Totalcare Homecare

“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 clinical record reviews, review of agency policies and interviews with agency personnel, for one of three patients (Patient #1) requiring medication pre-pouring and/or administration, the agency nurses failed to follow agency policies. The findings include: Patient #1 had a start of care date of 10/10/19 and diagnoses that included type II diabetes mellitus, osteoporosis and pervasive developmental disorder. The physician’s orders for the certification periods of 7/15/24 to 11/11/24 included nursing services once weekly for pre-pouring of medications and assessments including weekly vital signs, systems assessment and review of the patient’s blood sugar log during visits. Interview and review of LPN #1’s nursing notes dated 7/19/24 and 8/06/24 and LPN #2’s nursing note dated 9/05/24 with RN #1 on 11/04/24 at 1:15 PM identified the weekly pre-pouring of the patient’s medications but failed to identify documentation of the interval of medications and the medications pre-poured during the nursing visit according to agency expectations. Review of the agency Medication Setup Entry training tool directed to document medication setup entries which must be made via the “Medication Profile” button in the visit/form.”

“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 clinical record reviews, review of agency policies and interviews with agency personnel, for one of three patients (Patient #1) requiring medication management, the agency nurses failed to follow physician’s orders and failed to ensure the plan of care addressed the patient’s individual needs. The findings include: Patient #1 had a start of care date of 10/10/19 and diagnoses that included type II diabetes mellitus, osteoporosis and pervasive developmental disorder. The physician’s orders for the certification periods of 7/15/24 to 11/11/24 included nursing services once weekly for pre-pouring of medications and assessments including weekly vital signs, systems assessment and review of the patient’s blood sugar log during visits. Physician orders included Humalog Insulin 100 units/milliliter (u/ml) inject 6 units subcutaneously three times a day and Trulicity Insulin 1.5 milligrams/0.5 (mg/ml), inject 1 ml subcutaneously every week i. Interview and review of the plans of care dated 7/15/24 and 9/13/24 with the State Director of Operations/RN #1 on 11/04/24 at 11 AM identified that the patient self-administers both insulins, but failed to ensure the plans of care identified the self-administration of both insulins, and failed to identify the day of the week the Trulicity insulin was to be administered. Patient #1’s medications for pre-pouring included Bupropion Hydrochloride Extended Release (an antidepressant) 150 mg once daily, Diazepam (an anxiolytic) 2 mg tablet, 3 mg/1.5 tablets every 8 hours, Divalproex Sodium Delayed Release 500 mg, 2 tablets twice a day with food for migraines, Quetiapine Fumarate Extended Release (manages mood) 400 mg at bedtime and Quetiapine Fumarate 300 mg in the morning. On 7/16/24, LPN #1 identified pre-pouring some of the medications, but failed to identify Bupropion Hydrochloride, Diazepam and Quetiapine Fumarate 300 mg, for bedtime were pre-poured, and failed to reorder the medications that were unavailable for pre-pouring, and failed to follow physician’s orders. On 7/23/24, the Administrator/RN #2 identified pre-pouring some of the medications, but failed to identify Diazepam and Divalproex Sodium were pre-poured, and indicated that refills for both the medications were needed. RN #2 attempted to call two pharmacies for refills, but needed to leave a voicemail, and failed to follow physician’s orders. On 7/31/24, LPN #1 identified pre-pouring some medications, but failed to identify Divalproex Sodium was pre-poured, and failed to reorder the medications unavailable for pre-pouring, and failed to follow physician’s orders. On 8/13/24, LPN #1 identified pre-pouring some medications but failed to identify Bupropion Hydrochloride, Diazepam, Divalproex Sodium and Quetiapine Fumarate 300 mg at bedtime were pre-poured, failed to reorder the medications unavailable for pre-pouring and failed to follow physician’s orders. ii. Interview and review of RN #2’s nursing note and LPN #1’s nursing notes with RN #1 on 11/04/24 at 1 PM identified that on 9/15/24, LPN #1 received written counseling on the medication errors and indicated that the nursing staff failed to reorder/pick up the necessary medications missing and failed to follow physician’s orders. iii. Interview and review of the clinical record from 7/16/24 to 10/23/24 with RN #1 on 11/04/24 at 1:30 PM failed to identify a weekly nursing visit for pre-pouring of medications for the week of 8/18/24 to 8/24/24, failed to identify a follow up weekly visit which should have been scheduled on 8/27/24 but not completed until 8/30/24, and failed to follow the physician’s-certified plan of care. iv. Interview and review of the clinical record from 7/16/24 to 10/23/24 with RN #1 on 11/04/24 at 1:30 PM failed to ensure a weekly visit occurred after the 10/15/24 visit (due on 10/22/24) but not completed until 10/23/24, and failed to follow the physician’s-certified plan of care. Review of the agency policy for Plan of Care directed that the plan of care includes patient specific interventions and education, measurable outcomes and goals identified by the agency and patient.”

