Every finding on record at Gurusamy Inc.

A Complaint Survey was conducted by Healthcare Management Solutions, LLC on behalf of The Centers For Medicaid and Medicare Services (CMS). An unannounced on-site complaint survey conducted at the above named Home Health Agency (HHA) facility from 09/14/23 through 09/15/23 resulted in noncompliance with Condition(s) of Participation G570 (Care Planning, Coordination of Care and Quality of Care) respective to applicable CoP under 42 CFR 484 Subparts A through C and the following standard-level deficiency listed below.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on record review, documentation review, policy review, and staff and family interviews, it was determined the home health agency (HHA) (1) failed to ensure care planning, coordination of services, and quality of care for one Patient (P)1. The HHA failed to ensure it could meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence and could furnish needed services in accordance with accepted standards of practice. This failure led to P1 not receiving nursing services, social services, and other services required to maintain his overall health. Findings include: There is no documented evidence the HHA provided all necessary and ordered services, including nursing services related to the care of the patient’s indwelling urinary catheter required by P1. Refer to G576 and G578.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on record review, staff and family interview, and review of the agency's policies and procedures, the agency failed to include nursing services on the plan of care as ordered by the provider for one Patient (P) P1 of seven Patients reviewed in the sample. As a result of this failure, P1, who was admitted to the agency with an indwelling Foley catheter was not provided with necessary nursing care and services for P1’s indwelling catheter to maintain an acceptable level of general cleanliness and infection control. Findings include: Review of P1’s electronic medical record (EMR) revealed a Start of Care (SOC) date of 12/08/22 with a diagnosis of history of stroke, right below the knee amputation (BKA), and type 2 diabetes. P1 was discharged from Home Health Services without ever receiving nursing services on 01/13/23 and was subsequently admitted to a local acute care hospital on 01/17/23 with a diagnosis of Gangrenous Balanitis (gangrene infection of the penis) and necrotizing cellulitis. P1 passed away in the hospital on 02/26/23. P1’s Home Health “Physician’s Orders” dated 11/29/22 indicated, “Referring Diagnosis: CVA (stroke) late effects, DM (Diabetes), Bed Bound;” and “Services Needed: (boxes checked for) Homecare, Medical Transport, Medical Equipment, Diabetes Education, Physician Home Visits, Counseling, Foley (Catheter) Care, Physical Therapy, and Other (Title III; Home health);” and “Specify Orders: Age of caregiver at home limits care.” The Physician’s Orders were signed by the resident’s admitting physician and dated 11/29/22. P1’s “Intake SBAR” (assessment) dated 11/30/22 read, in pertinent part, “Assessment: Pt (patient) meets the following HH (home health) criteria: 1. Received HH referral from HSP (Health Services of the Pacific) Clinic. Notes attached to referral support the need for HHPT (Home Health Physical Therapy) services. 2. Pt is homebound – fall risk, R BKA, and L (left) sided weakness. 3. There is a need for HHSN (Home Health Skilled Nursing/PT (Physical Therapy)/HHA (Home Health Aide)/MSW (Master of Social Work) services. Order is for HHPT services.” Recommendations on the document included “Assess need for air mattress, MSW, and further assessment at initial visit.” P1's "Home Health Certification and Plan of Care" with a start date of 12/08/22 indicated the following Orders for Discipline and Treatments "PT [Physical Therapy] 12-08-22 1 x week x 1 week, 1 h [hour] duration; 12-11-22 2 x week x 8 weeks, 1 h durations; PT Start of Care 12/8/2022" There was no order for skilled nursing noted on the Home Health