Every finding on record at Excel Home Care Services, Inc

An Emergency Preparedness survey was conducted at Excel Home Care Services, Inc., from 6/21/22 through 6/22/22 and was found to be in compliance with § 484.22 Emergency Preparedness for Home Health Agencies.

A recertification survey, including compliance with staff vaccination requirements, was conducted at Excel Home Care Services, Inc., from 6/21/22 through 6/22/22. The agency was found to be non-compliant with the Federal Conditions of Participation Governing Home Health Agency. The following deficiencies were cited:

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on record review and interview the agency staff failed to accurately complete one Patient's (#6) current health status on the comprehensive assessment related to an unstageable pressure ulcer (a wound that is caused by pressure and is completely covered with eschar- dead tissue or slough- stringy tissues- therefore, unable to visualize the depth of the wound) to the right heel. Findings include: Patient #6 was admitted to the agency in August 2021 with an unstageable pressure ulcer to the right heel. Review of the physician orders for certification period, 8/17/21 through 10/15/21, indicated a diagnosis of an unstageable pressure ulcer on the right heel. Review of the Start of Care Outcome and Assessment Information Set (OASIS), dated 8/17/21, indicated in section M1023, the patient had an unstageable pressure to the right heel. Review of the Integumentary (skin) status section of the OASIS, indicated the patient had a very small, blackened area to the right heel that was not open. No further assessment was completed for the unstageable pressure ulcer. On 6/21/22 at 2:05 P.M., the Clinical Supervisor said the OASIS should have included the measurements of the unstageable pressure ulcer. Please refer to G578, example 4.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure that staff conformed with physician orders relative to skilled staff visits for two Patients (#4 and #7) and relative to wound care for two Patient (#3 and #6), out of a total sample of seven patients. Findings include: 3. For Patient # 3, the agency staff failed to follow the physician's order related to wound care. Patient #3 was admitted to the agency in February 2022 with a diagnosis of a stage 3 pressure ulcer (a wound caused by pressure with full thickness tissue loss). Review of the physician's order for certification period, 6/15/22 through 8/13/22, indicated to cleanse the wound with normal saline, apply moistened Prisma (a treatment that promotes healing), followed by Aquacel AG (a treatment that protects the wound from bacteria and promotes healing) covered by a 4 x 4 gauze then a Mepilex border dressing (a foam dressing). During on onsite home visit on 6/22/22 at 2:00 P.M., Nurse #2 removed the old dressing, once the dressing was removed there was not a 4 X 4 gauze visualized. After the dressing was complete, Nurse #2 and the surveyor spoke privately and she said the physician's order was not followed because the 4 X 4 gauze was left out. During an interview on 6/22/22 at 2:50 P.M., after reviewing the above observation, the Administrator said that further education would be needed. 4. For Patient #6, the agency failed to monitor an unstageable pressure ulcer (a wound that is caused by pressure and is completely covered with eschar- dead tissue or slough- stringy tissues- therefore, unable to visualize the depth of the wound) to the right heel. . Patient #6 was admitted to the agency in August 2021. Review of the Home Health Agency Assessment/Staging of Pressure Ulcers policy, dated August 2002, indicated; when assessing the pressure ulcer, the following parameters should be addressed consistently; - Site, stage and size (include length, width and depth), - Presence of necrotic tissue, and - Condition of surrounding tissue. Review of the Start of Care Outcome and Assessment Information Set (OASIS), dated 8/17/21, indicated in section M1023, the patient had an unstageable pressure to the right heel. Review of the Integumentary (skin) status section of the OASIS indicated, the patient had a very small blackened area to the right heel that was not opened. No further assessment was completed for the unstageable pressure ulcer. Review of the physician orders for certification period, 8/17/21 through 10/15/22, indicated the resident had a diagnosis of an unstageable pressure ulcer to the right heel. Further review indicated to monitor the right heel for worsening of signs and symptoms of skin breakdown. Skilled Nursing services were ordered one to two times a week for nine weeks. Review of the nurses notes indicated the following: - 8/17/21 no mention of heel ulcer - 8/20/21 small blackened area to right heel remains intact, very small in size - 8/23/21 small black spot to heel remains intact - 8/30/21 right heel continues to have very small closed sore, scabbed, not open - 9/3/21 right heel remains slightly scabbed in appearance, no open areas - 9/6/21 right heel remains intact, scab to area - 9/10/21 no documentation - 9/13/21 scab remains to right heel - 9/20/21 right heel pink, small scabbed area - 9/27/21 right heel pink, small scabbed area - 10/4/21 right heel remains with scab, slightly soft but intact - 10/11/21 small scab to right heel remains - 10/19/21 Patient discharged from services During an interview on 6/21/22 at 2:05 P.M., the Clinical Supervisor said that when a patient has a wound it should be measured and described weekly and the assessment should include surrounding tissue. The Clinical Supervisor did not know if the wound had been measured or described. During an interview on 6/22/22 at 2:34 P.M., the Administrator said that pressure ulcers needed to be measured on admission and then at least weekly. She said that she could not find the admission measurements. Review of the agency's Clinical Documentation policy, undated, indicated the following: -All skilled services provided by nursing, therapy or social services will be documented in the clinincal record. -Services not provided and the reason for the missed visits will be documented and reported to the physician. 1. For Patient #4, the agency failed to ensure staff conformed to the physician's order for skilled nursing visits. Patient #4 was admitted to the agency in May 2022 with a diagnosis of bilateral lower leg lacerations. Review of the physician's order for certification period, 5/19/22 through 7/17/22, indicated the following; skilled nursing once a day for one day, skilled nursing once a week for one week, skilled nursing twice a week for eight weeks and three skilled nursing visits as needed. Review of the clinical record indicated the patient had only been seen once during the week of 6/6/22 and not twice as ordered. During an interview on 6/22/22 at 12:00 P.M., the Administrator said nursing did not provided two visits during the week of 6/6/22 as ordered and did not document why a second visit was not provided. 2. For Patient #7, the agency failed to ensure staff provided skilled nursing services as ordered. Patient #7 was admitted to the agency in May 2019 with a diagnosis of major depressive disorder. Review of the physician's order for certification period, 10/11/21 through 12/9/21, indicated the following; skilled nursing services once a day for nine weeks and three skilled nursing visits as needed. Review of the clinical record indicated skilled nursing visits were not provided on 11/28/21 and 12/5/21. During an interview on 6/21/22 at 1:00 P.M., the Clinical Supervisor said, after reviewing the clinical record, that nursing did not document a reason for either missed visit. She said the skilled nursing services were not provided as ordered by the physician.

