Guardian Angel Home Health, Inc.

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on interview, record review, and policy review, the agency failed to conduct an initial assessment visit within 48 hours after receiving a referral to provide services for 1 (Patient #1) of 10 patients. This failure had the potential for the patient to not receive needed assessments and home care services and could have negatively impacted Patient #1’s health. The agency undated policy titled, “Admissions and Discharges,” revealed, “Admissions. Any patient admitted will be assessed by a qualified staff member (RN [Registered Nurse], PT [Physical Therapist], OT [Occupational Therapist], ST [Speech Therapist]) at the start of care, within 48 hours of the referral being received.” A “Fax Cover,” dated 05/21/2024, revealed a referral order for Patient #1 with a requested start date of 05/21/2024. Patient #1’s “Home Health Certification and Plan of Care,” dated 05/29/2024, revealed the start of care date was 05/24/2024 and a certification period of 05/24/2024 to 07/22/2024. According to the Home Health Certification and Plan of Care, Patient #1 had a medical history that included diagnoses of hemiplegia following cerebral infarct affecting the right dominant side (muscle paralysis after a stroke), chronic atrial fibrillation (irregular heartbeat), and unspecified diastolic (congestive) heart failure (when the heart muscle does not effectively pump blood). During an interview on 07/15/2024 at 3:48 PM, the Director of Nursing stated the agency expectation was to start care within 48 hours of receiving a referral for services, but sometimes the agency did not meet that time frame.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on observation, interview, record review, and agency policy review, the agency failed to provide wound care treatment as ordered by a physician for 1 (Patient #3) of 10 patients reviewed. Specifically, the agency nurses failed to review Patient #3’s plan of care (POC) prior to their visits, and thereby failed to identify a change in wound treatment orders. This failure resulted in Patient #3 not receiving the new ordered wound care treatment. An agency policy titled, “Job Description for Registered Nurse (RN),” revised 06/21/2024, revealed, “Skilled nursing services are performed in accordance with a physicians POC [plan of care] and under the direct supervision of a qualified nursing supervisor.” Patient #3’s “Home Health Certification and Plan of Care,” dated 06/26/2024, revealed the start of care was 01/02/2024 and a certification period of 06/30/2024 to 08/28/2024. According to the Home Health Certification and Plan of Care, Patient #3 had a medical history that included diagnoses of pressure ulcer of sacral region, stage 4 (a wound in the buttocks caused by pressure or friction that involves fat tissue and muscles), multiple sclerosis (a disease in which the immune system attacked the protective covering of nerves), and functional quadriplegia (the complete inability to move caused by another medical condition). Further review of the Home Health Certification and Plan of Care revealed, orders and treatments included skilled nurse (SN) to change dressing with each SN visit. The wound care treatment order instructed the nurse to remove the previous dressing from the patient’s sacral wound, cleanse the wound with wound wash and gauze, allow the wound to dry before applying skin prep to the skin surrounding the wound, then apply collagen ag (a treatment to help heal deep wounds) activated by one to two drops of sterile normal saline to the wound, followed by Hydrofera Blue Ready (a treatment that protected a wound from bacteria), a half of a piece of calcium alginate (a treatment that reduced wound drainage), and cover the wound with 6x6 bordered foam dressing (a dressing that protected skin from irritation from wound drainage). During a concurrent interview and observation conducted in Patient #3’s bedroom on 07/12/2024 at 11:35 PM, RN #1 stated she would be observing RN #2 complete Patient #3’s sacral wound care treatment. Patient #3’s family member (FM) stated the patient’s physician changed Patient #3’s sacral wound care order, had added Nasacort spray (a medication that decreased inflammation) and nystatin powder (a medication that reduced fungal growth) to be applied to the skin around Patient #3’s wound due to increased skin redness. The FM gave the updated wound care order to RN #1 to review and stated the Nasacort was available but they did not have nystatin powder. RN #2 removed Patient #3’s previous sacral wound dressing, cleansed the wound with wound wash and gauze, allowed the wound to dry, applied Nasacort to the skin surrounding the wound, then applied collagen ag activated by one to two drops of sterile normal saline to the wound, followed by Hydrofera Blue Ready. RN #1 instructed RN #2 she had forgotten to apply a half of a piece of calcium alginate and obtained it from an area of wound supplies. RN #2 then applied the calcium alginate on top of the Hydrofera Blue Ready and applied a bordered foam dressing to the wound. RN #1 reviewed the wound care treatment order provided by the FM and stated the order was created on 07/01/2024 and the agency may not have been aware of the change in the wound care treatment before this visit. RN #1 stated she performed Patient #3’s wound care on 