Every finding on record at Total Patient Care Home Health LLC

A recertification survey was conducted on 3/20/2023. The census was 406 Licensed and Certified patients. An exit conference was conducted on 4/04/2023. The agency was in compliance with 42 CFR Part 484.102, Emergency Preparedness Requirements for Home Health Agencies.

A recertification and complaint survey was conducted on 03/20/2023. The census was 406 Licensed and Certified patients. Intakes 273403 and 400273 were investigated. An exit conference was conducted on 4/04/2023. Abbreviations: CMS – Centers for Medicare/Medicaid Services HHA- Home Health Aide POC – Plan of care RN – Registered Nurse LVN – Licensed Vocational Nurse OASIS – Outcome Assessment Information Set PT- Physical Therapy / Physical Therapist OT- Occupational Therapy PTA- Physical Therapy Assistant

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on observation, record reviews and interviews the agency failed to ensure 9 patients (#1, #2, # 3, #4, #5, #6, # 7, # 8, and #9) of 17 patient records reviewed received the home health services that were written in the individualized plan of care as ordered by the physician /practitioner. Patient #1 did not receive any Occupational Therapy and less HHA service than ordered. Patient #3 and #9 did not receive the Physical Therapy services ordered. Patient #4 was not weighed per visit as ordered. Patient #5 did not receive nursing visits as ordered and was not weighed every visit as ordered. Patient #6 did not receive Occupational Therapy and did not receive weekly PT visits as ordered. Patient# 7 was not weighed per visit as ordered and had weights performed and blood pressures above the parameters ordered on the Plan of Care. Patient #8 did not receive the Occupational Therapy and health education by the nurse as ordered on the Plan of Care. These failures place patients at risk of receiving inadequate care and services when the plan of care is not followed and when the physician is not informed of the patient’s progress. Review of Patient 1’s record revealed a Plan of Care for the certification period 01/26/2022 to 03/26/22 which ordered an Occupational Therapy evaluation and treatment and Home Health Aide service twice a week for one week, three times per week for 4 weeks, and 2 times per week for 4 weeks. Review of the record revealed no OT evaluation. The HHA visits were provided one time per week for one week, and two times per week for 8 weeks. Patient 1 was transferred to hospice care on 03/26/22. Review of the record found no notification to the physician that the agency was not following the Plan of Care orders. In an interview with the Administrator / Director of Nurses on 04/03/2023 at 4:44 PM the surveyor reviewed the findings of the record review. The surveyor asked about the lack of OT evaluation and HHA visits. The Administrator / Director of Nurses stated: the twice a week HHA visits were well over the insurance authorization, and agreed there was no OT evaluation completed, and no notification to the physician. Review of Patient 3’s record revealed a Plan of Care for the certification period 11/14/22 to 01/12/23 which ordered a PT evaluation and treatment. The patient received nursing visits from 11/14/22 to 11/23/22 for wound care and was then transferred to the hospital on 11/28/22 and discharged for amputation of an infected limb. Review of the record found no PT evaluation was completed, and no notification to the physician that the agency was not following the Plan of Care orders. Review of Patient ’s 9’s record revealed a Plan of Care for the certification period 11/22/22 to 01/20/23 which stated PT goals met. The record contained an update to the plan of care via an order dated 01/04/23 which documented a verbal order by RN C as follows: “Patient requires Physical Therapy to evaluate and treat patient for balance/ strengthening / gait training. Patient with history of frequent / recent falls and requires new PT evaluation for strength and mobility.” Review of the record found no PT evaluation was completed, and no notification to the physician that the agency was not following the Plan of Care orders. In an interview with the Administrator / Director of Nurses on 04/03/23 at 4:30 PM the surveyor reviewed the findings of the record reviews for patient’s #3 and #9. The surveyor asked about the lack of PT evaluations and treatment. The Administrator / Director of Nurses reviewed the record and stated patient 9 had traditional Medicare and should have received the physical therapy and “this might be a mistake.” The Administrator / Director of Nurses responded for patient 3: “I’m sure the patient declined (and) nothing is written.” Review of Patient 4’s record revealed a Plan of Care for the certification period 03/09/23 to 05/07/23 which ordered nursing visits once a week for one week and twice a week for eight weeks, and PT to evaluate and treat. The POC ordered assessment of the patient with Paroxysmal atrial fibrillation (irregular heartbeat), hypertensive heart disease with heart failure (high blood pressure affecting heart pumping ability) and included orders for the nurse to weigh the patient each visit and report weight gain of 2 pounds per day or 5 pounds per week and to assess and notify the physician for edema of lower extremities. RN D documented a weight of 103 and two plus edema during the start of care assessment dated 03/09/23. Review of the record revealed no weights on skilled nurse notes by LVN B on 