Certification and Plan of Care. During an interview with Registered Nurse/Case Manager (RNCM)1 on 09/14/23 at 2:40 PM, he/she confirmed the assigned RNCM routinely received the physician’s orders/referral from each patient’s hospital or primary care physician. The RNCM1 revealed the RNCM was responsible for reviewing the orders/referral to ensure referred and required care and services were being initiated/provided for each patient. RNCM1 confirmed he/she was the RNCM responsible for coordination of P1’s overall home health care and services. He/She confirmed he/she was involved in P1’s care conference meetings, along with other interdisciplinary team members, including P1’s assigned physical therapists (PT1 and PT2). RNCM1 stated as a patient’s RNCM he/she was permanently assigned to the patient and was responsible for doing supervisory visits with patients at least every two weeks in their home. RNCM1 also revealed he/she was responsible for looking over therapy (physical therapy services in P1’s case) notes and it was his/her responsibility to give input on each patient’s case related to clinical care regardless of whether nursing services were ordered for that patient or not. RNCM1 indicated although he/she was responsible for reviewing P1’s physician’s orders/referral, he/she missed the checked boxes indicating catheter care, medical transport, medical equipment, diabetes education, and counseling services that had been referred and ordered by P1’s physician. RNCM1 confirmed that by checking boxes for all these services, this indicated the services had been referred and ordered by P1’s physician. RNCM1 confirmed when the boxes for services such as “Foley Care,” “Wound Care,” or “Diabetes Education” were checked, this indicated skilled nursing services had been referred/ordered related to those specific services. RNCM1 further confirmed that since P1 had been home bound, catheter care would have been provided by nursing for P1 in his/her home since he/she would not have been able to leave his/her home to receive those services in a clinic/office setting. During an interview with P1’s physician (Medical Doctor (MD1) and Medical Assistant (MA1) on 09/14/23 at 4:46 PM, MD1 verified his/her orders for Home Health Care, including catheter care, in the patient’s medical record and stated, “From top to bottom, I recommended PT, OT, HHA (nurses and CNAs (Certified Nursing Assistants) and bathers and anything we could throw at [P1] to help).” MA1 indicated he/she and MD1 were aware nursing had not visited P1 as P1’s [F1] informed them nursing had not been out to visit when they did the patient’s medical visit, and indicated MA1 reached out to the HHA to find out why P1 was not receiving nursing care for [the] catheter. MA1 stated he/she refaxed the home health referral/orders twice and also called the agency to attempt to find out why nursing care and other ordered services were not being provided. MA1 stated, “I recall being upset because we love our patients and we have to coordinate care and they were not providing services.”MD1 stated, “We were under the assumption everyone was seeing this patient. Certainly nursing.” MD1 further stated, “The [F1] did not know anything about Foley care, and [F1] could not roll [P1] in the bed. MD1 stated, “The reason for the referral to nursing, in part, was because of the Foley.” The survey team attempted to interview the Nursing Supervisor during the investigation, however the nursing supervisor refused the interview. Review of the undated agency policy titled, “Skilled Nursing Services,” revealed, “Skilled Nursing Services will be provided by a Registered Nurse or a Licensed Practical/Vocational Nurse under the supervision of a Registered Nurse and in accordance with a medically approved Plan of Care (Physician’s Orders). In determining whether a service required the skills of a Nurse, the inherent complexity of the service, condition of the client, and accepted standards of medical and nursing practice will be considered.”