07/05/2024 and was unaware of the 07/01/2024 order. RN #1 confirmed the updated wound care order from 07/01/2024 included Nasacort and nystatin and stated the FM was not home during her visit on 07/05/2024 to discuss medication/treatment changes and the patient may not have remembered there was a change. RN #1 stated the agency process was the patient’s wound care clinic staff would fax any updated treatment orders to the agency. RN #1 then reviewed Patient #3’s clinical record and stated the updated wound care order from 07/01/2024 was in the patient’s clinical record and RN #2 failed to review Patient #3’s record for any new orders prior to making the visit. Patent #3’s “Physician Order Details,” dated 07/01/2024, revealed on 07/01/2024 Patient #3’s physician updated Patient #3’s wound care order to include “Apply Nasacort spray to periwound erythema [redness]. Dust with Nystatin powder.” Patient #3’s “Wound Care Worksheet,” dated 07/03/2024, revealed RN #4 completed Patient #3’s wound care treatment and documented the skin surrounding Patient #3’s sacral wound was red, but did not reveal the application of Nasacort or Nystatin to the reddened skin around Patient #3’s wound as ordered. Patient #3’s “Wound Care Worksheet,” dated 07/05/2024, revealed RN #2 completed Patient #3’s wound care treatment and documented the skin surrounding Patient #3’s sacral wound was red, but did not the application of Nasacort or Nystatin to the reddened skin around Patient #3’s wound as ordered. Patient #3’s “Wound Care Worksheet,” dated 07/10/2024, revealed RN #5 completed Patient #3’s wound care treatment and documented the skin surrounding Patient #3’s sacral wound was red but did not reveal the application of Nasacort or Nystatin to the reddened skin around Patient #3’s wound as ordered. During an interview on 07/15/2024 at 11:38 AM, RN #5 stated staff were to review the patient’s plan of care prior to the provision of patient care. RN #5 stated that when the agency office staff received a new order with changes to wound care, the office staff entered the wound care order into the patient’s record and placed a paper copy in the clinician’s mailbox. During an interview on 07/16/2024 at 10:30 AM, the Administrator stated the agency expectation was nurses were to follow all physician orders and review a patient’s care plan to ensure they provided service according to the patient’s most updated orders. The Administrator confirmed the agency had not provided Patient #3’s wound care as ordered and acknowledged the agency did not meet expectations.”

“Aides are members of interdisciplinary team CFR(s): 484.80(g)(4) Home health aides must be members of the interdisciplinary team, must report changes in the patient’s condition to a registered nurse or other appropriate skilled professional, and must complete appropriate records in compliance with the HHA’s policies and procedures. This Element is not met as evidenced by: Based on interview, record review, and agency policy review, the agency failed to ensure a home health aide (HHA) reported a change in condition to the patient’s registered nurse (RN) or physical therapist (PT) for 1 (Patient #4) of 4 patients reviewed. This failure had the potential for the patient to not receive needed assessment and care. An agency policy titled, “Job Description for Home Health Aide,” revised 06/21/2024, indicated, “Report to the case manager, during the time of the visit, any anomalies in the patient’s condition or the parameters set forth in the care plan.” Patient #4’s “Home Health Certification and Plan of Care,” dated 06/12/2024, revealed the start of care date was 06/12/2024 and the certification period as 06/12/2024 to 08/10/2024. Per the Home Health Certification and Plan of Care, Patient #4 had a medical history that included diagnoses of a repaired displaced intertrochanteric fracture of the left femur (a broken leg bone near the hip), the presence of an artificial left knee joint, and a history of falling. Patient #4’s “Physician Order,” dated 06/21/2024, revealed Patient #4’s physician ordered the agency to provide the patient HHA services two times per week to assist the patient with grooming and hygiene needs. Patient #4’s “Aide Care Plan,” with a date of visit as 06/21/2024, revealed personal care to be provided included to check for pressure areas to the patient’s skin every visit. Patient #4’s “HHA Visit,” dated 07/02/2024, revealed the HHA assessed Patient #4’s skin and noted Patient #4 had a quarter-sized purple bruise behind their left thigh and scabs behind the right thigh, and the patient was unaware of what caused the bruise and scabs. There was no documented evidence the skin condition was reported to the patient’s nurse or other agency staff. During an interview on 07/12/2024 at 3:08 PM, RN #1 stated agency policy was HHAs should notify nurses or therapists of any patient skin changes and should immediately notify a nurse if they saw bruises or a scab on a patient. During an interview on 07/16/2024 at 10:30 AM, the Administrator stated the agency expectation was HHAs were expected to notify either a patient’s nurse or therapist of any changes to a patient’s skin observed during personal care. The Administrator stated the HHA should have notified Patient #4’s RN or PT of the patient’s scabbed and bruised areas. The Administrator acknowledged the agency did not follow policy.”