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on clinical record reviews, review of agency policies and interviews with agency personnel, for one of three patients (Patient #1) requiring medication management and blood glucose monitoring, the agency’s nurses failed to provide the necessary assessments. The findings include: Patient #1 had a start of care date of 10/10/19 and diagnoses that included type II diabetes mellitus, osteoporosis and pervasive developmental disorder. The physician’s orders for the certification periods of 7/15/24 to 11/11/24 included nursing services once weekly for pre-pouring of medications and assessments including weekly vital signs, systems assessment and review of the patient’s blood sugar log during visits. Interview and review of the weekly nursing notes dated 7/16/24 through 8/13/24, 10/15/24 and 10/23/24 with RN #1 on 11/04/24 at 1:30 PM, failed to identify the licensed personnel evaluated vital signs, and failed to evaluate blood glucose levels in accordance with the physician’s certified plan of care. Review of agency policy for Patient Assessments directed to collect data for current health status, psychosocial, functional and cognitive status, medical, nursing, rehabilitative, social and discharge planning needs.”

“Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This Element is not met as evidenced by: G 718 Based on clinical record reviews and interviews with agency personnel, for one of three patients (Patient #1) in the survey sample, the agency nurses failed to communicate with the physician involved in the plan of care. The findings include: Patient #1 had a start of care date of 10/10/19 and diagnoses that included type II diabetes mellitus, osteoporosis and pervasive developmental disorder. The physician’s orders for the certification periods of 7/15/24 to 11/11/24 included nursing services once weekly for pre-pouring of medications and assessments including weekly vital signs, systems assessment and review of the patient’s blood sugar log during visits. Patient #1’s medications for pre-pouring included Bupropion Hydrochloride Extended Release (an antidepressant) 150 mg once daily, Diazepam (an anxiolytic) 2 mg tablet, 3 mg/1.5 tablets every 8 hours, Divalproex Sodium Delayed Release 500 mg, 2 tablets twice a day with food for migraines, Quetiapine Fumarate Extended Release (manages mood) 400 mg at bedtime and Quetiapine Fumarate 300 mg in the morning. On 7/16/24, LPN #1 identified pre-pouring some of the medications, but failed to identify Bupropion Hydrochloride, Diazepam and Quetiapine Fumarate 300 mg for bedtime were pre-poured, and failed to notify the physician of the unavailability of the medications to be pre-poured. On 7/23/24, the Administrator/RN #2 identified the pre-pouring of Bupropion Hydrochloride and Quetiapine medications, but failed to identify Diazepam and Divalproex Sodium were pre-poured, and indicated that refills for both the medications were needed. RN #2 attempted to call two pharmacies for refills, but needed to leave a voicemail, and failed to notify the physician of the unavailability of the medications to be pre-poured during the nursing visit and failed to identify a follow up call to the pharmacy and/or visit was scheduled for pre-pouring the medications needing reordering. On 7/31/24, LPN #1 identified pre-pouring some of the medications, but failed to identify Divalproex Sodium was pre-poured, and failed to notify the physician of the unavailability of the medications to be pre-poured. On 8/13/24, LPN #1 identified pre-pouring some medications, but failed to identify Bupropion Hydrochloride, Diazepam, Divalproex Sodium and Quetiapine Fumarate 300 mg at bedtime were pre-poured, and failed to notify the physician of the unavailability of the medications to be pre-poured. Interview and review of the weekly nursing notes dated 7/16/24 through 8/13/24 with RN #1 on 11/04/24 at 1:40 PM failed to identify physician notification of the medications omitted during the pre-pour process.”