03/15/23, 03/17/23, and 03/22/23 with documentation of NA for edema. RN D documented a weight of 103 and two plus edema during the start of care assessment dated 03/09/23. PT A documented bilateral edema of lower extremities on visit notes dated 03/20/23 and 03/22/2023. Review of the record found no notification to the physician of the lower extremity edema and that the agency nurse was not following the Plan of Care orders to weight the patient each visit. In an interview with LVN B on 03/31/23 at 12:34 PM the surveyor asked about the lack of weights and edema assessment for Patient #4. LVN B stated the patient was complaining about swollen legs and feet and the nurse didn’t see it. LVN B stated they had ordered a scale. The nurse attempted and was unable to reach the PT A. During a home visit with Patient #4 on 03/24/23 at 3:00 PM the surveyor asked if LVN B weighed the patient during visits. Patient 4 replied that they “get fluid over my legs. Mostly my right leg swells. I am supposed to weigh.” The surveyor asked if the patient had a scale. Patient 4 stated she had a scale and was able to weigh. Patient 4 stated LVN B did not weigh the patient. In an interview with the Administrator / Director of Nurses on 04/03/2023 at 3:20 PM the surveyor reviewed the findings of the record review and home visit with Patient #4. The surveyor asked about the lack of weights and documentation of NA for edema. The surveyor asked about the discrepancy between the PT documenting edema on 03/22/23 and the LVN documenting NA for edema. The Administrator / Director of nurses stated Patient # 4 should have had weights done, and the NA was what the nurse used to mean no edema, and the PT should have reported the edema. Review of Patient 5’s record revealed a Plan of Care for the certification period 01/07/23 to 03/07/23 which ordered nursing visits once a week for one week and twice a week for eight weeks. The POC ordered the nurse to report weight greater than 181 and less than 171. The POC ordered the nurse to instruct the patient on daily weight self-monitoring program where the patient reports to the nurse weight gain of 2 pounds per day and / or 5 pounds per week. Review of the record revealed a 21- day gap in nursing visits with a visit on 02/01/23 with no recorded no weight for the patient, and the next nursing visit is 02/22/23 with no weight documented. The next nursing visit documented was on 03/01/23 and no weight was documented. The record contained no explanation for the missed nursing visits, and no notice to the physician that nursing visits were not occurring per the plan of care. During a home visit on 03/24/23 at 2:00 PM with Patient #5 the surveyor asked if the patient weighed daily. The patient stated the nurse weighs him. The surveyor asked if the nurses came at a preset time / day and the patient stated they did not and they call the night before they are coming. The patient said there were gaps when the nurse did not come, and he did not remember when or why. In an interview with the Administrator / Director of Nurses on 04/03/2023 at 12:19 PM the surveyor reviewed the findings of the record review and home visit with Patient 5. The surveyor asked about the lack of nursing visits and weights. The Administrator / Director of Nurses stated: “I guarantee it’s authorization (from the insurance company).” The Administrator / Director of nurses stated Patient 5 should have had weights done, and there was no additional explanation available in the record or provided to the surveyor. Review of Patient 6’s record revealed a Plan of Care for the certification period 12/08/22 to 02/05/23 which ordered PT and OT to evaluate and treat. Review of the record found a PT evaluation completed on 12/21/22 with orders for PT twice a week. Review of the record revealed a 28- day gap in PT visits with the next visit on 01/19/23 with no notification to the physician. No OT evaluation was completed and the record contained no notification to the physician. The record contained no explanation for the missed PT visits. During a home visit on 03/28/23 at 3:15 PM with Patient #6 the surveyor asked about the 28-day gap in PT visits. The patient stated that the PT told the patient they “went out of the country during that time.” The surveyor asked if the patient was offered a different therapist. The patient stated: “No.” In an interview with the Administrator / Director of Nurses on 04/03/2023 at 12:01 PM the surveyor reviewed the findings of the record review and home visit with concerning Patient #6. The surveyor asked about the lack of PT visits and the OT evaluation. The Administrator / Director of Nurses stated: “We contract PT, and they never notified the Care Manager.” The Administrator / Director of nurses stated the patient should have had the PT visits and OT evaluation offered. Review of Patient 7’s record revealed a Plan of Care for the certification period 02/14/23 to 04/14/23 which ordered nursing visits twice a week for nine weeks. The POC included orders for the nurse to assess the patient’s weigh log every visit and to report weight greater than 234 pounds or less than 224 pounds. Review of the record revealed a weight of 229 pounds recorded on the start of care assessment on 02/14/23, and a weight of 243 pounds recorded on 02/22/23 by LVN C. The nurse notes for the visits on 02/24/23 and 02/27/23 had N/A recorded for Patient #7’s weight. The POC also included orders for PT to evaluate and treat and orders to report blood pressure