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on record review and interview the agency staff failed to follow professional standards of practice and failed to follow the agency's policy, by not rotating insulin injections sites for one Patient (#1) out of a total sample of seven patients. Findings include: Patient #1 was admitted to the agency in August of 2018 with a diagnosis of Diabetes Mellitus (DM). Review of the agency's Subcutaneous (sc -beneath the skin)) Injection policy, dated August 2002, included: - When administering daily insulin injections, rotate injection site daily, and - Document site of administration. Review of the Levemir insulin (long acting) guidelines indicated under warning and precautions; to change injections site, continued injections in the same place can effect the amount of medication absorbed. Review of the Novolog insulin (short acting) guidelines indicated; change (rotate) injection sites to reduce the risk of lipodystrophy (thickening of the skin). Review of the physician orders for certification period dated, 5/24/22 through 7/22/22, indicated the following insulin orders: - Levemir insulin 100 units/per milliliter (ml), give 12 units sc in the morning, this order was discontinued on 6/8/22 and changed to Levemir insulin 100 units/ml give 16 units sc every morning, - Levemir insulin100 units/ml, give 14 units sc in the evening, this order was discontinued on 6/8/22 and changed to Levemir insulin 100 units/ml give 16 units sc every evening, and - Novolog insulin100 units/ml, give per sliding scale three times a day before breakfast, lunch and dinner. Review of the Medication Administration Record (MAR), dated June 2022, indicated: - The Levemir insulin; was documented as administered in the right upper extremity for 23 out of the 42 injections, and ten times there were no administration sites documented. - The Novolog insulin was documented as administered in the right upper extremity for 26 out of the 56 injections, and 13 times there were no administration sites documented. During an onsite home visit on 6/21/22 at 4:00 P.M., Nurse #1 showed the surveyor the June 2022 MAR. She reviewed the MAR with the surveyor and said that some nurses did not document the location of the insulin injections. Nurse #1 said the Patient's injection sites always needed to be rotated. During an interview on 6/22/22 at 8:33 A.M., the Administrator said that she expected the agency staff to rotate the insulin injections and document the sites.