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 record review, staff and family interview, and review of the agency's policies and procedures, the agency failed to ensure nursing services were initiated as ordered by the provider for one Patient (P) P1 of seven Patients reviewed in the sample. As a result of this failure, P1, who was admitted to the agency with an indwelling Foley catheter was not provided with necessary nursing care and services for P1’s indwelling catheter to maintain an acceptable level of general cleanliness and infection control. Findings include: Review of P1’s electronic medical record (EMR) revealed a Start of Care (SOC) date of 12/08/22 with a diagnosis of history of stroke, right below the knee amputation (BKA), and type 2 diabetes. P1 was discharged from Home Health Services without ever receiving nursing services on 01/13/23 and was subsequently admitted to a local acute care hospital on 01/17/23 with a diagnosis of Gangrenous Balanitis (gangrene infection of the penis) and necrotizing cellulitis. P1 passed away in the hospital on 02/26/23. P1’s Home Health “Physician’s Orders” dated 11/29/22 indicated, “Referring Diagnosis: CVA (stroke) late effects, DM (Diabetes), Bed Bound;” and “Services Needed: (boxes checked for) Homecare, Medical Transport, Medical Equipment, Diabetes Education, Physician Home Visits, Counseling, Foley (Catheter) Care, Physical Therapy, and Other (Title III; Home health);” and “Specify Orders: Age of caregiver at home limits care.” The Physician’s Orders were signed by the resident’s admitting physician and dated 11/29/22. P1’s “Intake SBAR” (assessment) dated 11/30/22 read, in pertinent part, “Assessment: Pt (patient) meets the following HH (home health) criteria: 1. Received HH referral from HSP (Health Services of the Pacific) Clinic. Notes attached to referral support the need for HHPT (Home Health Physical Therapy) services. 2. Pt is homebound – fall risk, R BKA, and L (left) sided weakness. 3. There is a need for HHSN (Home Health Skilled Nursing/PT (Physical Therapy)/HHA (Home Health Aide)/MSW (Master of Social Work) services. Order is for HHPT services.” Recommendations on the document included “Assess need for air mattress, MSW, and further assessment at initial visit.” P1’s “Request for Prior Authorization (Insurance coverage for Home Health Services)”, dated 12/03/22, indicated a request for coverage of PT services only. There was no request for insurance coverage made for any of P1’s other ordered services (including nursing services). P1’s “PT Start of Care Services Note” (the initial provider/patient contact note by a member of the Home Health Agency Team), dated 12/08/22, indicated P1 was being seen initially for PT services, and indicated further recommendations by the physical therapist for P1 to be seen by an Occupational Therapist (OT) and a home health aide (HHA) once authorized by insurance. No mention was made of the patient’s indwelling urinary catheter or the need for nursing services anywhere in the initial encounter note. P1’s “Endorsement/Care Conference” documentation dated 12/14/22, indicated P1 was receiving only physical therapy (PT) services from the HHA (Home Health Agency). The document indicated PT was to continue and indicated a referral was needed for additional Occupational Therapy and Home Health Aide services due to the patient’s caregiver’s reports of being overwhelmed with the patient’s care and potential caregiver burnout. The document did not indicate P1’s indwelling foley catheter or the need for nursing services as ordered by the patient’s physician. The document was signed by an interdisciplinary team (IDT) including a Registered Nurse (RN)/Case Manager (RN/CM1), social worker, and three members of the physical therapy team (including PT1 and PT2). P1’s “Communication Note” dated 01/13/23 read, in pertinent part, “The patient cancelled for the third time today due to scrotal pain. The patient’s [parent] noted that [P1] was seen by (physician) and that [P1’s] penile condition was worse and significantly more painful. PT noted that visits will be discontinued due to multiple cancellations.” P1’s “Initial Emergency Department Physician’s Progress Note,” provided to the survey team by Local Hospital 2 and dated 01/17/23, read, in pertinent part, “Chief Complaint: pain and swelling to the groin;” and “Medical Decision Making: Differential Diagnosis Comment: 48 year old [patient] with PMH. . . as above here for scrotal swelling and foul smelling penile discharge. [Patient] has had an indwelling Foley catheter since November. For the past 1-2 weeks [patient] has been on antifungals and antibiotics prescribed by clinic doctor but has had