reading above 160/90. The PTA A visit note documented 02/20/23 documented the patient’s blood pressure as 169/95, PTA A visit note on 03/07/23 documented blood pressures of 182/101 and 174/94, and the PTA A documented blood pressures of 198/101 and 171/94 on the visit note dated 03/24/23. The record contained no evidence the weights and blood pressures were reported to the physician as ordered on the Plan of Care. During a home visit with Patient #7 on 03/27/23 at 1:30 PM the surveyor asked about the patient’s health problems. Patient 7 stated their blood pressure and weight were very high, the patient had a lot of stress, and was very upset. Patient 7 said her weight was 247 pounds. Patient 7 stated the nurse took the patient’s blood pressure, weight and pulse every visit. In an interview with the Administrator / Director of Nurses on 04/04/2023 at 11:40 PM the surveyor reviewed the findings of the record review and home visit with Patient # 7. The surveyor asked about the lack of weights and lack of notice to the physician regarding the weights and blood pressures above the parameters ordered on the Plan of Care. The Administrator / Director of Nurses reviewed the record and stated: “I think they (the nurse and the therapist) should have called the doctor.” Review of Patient 8’s record revealed a Plan of Care for the certification period 01/14/23 to 03/14/23 which ordered nursing visits once a week for nine weeks, PT and OT evaluations. The POC stated the patient was admitted to home care with a primary diagnosis of encounter for care post digestive system surgery (care after abdominal surgery), hypertensive heart disease and chronic kidney disease with heart failure (high blood pressure affecting heart and kidneys), urinary tract infection (bladder infection), hypothyroidism (low thyroid), Acute lymphoblastic leukemia (blood cancer), in remission, atrial fibrillation (irregular heart beat), atherosclerotic heart disease (heart blood vessel disease), and nutritional anemia (low blood iron). Orders for the nurse included to teach / instruct the following: pain medication / control, and nonpharmacologic pain relief measures, factors that contribute to shortness of breath, energy conservation measures, controlling stress, daily weight self-monitoring program, measures to recognize cardiac dysfunction and relieve complications, bladder training and signs and symptoms of urinary tract infection, signs and symptoms of heart attack, when to call 911, disease processes and associated medications, prevention of exacerbation, when to notify the nurse an physician, signs and symptoms and relief of constipation, aftercare for digestive system surgery including diet, medications and other measure to manage this condition, heart healthy high fiber high protein diet, fall prevention, and safety measures. Review of the weekly LVN D notes dated 01/18/23 revealed instruction on urinary tract infections, this was the same instruction documented on notes dated 01/25/23, 02/08/23, 02/16/23, 02/23/23, 03/01/23, and a missed visit was documented for 02/03/23 due to weather. All the weekly visit nurse notes were provided by LVN D and review of the notes revealed the same instruction on urinary tract infections on each note, and none of the other areas ordered on the Plan of Care. The record contained no evidence of the ordered OT evaluation or notice to the physician that the OT evaluation was not done as ordered. In an interview with the Administrator / Director of Nurses on 04/04/2023 at 11:50 AM the surveyor reviewed the findings of the record review for Patient 8. The surveyor asked about the lack of health education and OT evaluation that were ordered on the Plan of Care. The Administrator / Director of Nurses reviewed the record and stated: the lack of an OT evaluation may be insurance denial and stated “The nurse (LVN D) should not be teaching the same thing.” The Administrator / Director stated they did not find notice to the physician of the lack of an OT evaluation in the record. The surveyor left a voice mail for LVN D 03/31/23 at 4:00 PM but did not get a call back. A review of the agency policy titled Plan of Care, numbered PC.35 revised on 12102 read in part: “Each patient/client 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/client-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the Agency anticipates will occur as a result of implementing and coordinating the plan of care… Each patient/client must receive the home health services that are written in an individualized plan of care that identifies patient/client-specific measurable outcomes and goals … The individualized plan of care must be reviewed and revised by the physician and/or non-physician practitioner who is responsible for the home health plan of care and the Agency as frequently as the patient’s/client’s condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. The Agency must promptly alert the relevant physician(s), and/or non-physician practitioner(s) to any changes in the patient’s/client’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered…”

