Every finding on record at Firstat Nursing Services - West Palm Beach

During the unannounced Recertification survey commenced on 08/07/2023 and concluded on 08/10/2023 at Firstat Nursing Services-West Palm Beach a Home Health Agency provider, Emergency Preparedness was reviewed. Firstat Nursing Services-West Palm Beach was in compliance with 42 Code Of Federal Regulations (CFR) Part 484.102, Condition of Participation for Home Health Agencies.

An unannounced Recertification survey was commenced on 08/07/2023 and concluded on 08/10/2023 at Firstat Nursing Services-West Palm Beach, Home Health Agency provider, located at 5601 Corporate Way Ste. 404 West Palm Beach, FL 33407. The provider was not in compliance with 42 Code Of Federal Regulations (CFR) Part 484 Subpart A-C, Conditions of Participation for Home Health Agencies.

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based on review of the Home Health Agency (HHA)'s, Policy and Procedure, record review and interview, the HHA's Skilled Nurse failed to ensure education to 2 of 16 sampled patients and or caregivers related to the patient's principal diagnosis (Patient #8 and #13). The findings included: 1) Review of HHA's Policy and Procedure titled, “Monitoring patient’s response/reporting to Physician," Policy No.HH:2-015.1 documented, "During each home visit, the clinician will monitor the patient’s response to care against the established goals including, but not limited to teaching." Review of the record revealed Patient #8 was admitted to the HHA's services on 07/15/23 with a Foley (indwelling urinary drainage device) catheter and principal diagnosis of Urinary Tract Infection (UTI). Review of the corresponding Plan of Care for the certification period of 07/15/23 through 09/12/23 documented the Skilled Nurse was to instruct the patient/caregiver on signs/symptoms of UTI to report to Medical Doctor (MD) and Skilled Nurse (SN) and to instruct on complications of Foley catheter. Review of the Skilled Nursing Visit Notes for Patient #8, dated from 07/15/23 through 07/23/23 lacked any documented instructions on proper Foley care or cleaning, which may prevent a UTI. 2) Review of the record revealed Patient #13 was admitted to the HHA's services on 01/05/23 with a principal diagnosis of COVID-19. Review of the Plan of Care for the certification period of 01/05/23 through 03/05/23 documented the Skilled Nurse was to instruct the patient/caregiver on signs/symptoms of complications of COVID-19. Review of the Skilled Nursing Visit Notes for Patient #13, dated 01/05, 01/13, 01/17, 01/19 and 01/23/23 lacked any documented instructions on COVID-19. During an interview on 08/10/23 at 11:56 AM, the Director of Nursing (DON) agreed with the lack of documented education for patient #8 and #13 and agreed that the Skilled Nurses should have educated the patients on the patient's principal diagnosis.

Contents of clinical record CFR(s): 484.110(a) Standard: Contents of clinical record. The record must include: This STANDARD is not met as evidenced by: Based on the Home Health Agency (HHA)'s Policy and Procedure review, record review, and interview, the HHA failed to ensure an accurate and complete record for 2 of 16 sampled patients as evidenced by the failure to ensure an accurate diagnosis was recorded in Patient #3’s Plan of Care (POC) and include "Missed Visit" Notes as part of Patient #7's record (Patient #3 and #7). The findings included: 1) Review of the HHA's Policy and Procedure titled, "Continuity Of Care" Policy No. HH:2-013.1 dated January, 2018 reveals, "All documentation must be in the office within 7 days or the week after care." Record review reveals that Patient #3 was admitted to the HHA 's services on 06/21/23 for the provision of care to include Skilled Nursing. Review of the POC for the certification period of 06/21/23 through 08/19/23 documents a principal diagnosis of Pressure Ulcer of Right Elbow. Review of the "Referral" record documents Patient #3 had a Pressure Ulcer to the Right Buttock. On 08/08/23 at 12:04 PM, an interview was held with the Director of Nursing (DON), who stated that the Nurse put the wrong principal diagnosis on the POC and the DON confirmed the diagnosis documented on the "Referral" records was the correct principal diagnosis. 2) Review of the record reveals Patient #7 was admitted to the HHA's services on 06/25/23 for the provision of care to include Skilled Nursing. Review of the POC for the certification period of 06/25/23 through 08/23/23 documented the following Physician's orders, "Skilled Nurse to conduct 1 visit daily for 60 days for (wound care) starting on 06/25/23. Further review reveals "Skilled Nurse Visit Notes Not Started” on 7/13/23, and 7/17/23. On 08/10/23 at 11:36 AM an interview was held with the DON, who stated that the Nurse went to the patient's home on those dates, Patient #7 was not there, the care wasn’t rendered, but the Nurse did not do a "Missed Visit Note" and did not notify the patient's physician of the missed visits.