worsening pain and swelling with Foley erosion through the penis x 2 days. On exam [patient] has an old Foley catheter eroding through the lateral penis and a necrotic ulcer on the lateral shaft of the penis, diffuse scrotal swelling without palpable crepitus or areas of necrosis….I covered [patient] with Vancomycin and zosyn [both powerful antibiotics] given concern for necrotizing infection of the penis, unsure whether patient will require penectomy….and patient admitted with poor prognosis.” P1’s “Hospital Discharge Summary,” dated 02/26/23 and provided to the survey team by Local Hospital 2, indicated, “Preliminary cause of death: (1) ARDS (Acute Respiratory Distress Syndrome), (2) Severe sepsis due to Balanitis – gas gangrene/necrotic erosive, and (3) Diabetes, Hypertension, History of Pontine CVA (stroke).” During an interview with P1’s family member/primary caretaker (F1) on 09/11/23 at 10:04 AM, he/she confirmed P1 had never been seen by anyone from nursing services during [P1’s] admission to the HHA. F1 stated, “They (the home health agency) stated they were waiting on Medicaid (insurance) approval to get home health nursing coverage…..We got [P1] enrolled to [name of home health agency] and the doctor came out to do an admission with the nurse and then no one ever came out to do any nursing care….. I was left to care for all this myself and I am not a medical person.” F1 indicated he/she was not comfortable providing care for P1’s catheter, stating, “[P1] was released [from the hospital] with a catheter and we (family) don’t know what to do with a catheter.” F1 indicated he/she had been told, by a hospital nursing staff member, to empty the urine out of P1’s catheter bag and note the color and amount, and F1said that was what he/she had been doing. During an interview with P1’s family member (F2) on 09/12/23 at 8:20 AM, he/she indicated he/she was a frequent visitor to P1, but lived in a different state and so was only able to provide limited assistance with P1’s care when he/she was in town. He/She stated, “My [P1] had a lot of needs physically. [P1] needed so much help. [P1] was bedridden. When they released [P1] from the hospital, I did not leave that Island (for a while) because they left us stranded. It was just terrible. We did not have to go through all this. They left no instructions for [P1’s] catheter. My [F1] asked them, What I am I supposed to do with catheter?” F2 indicated he/she was in town and was attempting to assist F1 with P1’s care at home when [P1] was admitted to home health services. F2 stated, “I took care of [P1] during that time. [P1] was complaining the tip of [P1’s] penis was hurting, and I said, “When are these people (home health nurses) going to come to check[P1]?” F2 indicated neither he/she or F1 had received any instruction on how to care for P1’s catheter except they were told to measure P1’s output and monitor the color of [P1’s] urine. He/She stated, “My [P1] was septic when [P1] finally went into second hospital. By that time, [P1] was so damaged down there they were going to need to amputate [P1’s] penis. They needed to put in a catheter on the outside that goes straight into [P1’s] bladder (a suprapubic catheter inserted directly into the bladder through the abdomen). They had to perform surgery on [P1] right away. My [P1’s] condition started to decline severely after that. The infection was so bad it started to spread through [P1’s] body;” and “The Home Health Nurse needed to take care of the catheter and no home health nurse ever came out to do that. They were trying to finally schedule an appointment for the home health nurse to come out AFTER my [P1] was readmitted to the hospital. They (the HHA) called two days after (P1) was readmitted to do a (nursing) visit.” F2 further confirmed P1’s general/daily catheter care/cleaning was not being done by [P1’s] family members at home. F2 stated, “[P1] went without the catheter being cleaned. No one told us how to do that. [F1] would just empty the bag. That’s all [F1] instructed to do. We were not taught how to provide any care to the catheter. We did not do any care to the catheter at all;” and “We had no instruction on how to clean (the catheter) tubing or anything or we would have been doing that from the get-go.” During an interview with Registered Nurse/Case Manager (RNCM)1 on 09/14/23 at 2:40 PM, he/she confirmed the assigned RNCM routinely received the physician’s orders/referral from each patient’s hospital or primary care physician. The RNCM1 revealed the RNCM was responsible for reviewing the orders/referral to ensure referred and required care and services were being initiated/provided for each patient. RNCM1 confirmed he/she was the