“Make patient and personnel assignments, CFR(s): 484.105(c)(1) Making patient and personnel assignments, This Element is not met as evidenced by: Based on clinical record reviews and interviews with agency personnel, for one of three patients (Patient #1) in the survey sample, the Clinical Manager failed to provide oversight of all patient care services and personnel related to patient assignments. The findings include: Patient #1 had a start of care date of 10/10/19 and diagnoses that included type II diabetes mellitus, osteoporosis and pervasive developmental disorder. The physician’s orders for the certification periods of 7/15/24 to 11/11/24 included nursing services once weekly for the pre-pouring of medications and assessments which included weekly vital signs monitoring, systems assessments, and review of the patient’s blood sugar log during visits. i. Interview and review of the clinical record from 7/16/24 to 10/23/24 with RN #1 on 11/04/24 at 1:30 PM failed to identify a weekly nursing visit for the pre-pouring of medications for the week of 8/18/24 to 8/24/24 (as evidenced by a grey block denoted in the record on 8/20/24 where the visit should have been scheduled and assigned), and failed to identify a follow up weekly visit was performed for the week of 8/18/24 to 8/24/24, which should have been scheduled on 8/27/24, but was not completed until 8/30/24, and failed to ensure oversight of patient care and personnel assignments by the Clinical Manager for a patient requiring weekly pre-pouring of medications. ii. Interview and review of the Clinical Manager’s visit note dated 10/15/24 with RN #1 on 11/04/24 at 1:30 PM, identified the pre-pouring of medications until 10/22/24 and indicated Divalproex was called into the pharmacy although, review of the subsequent visit note dated 10/23/24 indicated that only 5 days of Divalproex was available and the nursing staff needed to reorder the medication. Subsequently, RN #1 indicated that the Clinical Manager did not go to the pharmacy to pick up the Depakote and failed to notify the next of kin of the medication refill needed. iii. Interview and review of the Clinical Manager’s visit note dated 10/15/24 with RN #1 on 11/04/24 at 1:30 PM failed to ensure the scheduling of the next nursing visit (7) seven days following the completed 10/15/24 visit, (next visit was due on 10/22/24 per the physician order), but was not scheduled and completed until 10/23/24, and the agency failed to ensure supervisory oversight of patient care and personnel assignments by the Clinical Manager for a patient requiring weekly pre-pouring of medications. Per RN # 1 the Clinical Manager was terminated for failing to maintain supervisory oversight for the assurance of patient safety.”

“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 clinical record review, review of agency policies and interview with agency personnel, for two of four patients (Patient’s #4 & #6) requiring medication pre-pouring and/or administration, and for one of one patient (Patient #8) requiring wound care, the agency nurses failed to follow agency policies. The findings include: a. Patient #4 had a start of care date of 12/12/22 with diagnoses that included end stage renal disease, type II diabetes mellitus, hypertension and dependence on renal dialysis. The initial assessment identified the presence of a left arm arterio-venous fistula. The physician’s orders for the certification period of 8/03/24 to 10/01/24 included nursing services two times per week for six weeks for pre-pouring of medications weekly, monitoring blood glucose levels and assessments. Physician’s orders included Lyrica (a Schedule V Controlled substance used to treat nerve pain) 75 milligrams/mg once a day, and 75 mg daily at bedtime on Tuesday, Thursday and Saturday (dialysis days). Interview and review of the clinical record from 8/07/24 to 8/21/24 with the Administrator on 8/27/24 at 12:30 PM failed to identify a Controlled Substance Form was utilized for the pre-pouring of Lyrica, a Schedule V Controlled Substance. b. Patient #6 had a start of care date of 2/23/24 and diagnoses that included epilepsy and cerebral infarction. The physician’s orders for the certification periods of 4/20/24 to 8/20/24 included nursing services once weekly for pre-pouring of medications and assessments. Physician’s orders included Clobazam (a Schedule IV Controlled substance used to treat seizure activity) 10 mg tablet, take 5 mg daily at bedtime. Interview and review of the clinical record from 2/23/24 to 7/05/24 with the Administrator on 8/27/24 at 12:35 PM failed to identify a Controlled Substance Form was utilized for the pre-pouring of Clobazam, a Schedule IV Controlled Substance. Interview and review of Registered Nurse/RN #1’s nursing note dated 6/26/24 with the Administrator on 8/27/24 at 12:35 PM identified the weekly pre-pouring of the patient’s medications, but failed to identify documentation of the medications pre-poured during the nursing visit according to agency expectations. Review of the agency policy for Medication Documentation directed for controlled substances being accessed by a clinician for medication administration and/or set-up, the clinician will maintain a controlled substance record and count medications during the visit when medication is being accessed and document findings, including staff initial and date and time of count. Review of the agency Medication Setup Entry training tool directed to document medication setup entries which must be made via the “Medication Profile” button in the visit/form. c. Patient #8 had a start of care date of 4/25/24 and diagnoses that included hidradenitis suppurativa. The physician’s orders for the certification periods of 6/24/24 to 10/21/24 included nursing services seven times a week for wound care to the right axilla and across the back and weekly wound measurements. Interview and review of the clinical record from 6/24/24 to 8/23/24 (eight weeks) with the Administrator on 8/27/24 at 1:30 PM, failed to identify wound measurements in four out of eight weeks and failed to follow agency policies requiring weekly wound measurements. Review of the agency policy for Wound Assessment and Documentation directed clinical staff to assess wounds at least weekly.”

