Every finding on record at Total Nursing Svcs Inc

During the recertification survey conducted on 05/05/2025 to 05/08/2025 at Total Nursing Services Inc., a Home Health Agency, Emergency Preparedness was reviewed. Total Nursing Services Inc. is in compliance with Emergency Preparedness per Code of Federal Regulations (CFR) 42, Part 484.22, Condition of Participation for Home Health Agencies.

A recertification survey was conducted on 05/05/2025 to 05/08/2025 at Total Nursing Services Inc. The home health agency was in non-compliance with 42 CFR (Code of Federal Regulations) 484 Subpart A-C, Requirements for Home Health Agencies.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on record review, interview and direct observation the agency failed to provide infection control on 1 out of 3 Sampled Patients (SP) during home visits. SP #4. Findings Include: A home visit of Sample Patient (SP) #4 was conducted on 05/07/2025 with Administrator and field nurse//LPN Staff K. At 12:18pm the surveyor observed staff K removed used gloves and dispose of them in garbage and put on new gloves without sanitizing hands. Staff K proceeded to cleanse the wound with Normal Saline Solution, he then reached into the container that had clean supplies and took a bottle of betadine solution and poured that over the patient's wound, then he reached into the container and grabbed wrapped sterile 4X4 gauze pads in individual packages and grabbed 2 and opened them and then dabbed the wound to wipe off extra betadine solution. He then reached into the supply box and took out a package of sterile Q-Tips, opened up the end of that package and then took them out and put betadine on the tips and dabbed that on top of the wound. He then reached again into the box of supplies, grabbed a wrapped package of Kerlix gauze opened it up and wrapped the wound and then went into the supply box and got tape to wrap the Kerlix with, all this time using his soiled dirty gloves to reach into the box and remove supplies and place them on the wound. At the same time staff K was cleansing the wound with Normal Saline Solution some had spilled onto the floor and when he was cleaning up, he didn't notice the liquid on the floor and the administrator had to advise him of such and then the administrator got paper towels to wipe up the liquid on the floor to prevent the patient from slipping and falling. Interview with the administrator on the ride back to the office 05/07/2025 at 12:50pm from the SP #4 home she confirmed she saw all the things happen during the wound care that was written about above. She expressed that Staff K was a physician in his own country but here in the United States has been an LPN for at least 10 years, and possibly he wasn't used to having nurses question the way he is providing care. She also expressed sometimes the staff get "sloppy" in the way they perform wound care.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review, direct observation and interview the agencies staff failed to follow the orders written in 1 out of 3 Sampled Patients (SP). SP #4. Findings Include: Home visit was performed on Sample Patient (SP) #4 05/07/2025 between 12:05pm and 12:40pm. Record review of SP#4 Plan of Care orders include every visit for the skilled nurse to perform vital signs. This includes Complete head to toe assessment, Temperature, Pulse, Respiratory Rate and Heart Rate. The surveyor observed staff K take the patients' blood pressure and temperature. No other vital signs were obtained during this visit. Head to toe assessment were not performed either. Staff K went from taking temperature and blood pressure to the wound care but did no other assessment. Interview with the Administrator on the car ride home from the home visit at 12:45pm, she agreed that only part of the vital signs was conducted, and no head-to-toe assessment was done either.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency is unable to demonstrate a completed termination summary, including the type of services being provided, frequency of services, lab data (as applicable) and medication list at the time of discharge for 2 out of 5 Sampled Patients (SP). SP #1 and SP #2. Findings Include: Closed record reviews of Sample Patients (SP) #1 and #2 were conducted on 05/05/2025 to 05/08/2025. The clinical record for SP #1 contained a discharge summary from the agency with a discharge date of 04/12/2025; and SP #2 contained a discharge summary from the agency with a discharge date of 04/04/2025. The discharge summaries of SP #1 and SP #2 omitted information such as type of services being received, frequency of services, Lab data (as applicable) and medications at the time of discharge. Interview conducted on 05/08/2025 between 11:45am and 12:15pm with the Administrator and 2 office staff, they acknowledge the summaries for SP #1 and SP #2 were incomplete, missing the required notations as previously mentioned.

During the recertification survey conducted on 02/28/2022 to 03/02/2022 at Total Nursing Services, Inc., a Home Health Agency, Emergency Preparedness was reviewed. Total Nursing Services, Inc. is in compliance with Emergency Preparedness per Code of Federal (CFR) 42 Part 484.102, Condition of Participation for Home Health Agencies.

A recertification survey was conducted on 02/28/2022 to 03/02/2022 at Total Nursing Services, Inc. The home health agency was in non-compliance with 42 CFR 484 Subpart A-C, Requirements for Home Health Agencies.

Patient's or legal representative's signature CFR(s): 484.50(a)(2) Obtain the patient's or legal representative's signature confirming that he or she has received a copy of the notice of rights and responsibilities. This ELEMENT is not met as evidenced by: Based on record review and interview, the provider failed to demonstrate it had obtained the patient's or legal representative's signature confirming that he or she has received a copy of the notice of rights and responsibilities for 1 out of 12 Sampled Patients (SP). SP#4 Findings include: Clinical record review conducted on 02/28/22 of SP#4 revealed a start of care date 02/10/2021. Review of the clinical record contained a Plan of Care that revealed the patient lives at an assisted living and retirement facility (ALF). Further review revealed the Client Service Agreement signed and dated 02/10/2021 with notation under “relationship of authorized representative” reads “Staff”. During an interview conducted with the Administrator and Director of Nursing on 03/02/22 at 2:45 PM, the Administrator confirmed that the signature on the service agreement form is of the caregiver at the ALF facility and not a patient's legal representative. The Director of Nursing acknowledged that sometimes the SP#4 can sign for the visit time record sheet.

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: Based on record review and interview, the provider failed to demonstrate that 3 out of 10 (Staff D, G, and I) active staff received annual in-service on infection control. Findings include: Record review revealed that the provider conducted an annual infection control education in-service on 2/18/21, 4/22/21, 6/22/21, 7/16/21, 9/21/21 and 12/01/21. Documentation review revealed no documentation to show that Staff D G and I participated in an annual in-service infection control for the year 2021. Further review of the active staff list provided by provider revealed that not all staffs actively/providing care have received training 2021. On 03/02/22 at approximately 2:43 PM, the Administrator and Director of Nursing acknowledged that not all the active staff have participated in annual infection control in-services. Review of the provider’s policy and procedures titled “5.4 Infection Control Education/Training” reads “1. All employees and, as indicated, patients/caregivers will be trained…. 2. Employee education shall occur at the time of employment, within 30 days of when changes occur and on an annual basis.”

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on record review and interview, the provider failed to maintain the content of a clinical record that includes services rendered by the home health agency staff for 1 out of 12 Sampled Patients (SP). SP#3 Findings include: Clinical record review of SP#3 conducted on 02/28/22 showed the patient was admitted to service on 01/22/22 and the Plan of Care for certification period 01/22/22 to 03/22/22 reads "Physical Therapy (PT): 1wk1 (one time for one week), 2wk4 (twice a week for four weeks) and “HHA (Home Health Aide): 3wk4 (three times a week for four weeks)." Further review of the record contained a physical therapist note last dated 02/10/22 and the home health aide note last dated 02/04/22. Interview conducted on 02/28/22 at 1:37 pm with the office clerk/staff confirmed that HHA and PT have not submitted notes and confirmed last notes in clinical record are as of 02/04/22 and 02/10/22.