RNCM responsible for coordination of P1’s overall home health care and services. He/She confirmed he/she was involved in P1’s care conference meetings, along with other interdisciplinary team members, including P1’s assigned physical therapists (PT1 and PT2). RNCM1 stated as a patient’s RNCM he/she was permanently assigned to the patient and was responsible for doing supervisory visits with patients at least every two weeks in their home. RNCM1 also revealed he/she was responsible for looking over therapy (physical therapy services in P1’s case) notes and it was his/her responsibility to give input on each patient’s case related to clinical care regardless of whether nursing services were ordered for that patient or not. RNCM1 indicated although he/she was responsible for reviewing P1’s physician’s orders/referral, he/she missed the checked boxes indicating catheter care, medical transport, medical equipment, diabetes education, and counseling services that had been referred and ordered by P1’s physician. RNCM1 confirmed that by checking boxes for all these services, this indicated the services had been referred and ordered by P1’s physician. RNCM1 confirmed when the boxes for services such as “Foley Care,” “Wound Care,” or “Diabetes Education” were checked, this indicated skilled nursing services had been referred/ordered related to those specific services. RNCM1 further confirmed that since P1 had been home bound, catheter care would have been provided by nursing for P1 in his/her home since he/she would not have been able to leave his/her home to receive those services in a clinic/office setting. During an interview with Physical Therapist (PT)1 on 09/14/23 at 3:35 PM, PT1indicated they had not been the staff member to do P1’s initial visit encounter, however had been out to see P1 to provide PT. PT1 confirmed it was his/her responsibility to make referrals to other disciplines if he/she saw the need for it. He/She stated he/she did not notice P1 had an indwelling catheter when he/she was out to visit and so he/she had not passed that information on to the rest of the team. PT1 stated, “If I had known [P1] had a catheter I would have shared that with nursing because that is a nursing need.” During an interview with PT2 on 09/14/23 at 4:23 PM, he/she confirmed he/she had completed P1’s initial encounter visit. He/She stated he/she thought the initial order for P1 had been just for PT. He/She stated, “As the first person going out (to see P1) I did refer to OT and HHA for care once authorized by insurance,” but indicated he/she did not see the patient’s catheter when he/she did his/her visit, nor did he/she see anything about a catheter in P1’s record. He/She stated, “I would have referred [P1] to nursing if I knew [P1] had a catheter.” During an interview with P1’s physician (Medical Doctor (MD1) and Medical Assistant (MA1) on 09/14/23 at 4:46 PM, MD1 verified his/her orders for Home Health Care, including catheter care, in the patient’s medical record and stated, “From top to bottom, I recommended PT, OT, HHA (nurses and CNAs (Certified Nursing Assistants) and bathers and anything we could throw at [P1] to help).” MA1 indicated he/she and MD1 were aware nursing had not visited P1 as P1’s [F1] informed them nursing had not been out to visit when they did the patient’s medical visit, and indicated MA1 reached out to the HHA to find out why P1 was not receiving nursing care for [the] catheter. MA1 stated he/she refaxed the home health referral/orders twice and also called the agency to attempt to find out why nursing care and other ordered services were not being provided. MA1 stated, “I recall being upset because we love our patients and we have to coordinate care and they were not providing services.”MD1 stated, “We were under the assumption everyone was seeing this patient. Certainly nursing.” MD1 further stated, “The [F1] did not know anything about Foley care, and [F1] could not roll [P1] in the bed. MD1 stated, “The reason for the referral to nursing, in part, was because of the Foley.” The survey team attempted to interview the Nursing Supervisor during the investigation, however the nursing supervisor refused the interview. Review of the undated agency policy titled, “Skilled Nursing Services,” revealed, “Skilled Nursing Services will be provided by a Registered Nurse or a Licensed Practical/Vocational Nurse under the supervision of a Registered Nurse and in accordance with a medically approved Plan of Care (Physician’s Orders). In determining whether a service required the skills of a Nurse, the inherent complexity of the service, condition of the client, and accepted standards of medical and nursing practice will be considered.”