“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 clinical record review and interview with agency personnel, for one of four patient’s (Patient #6) requiring medication management, and/or for one of one patient (Patient #8) requiring wound care, the agency nurses failed to follow physician’s orders and failed to ensure the plan of care addressed the patient’s individual needs. The findings include: Patient #6 had a start of care date of 2/23/24 and diagnoses that included epilepsy and cerebral infarction. The physician’s orders for the certification periods of 4/20/24 to 8/20/24 included nursing services once weekly for pre-pouring of medications and assessments. Interview and review of Registered Nurse/RN #1’s nursing notes dated 5/30/24 and 6/26/24, and RN #2’s nursing note dated 6/11/24 with the Administrator on 8/27/24 at 1:15PM, identified the pre-pouring of medications for two weeks at a time and failed to follow physician’s orders which directed to pre-pour medications weekly. b. Patient #8 had a start of care date of 4/25/24 and diagnoses that included hidradenitis suppurativa. The physician’s orders for the certification periods of 6/24/24 to 10/21/24 included nursing services seven times a week for wound care to the right axilla and across the back and weekly wound measurements. Interview and review of the wound care orders dated 6/24/24 and 8/23/24 with the Administrator on 8/27/24 at 1:20 PM, identified twice daily wound care using quarter strength Dakin’s solution packed into the right axilla wound, and a damp to dry dressing, and failed to ensure the care plan addressed wound care once daily as ordered. Interview and review of the clinical record from 6/24/24 to 8/23/24 (eight weeks) with the Administrator on 8/27/24 at 1:30 PM, failed to identify wound measurements in four out of eight weeks and failed to follow physician’s orders.”

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on review of the clinical record, review of agency policies and interview with agency personnel, for one of one patient (Patient #4) with an arterio-venous fistula (AVF) for hemodialysis treatment who required blood glucose monitoring, the agency’s nurses failed to provide the necessary assessments. The findings include: Patient #4 had a start of care date of 12/12/22 and diagnoses that included end stage renal disease, type II diabetes mellitus, hypertension and dependence on renal dialysis. The initial assessment further identified the presence of a left arm arterio-venous fistula. The physician’s orders for the certification period of 8/03/24 to 10/01/24 included nursing services two times per week for six weeks for pre-pouring of medications weekly, monitoring blood glucose levels and assessments. Interview and review of Licensed Practical Nurse (LPN) #1’s nursing note dated 8/09/24 and LPN #2’s nursing note dated 8/16/24, with the Administrator on 8/27/24 at 12:30 PM, failed to identify LPN’s #1 and #2 evaluated Patient #4’s left arterio-venous fistula for the presence of bruit and thrill and failed to evaluate blood glucose levels. Review of the agency policy for Patient Assessments directed to collect data for current health status, psychosocial, functional and cognitive status, medical, nursing, rehabilitative, social and discharge planning needs. Furthermore, the Administrator failed to identify agency policies and procedures on the assessment of arterio-venous fistulas and/or other implanted hemodialysis accesses.”

“Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This Element is not met as evidenced by: Based on review of agency documentation and interview with the agency personnel, the agency failed to ensure the alternate administrator was hired by the agency and available for all day-to-day operations of the Home Health Agency/HHA and actively involved in the daily responsibilities of running the HHA in the absence of the Administrator. The findings include: During the entrance conference on 8/26/24 at 9:00 AM, the Business Manager indicated that the Administrator was unavailable for the day. At 9:45 AM, the appointed alternate Administrator arrived at the agency to assist with the survey. Further review of the agency documentation identified the appointment letter dated 8/19/24 of the alternate Administrator appointed, was identified as the present fulltime Administrator/SCS of another home health agency in the state of Connecticut.”