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 record review and interview, the agency failed to ensure the Plan of Care included a description of the wound care treatments provided to 2 (Patient 1 and 2) of 3 discharged patients whose records included wound care treatments by the agency staff. The wound care treatments were not included in the Plan of Care. The failure to include the wound care treatment orders on the plan of care meant the patients were subjected to a potential for delayed wound care healing and poor health outcomes. Review of the Plan of Care for Patient 1 for the certification period 01/26/2022 to 03/26/22 failed to find a description of the wound care treatments provided by the agency nursing staff. The POC ordered nursing visits twice a week for one week and 3 times per week for 8 weeks for the patient with a stage 3 pressure ulcer of the right heel. Review of the start of care nursing assessment dated 01/26/2022 revealed wound measurements of 3.5cm in length by 3.5cm in width by 0.1cm in depth by RN A and wound treatment as follows: cleaned with wound spray, “Medihoney” applied, Calcium Alginate (wound care supplies), and then Mepilex (bordered foam). Review of the nursing visit by LVN A dated 01/28/22 found wound measurements of 5cm (length) by 4.5cm (width) X 0.4cm (depth), and wound care as follows: “cleansed with normal saline and gauze, applied bordered foam dressing secured with tape and wrapped with kerlix roller gauze. Wound care orders have not been written … “ Review of nursing visits by LVN A dated 01/31/22, 02/02/22, 02/07/22, 02/09/22, 02/11/22, 02/16/22, 02/18/22, 02/23/22, 02/25/22, 02/28/22, 03/02/22, 03/04/22, 03/07/22, 03/09/22, 03/11/22, 03/14/22, and 03/16/22 documented wound measurements of 5cm by 4.5cm X 0.4cm, and wound care as follows: cleaned with normal saline and gauze, applied “Medhoney”, and bordered foam dressing secured with tape and wrapped with kerlix roller gauze. The discharge OASIS dated 03/26/22 by RN A documented Patient 1 was discharged to hospice with the wound measurements as 5cm X 4.5cm X 0.4 cm and wound care was provided as follows those documented cleaned with normal saline and gauze, applied “Medihoney,” and bordered foam dressing secured with tape and wrapped with kerlix roller gauze. The surveyor reviewed all the orders in Patient 1’s record during the certification period reviewed and found no orders for the wound care provided by the agency nurses. An interview was conducted with LVN A on 03/31/23 at 2:23 PM. The surveyor asked about the wound care treatment orders for Patient 1 and how LVN A knew what to do with a new wound. LVN A said stated they “dismantle (the current dressing) and look at what supplies were provided (to the patient) and look at what was on there (the wound) until we get the supplies, and the nurse was “not surprised about no wound care orders.” The LVN A further stated they get a text message from a scheduler to make visits to a new patient, and later the nurse receives a notice when the plan of care is ready. The LVN A stated wound orders for most patients come from a wound care clinic. Finally, LVN A stated Patient 1 had a low protein intake that LVN A felt contributed to the lack progress with the wound. An interview was conducted with the Administrator / Director of Nurses on 04/03/23 at 4:44 PM. The surveyor reviewed the findings from the record review and asked about the lack of wound care treatment orders on the Plan of Care. The Administrator / Director of Nurses reviewed the record and stated they agreed with the findings that there were no wound treatment orders on the Plan of Care and stated: “I found wound orders in referral documents, and they were not put on the Plan of Care.” A review of the Plan of Care for Patient 2 revealed a start of care of 06/06/22 with a certification period of 06/06/22 to 08/04/22. A review of the entire plan of care and all subsequent orders in the certification period failed to find a description of the wound care treatments provided by the agency nurse. The POC ordered nursing visits once a week for 9 weeks for the patient with a primary diagnosis of Ischemic Cardiomyopathy (irregular heart beat caused by heart damage). A nursing visits by RN B on 06/07/22 documented wound care to a left groin wound as follows: cleaned with normal saline and gauze, covered with zinc oxide cream, 4 by 4 gauze, and taped with 3- inch cloth tape. A discharge OASIS dated 06/10/22 by RN B documented Patient 2 was discharged to hospice on 06/10/22 with the wound not healed. An interview was conducted with RN B on 03/31/23. The surveyor reviewed the findings with RN B and asked about the wound care treatment orders. RN B stated that they didn’t remember this particular patient. RN B stated: “Normally we treat it (the wounds) with whatever I have and then I get an order. The office would get the order.” An interview was conducted with the Administrator/Director of Nurses on 04/03/23 at 4:00 PM. The surveyor reviewed the findings from the record review for Patient 2 and asked about the lack of wound care treatment orders. The Administrator / Director of Nurses reviewed the patient record, failed to find wound care treatment orders, and stated: “All she had to do was call the Clinical Manager. I don’t know what RN B was thinking.” A review of the agency policy titled Plan of Care, numbered PC.35 revised on 12102 read in part: “Each patient/client 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/client-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the Agency anticipates will occur as a result of implementing and coordinating the plan of care. A. The individualized plan of care must include the following: … The types of services, supplies, and equipment required; … All medications and treatments… All patient/client care orders, including verbal orders, must be recorded in the plan of care.”