the protection of the access site. During an interview on 01/24/23 at 3:46 p.m., RN C said she developed Patient #4’s POC and Patient #4 had a dialysis access site to her right arm. RN C said Patient #4’s POC should have included the location of Patient #4’s access site, safety measures to protect Patient #4’s right arm from blood pressure checks and venipunctures (collecting blood from a vein), and to assess/monitor the dialysis access site for thrill (vibration felt at dialysis access site), infection, and malfunction. She said she knew safety measures and interventions regarding Patient #4’s dialysis access site should have been included on the POC and she could not believe she left them off. During an interview on 01/24/23 at 3:10 p.m., the Administrator/Supervising Nurse said a patient with a dialysis access site should have orders on the POC to assess the site for bruit (sound heard at dialysis access site) and thrill, signs of infection, or other complications and to report any issues to the dialysis center. She said the location of the access site should be included on the POC and safety precautions to ensure blood pressure and venipunctures were not accessed with the arm of the dialysis access site. During an interview on 01/25/23 at 11:12 a.m., the Administrator/Supervising Nurse said she ensured accuracy of POCs by reviewing POCs herself. She said if there was a discrepancy found in the POC, it was flagged, and returned to the nurse to correct. She said it was important for the POC to include safety precautions to protect from injury and interventions because the nurse would know to assess the patient’s dialysis access site for bruit and thrill and notify the dialysis center if the bruit and thrill was not present. She said safety precautions were important to be included on the POC to ensure the nurse did not take blood pressure or venipunctures from the same arm as the dialysis access site because it could lead to a complication. Record review of https://www.kidney.org/atoz/content/hemoaccess#keeping-your-access-working accessed on 01/26/23 indicated “…an access that is not working well can decrease the amount of dialysis you receive… Check the blood flow several times each day by feeling for a vibration, also called a pulse or thrill. If you do not feel this, or if there is a change, call your doctor or your dialysis center. Do not wear tight clothes or jewelry on your access arm. Do not carry anything heavy or do anything that would put pressure on the access. Do not sleep with your head on the arm that has your access. Do not let anyone use a blood pressure cuff on your access arm. Do not let anyone draw blood from your access arm…” Record review of the agency’s plan of care policy dated 12/10/21 indicated “…the individualized plan of care must include the following: safety measures to protect against injury…patient-specific interventions and education…”

Assure implementation of plan of care CFR(s): 484.105(c)(5) Assuring the development, implementation, and updates of the individualized plan of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the Clinical Manager did not assure the development, implementation, and updates of the individualized plan of care for 1 of 7 patients reviewed for plans of care. (Patient #4) The Clinical Manager failed to ensure Patient #4’s POC contained patient specific interventions and safety measures to protect against injury. This failure could place patients at risk injury to a dialysis access site, leading to complications and hospitalization. Findings included: Record review of Patient #4’s POC dated 12/15/22 to 02/12/23 indicated she was 55 years old with diagnoses including end stage renal disease (final stage of kidney failure). The POC indicated Patient #4 was ordered skilled nursing visits one time a week for 9 weeks. The POC narrative indicated Patient #4 went to dialysis (treatment that removes waste and toxins from blood) 3 times a week. Skilled nurse interventions included to assess for signs and symptoms of end stage renal disease exacerbation and instruct patient as needed. The POC did not include orders to assess the patient’s dialysis access site (access to reach the blood for dialysis) and it did not address the location, safety measures, or care interventions for the protection of the access site. During an interview on 01/24/23 at 3:46 p.m., RN C said she developed Patient #4’s POC and Patient #4 had a dialysis access site to her right arm. RN C said Patient #4’s POC should have included the location of Patient #4’s access site, safety measures to protect Patient #4’s right arm from blood pressure checks and venipunctures (collecting blood from a vein), and to assess/monitor the dialysis access site for thrill (vibration felt at dialysis access site), infection, and malfunction. She said she knew safety measures and interventions regarding Patient #4’s dialysis access site should have been included on the POC and she could not believe she left them off. During an interview on 01/24/23 at 3:10 p.m., the Administrator/Supervising Nurse said a patient with a dialysis access site should have orders on the POC to assess the site for bruit (sound heard at dialysis access site) and thrill, signs of infection, or other complications and to report any issues to the dialysis center. She said the location of the access site should be included on the POC and safety precautions to ensure blood pressure and venipunctures were not accessed with the arm of the dialysis access site. During an interview on 01/25/23 at 11:12 a.m., the Administrator/Supervising Nurse said she ensured accuracy of POCs by reviewing POCs herself. She said if there was a discrepancy found in the POC, it was flagged, and returned to the nurse to correct. She said it was important for the POC to include safety precautions to protect from injury and interventions because the nurse would know to assess the patient’s dialysis access site for bruit and thrill and notify the dialysis center if the bruit and thrill was not present. She said safety precautions were important to be included on the POC to ensure the nurse did not take blood pressure or venipunctures from the same arm as the dialysis access site because it could lead to a complication. Record review of https://www.kidney.org/atoz/content/hemoaccess#keeping-your-access-working accessed on 01/26/23 indicated “…an access that is not working well can decrease the amount of dialysis you receive… Check the blood flow several times each day by feeling for a vibration, also called a pulse or thrill. If you do not feel this, or if there is a change, call your doctor or your dialysis center. Do not wear tight clothes or jewelry on your access arm. Do not carry anything heavy or do anything that would put pressure on the access. Do not sleep with your head on the arm that has your access. Do not let anyone use a blood pressure cuff on your access arm. Do not let anyone draw blood from your access arm…” Record review of the agency’s plan of care policy dated 12/10/21 indicated “…the individualized plan of care must include the following: safety measures to protect against injury…patient-specific interventions and education…” Record review of the agency’s responsibilities of the Clinical Manager dated 01/13/18 indicated “…the agency defines the responsibilities of the Clinical Manager to include, but not be limited to: assuring the development, implementation, and updating of the individualized plan of care…”