Mcangel Home Visiting Nurses, LLC

“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 an agency policy and interview with agency personnel, for one of three patients (Patient #3) who required wound care, the agency’s licensed personnel failed to measure wounds in accordance with agency policy. The findings include: Patient #3 had a start of care date of 02/07/2024 and diagnoses that included hypertension, type II DM and a venous statis ulcer to the left ankle. The physician’s orders for the certification periods of 04/07/2024 through 06/05/2024 included nursing services three times per week for nine weeks for assessments and wound care to the left ankle. Interview and review of Patient #3’s clinical record with the Supervisor of Clinical Services (SCS) on 05/23/2024 at 11:40 AM, identified the venous statis ulcer to the Patient’s left ankle was diffuse making the wound difficult to measure, therefore, no measures were obtained during the certification period in accordance with the agency’s policy.”

“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, review of agency policies and interview with agency personnel, for one of two patients (Patient #6) requiring weight monitoring for a diagnosis of congestive heart failure, and/or for one of one patient (Patient #7), requiring nephrostomy care, the agency nurses failed to ensure the plan of care addressed the patient’s individual needs and pertinent interventions. The findings include: Patient #6 had a start of care date of 12/01/23 and diagnoses that included hypertensive heart disease with heart failure. The physician’s orders dated 12/01/23 included nursing services once weekly for nine weeks for assessments. Interview and review of the physician’s certified plan of care dated 12/01/23 with the SCS on 5/23/24 at 12:45 PM failed to identify communication with the physician for the need for/frequency of weight monitoring and parameters for reporting abnormal findings to the physician. 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. Review of agency policy for Congestive Heart Failure directed in part to record weight daily to monitor for sudden weight gain indicative of fluid retention. Patient #7 had a start of care date of 10/09/2023 and diagnoses that included retention of urine, enlarged prostate, hydronephrosis and renal failure. The physician’s orders for the certification period of 02/06/2024 through 04/05/2024 included nursing services once per week for nine weeks for assessments and management of Nephrostomy tubes (tubes that allow urine to drain from the kidney). Review of Patient #7’s plan of care interventions dated 02/02/2024, indicated the nurse was to instruct/teach the patient or caregiver Urostomy Care and Management Review of Patient #7’s nursing notes dated 02/07/2024, 02/09/2024, 02/23/2024, 02/27/2024 and 03/13/2024 identified the nurse changed the bilateral nephrostomy tube dressings and flushed each tube with 10 ml (milliliter) of normal saline. Interview and review of Patient #7’s clinical record with the Supervisor of Clinical Services (SCS) #1 on 05/23/2024 at 11:50 AM, identified the Patient had bilateral Nephrostomy tubes, not a Urostomy. SCS #1 failed to identify the Patient’s plan of care interventions included instructing/teaching the patient or caregiver Nephrostomy care/management, the frequency of tube flushes and amount of normal saline required for the flushes. Review of the agency’s Admission Criteria policy, identified the agency would establish and maintain each patient accepted for care and the clinical record would include plan of treatment, plan of care or plan for personal care services in its entirety.”

“Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). 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 two of eight patients (Patient’s #2 and #4) in the survey sample, the agency Registered Nurse/RN failed to supervise the care provided by the Licensed Practical Nurse/LPN. The findings include: Patient #2 had a start of care date of 10/03/22 and diagnoses that included pneumonia, bronchiectasis, hypertension and myoneural disorder. Physician’s orders for the certification period of 4/15/24 to 6/13/24 included nursing services one time a week for assessments and home health aide services one time a week for assistance with personal care. Interview and review of the weekly nursing notes from 4/15/24 to 5/21/24 (six visits) with the SCS on 5/23/24 at 12:50 PM identified that LPN #1 conducted the weekly visits, and failed to identify a nursing visit by the RN at least every thirty days to monitor and evaluate the LPN’s performance. Patient #4 had a start of care date of 2/27/23 and diagnoses that included gastrointestinal hemorrhage, chest pain and type II diabetes mellitus. Physician’s orders for the certification period of 4/22/24 to 6/20/24 included nursing services one time a week for assessments and home health aide services three times a week for assistance with personal care. Interview and review of the weekly nursing notes from 4/22/24 to 5/20/24 (five visits) with the SCS on 5/23/24 at 1:00 PM identified that LPN #1 conducted the weekly visits and failed to identify a nursing visit by the RN at least every thirty days to monitor and evaluate the LPN’s performance. Review of agency policy for Nurse Supervision directed that LPN’s will be supervised at least every thirty days by an RN in the patient’s home with or without the LPN present.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. 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 three of four patients (Patient’s #1, #2 and #4) who received skilled nursing services along with home health aide services, the agency Registered Nurse/RN failed to provide onsite supervisory visits no less frequently than every 14 days. The findings include: Patient #2 had a start of care date of 10/03/22 and diagnoses that included pneumonia, bronchiectasis, hypertension and myoneural disorder. Physician’s orders for the certification period of 4/15/24 to 6/13/24 included nursing services one time a week for assessments and home health aide services one time a week for assistance with personal care. Interview and review of the clinical record from 4/15/24 to 4/21/24 (five weeks) with the SCS on 5/23/24 at 12:55 PM identified that LPN #1 conducted the weekly visits and failed to identify an onsite supervisory visit to Patient #2 by the RN every 14 days. Patient #4 had a start of care date of 2/27/23 and diagnoses that included gastrointestinal hemorrhage, chest pain and type II diabetes mellitus. Physician’s orders for the certification period of 4/22/24 to 6/20/24 included nursing services one time a week for assessments and home health aide services three times a week for assistance with personal care. Interview and review of the clinical record from 4/17/24 to 5/22/24 with the SCS on 5/23/24 at 1:05 PM identified that the RN conducted a home health aide supervision on 4/17/24, LPN #1 conducted the weekly visits thereafter, and failed to identify an onsite supervisory visit to Patient #4 by the RN every 14 days (a period of thirty-five days). Review of the agency policy for Home Health Aide Supervision directed home health aides will be supervised at least every 14 days by an RN on site. Patient #1 had a start of care date of 05/27/2023 and diagnoses that included mild cognitive impairment, hypertensive heart disease with heart failure, and chronic atrial fibrillation. The physician’s orders for the recertification period of 03/22/2024 to 05/20/2024 included nursing services once per week for nine weeks for nursing assessments and home health aide services for four hours per week for assistance with activities of daily living. Interview and review of the Patient #1’s clinical record with the Supervisor of Clinical Services (SCS) #1 on 05/23/2024 at 11:30 AM, identified one home health aide supervision occurred during a sixty-day period and failed to identify supervisory visits no less frequently than every two weeks.”