An unannounced Complaint Survey, #2022003820 and #2022003830, was conducted on 05/04/2022 and 05/06/2022 at Firstat Nursing Services - West Palm Beach, Home Health Agency provider. The provider is not in compliance with 42 CFR Part 484, Subpart A-C, Conditions of Participation for Home Health Agencies.

Make complaints to the HHA CFR(s): 484.50(c)(3) Make complaints to the HHA regarding treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who is furnishing services on behalf of the HHA; This ELEMENT is not met as evidenced by: Based on the Home Health Agency (HHA)'s Policy review, record review and interview, the HHA failed to follow their own Complaint Policy, and findings of their "Complaint Report and investigation, to ensure follow up for 1 of 3 sampled patients (Patient #1). The findings included: Review of the HHA's Policy "Complaint/Grievance Process" dated January 2018 documented, "Procedure: 1. … The supervisor will investigate the grievance within five (5) days after receipt of such grievance and will make every effort to resolve the grievance to the patient's satisfaction. Response to the patient regarding the complaint will occur within ten (10) days of receipt. … 4. Complaints and any action taken will be documented on a complaint form." Review of the HHA's Grievance Manual provided by the Director of Nursing (DON), revealed a Complaint/Grievance Report for Patient #1 dated 03/05/22 that documented the HHA received a telephone call from the patient who was very upset because staff who had informed the patient of a home visit had not shown up. Documented "Action Taken" on this report revealed the HHA was unable to reach the assigned nurse, but the patient and spouse felt they would be fine without the nurse for the day. Review of the record revealed Patient #1 was admitted to the HHA's services on Friday 03/04/22, having been discharged from the hospital on 03/02/22 and a home visit was made for Patient #1 on 03/04/22. Review of the "Logging Comments Information" dated Saturday 03/05/22, which is the HHAs means of documented communication, revealed Patient #1 telephoned the HHA at 8:00 AM that morning, wanting to know who their nurse was for that day. Patient #1 explained to the On Call Coordinator that "someone called ... yesterday and said they would not be coming today because they have been moved to a different area." The On Call Coordinator documented there was no one scheduled in their Electronic Medical Record (EMR) for a visit for the day. The extensive note described the On Call Coordinator ultimately was unable to schedule a home visit for that day, but lacked documented evidence, "the patient and spouse felt they would be fine without the nurse for the day," as per the Complaint Report. Further review of the Complaint Report documented a concern with the lack of supplies. The "Action Taken" section of the report also documented the HHA was to follow up with the surgeon and supply company related to supplies. Further review of the extensive Logging Comments Information dated 03/05/22 by the On Call Coordinator documented a conversation with the spouse regarding needed supplies. The On Call Coordinator explained they would need to be ordered by the Case Manager. The spouse voiced they needed assistance to change the ostomy bag later in the week. The record lacked any evidence the HHA followed up with the surgeon and or supply company related to needed supplies, as per their documented "Action Taken" in the Complaint/Grievance Report. During an interview on 05/04/22 at 1:35 PM, the Clinical Supervisor explained they did not have orders for "ostomy care" for Patient #1. The Clinical Supervisor explained they could not care for the ostomy without orders, nor could they get supplies. When asked why she had not reached out the surgeon's office for an ostomy care order and supplies, the Clinical Supervisor stated, "They (the surgeon) always tell her they haven't seen the patient in the office since the surgery, and that they need to do so for correct orders and supplies." The Clinical Supervisor stated she thought Patient #1 had an appointment with the surgeon for that Monday or Tuesday.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on record review and interview, the Home Health Agency (HHA) failed to ensure 1 of 3 sampled patients was informed of the services and frequency of proposed visits of care (Patient #1). The findings included: Review of the record revealed Patient #1 was admitted to the HHA on 03/04/22. An "Authorization and Agreement for Home Health Services and Release" was completed and signed by Patient #1 on 03/03/22; this form had a section to document the "Proposed Services, Frequency and Duration" of services and this area of the consent was left "blank." Further review of the "Admission Paperwork" in the Electronic Medical Record revealed the "Start of Care Assessment" and additional paperwork was completed on 03/09/22, with the second Skilled Nursing visit. The delay in services was related to the lack of complete orders (please refer to G0608 related to Coordination of Care) and timing of the initial assessment that was waived related to the COVID-19 pandemic. The record lacked any evidence Patient #1 was informed of the proposed services and frequency of visits. Interview on 05/04/22 at 11:40 AM with Staff B, the Coordinator for Managed Care, revealed she attempts to schedule the Start of Care assessment with the Registered Nurse (RN) for the day after the "referral date." The scheduler explained that because of the staffing challenges related to the pandemic, she has had to delay the RN's start of care but has been able to have the patients seen as per physician's orders. During an interview on 05/04/22 at 1:35 PM, the Clinical Supervisor for Managed Care was shown the consent signed by Patient #1. When asked who signed as the Agency (HHA) Representative, the Clinical Supervisor explained it was the HHA's "Liaison," as the patient was probably still in the hospital.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on record review and interview, the Home Health Agency (HHA) failed to ensure coordination of care for 1 of 3 sampled patients. Documentation revealed Patient #1 had asked to speak with a supervisor on two different occasions and the record lacked evidence of the requested communication. There were delays with scheduling of a second home visit related to the lack of "ostomy orders," with no evidence the HHA reached out to the surgeon for needed orders. Patient #1 was told there would be nurse visits on 03/05/22 and 03/08/22, which were not completed due to a lack of coordinated care (Patient #1). The findings included: Review of the record revealed Patient #1 was admitted to the HHA on 03/04/22, having been discharged from the hospital on 03/02/22. Patient #1 had surgery for the placement of a new colostomy while in the hospital. Review of "Logging Comments Information," the HHA's system of communication, revealed the "Scheduler" called Patient #1 on 03/03/22 at 12:44 PM, informing the patient they had not yet obtained a Nurse for the first visit. Patient #1 requested to speak with the Supervisor. This "Communication Note" documented an e-mail was sent to the Director of Nursing and the Clinical Supervisor for Managed Care. A subsequent entry in the "Logging Comments Information" dated 03/03/22 at 7:47 PM revealed Patient #1 called and stated she was very upset they were unable to get a Nurse out to see her that same day. Patient #1 again asked to speak with a supervisor ASAP (As Soon As Possible). The record lacked any evidence a Supervisor contacted and spoke with Patient #1. Further review of the record revealed a Skilled Nurse visit was made on 03/04/22, with the next visit not occurring until 03/09/22. Review of the "Logging Comments Information" dated Saturday 03/05/22, documented an extensive note by the On Call Coordinator explaining Patient #1 called, upset regarding the lack of a nurse visit. During an interview on 05/04/22 at 1:35 PM, the Clinical Supervisor explained there was a delay in the second visit because they did not have orders for "ostomy care" for Patient #1. Side-by-side record review and continued interview revealed orders for wound care and drain care, which Patient #1 had neither as the surgical incision had healed enough to not need a dressing, and the drain had been removed at the hospital. The Clinical Supervisor explained they could not care for the ostomy without orders. The Clinical Supervisor agreed she had not reached out to the surgeon for needed ostomy care orders. Review of the "Logging Comments Information" dated 03/05/22 also documented the On Call Coordinator was unable to find orders for ostomy care, and that the HHA would need to reach out to the surgeon. Further review of the "Logging Comments Information" from 03/05/22 revealed Patient #1 called the On Call Coordinator and was upset, wanting to know which nurse would see her that day. Patient #1 explained someone called her the previous day and said she would not be coming that day because they had been moved to a different area. "This Logging Comments Information" revealed the scheduled nurse could not do the visit because of a full schedule and the On Call Coordinator could not find anyone else for that same day. Final review of the "Logging Comments Information" dated 03/08/22 at 3:36 PM documented by scheduling that the spouse of Patient #1 had been calling the managed care company because they had not heard from the nurse for that day. A "supplemental note" dated 03/08/22 at 3:36 PM by scheduling documented Staff A, an LPN (Licensed Practical Nurse), was "scheduled for today after her shift." This note documented Patient #1 was called and informed of same. Review of the Skilled Nursing visits lacked any home visit for 03/08/22. During a telephone interview on 05/06/22 at 10:59 AM, Staff A, the LPN who was scheduled for a home visit for Patient #1 on 03/08/22, confirmed she recalled the patient. Staff A explained she works another job and sees patients for this HHA after her shift. When asked about the 03/08/22 visit for Patient #1, after reviewing her messages, she recalled the event. Staff A explained she had received a request to see Patient #1 on 03/08/22 at 4:40 PM. The LPN explained she had asked about routine supplies such as gloves, Normal Saline, and gauze to care for the ostomy, which Patient #1 did not have, and was told she could get them at the office. The LPN stated she spoke with Patient #1 about the need for supplies and scheduling and they had decided upon 03/10/22 for the visit. When asked if this was communicated with the HHA office, the LPN stated she did, but was unable to find any documented evidence.