Doctors Choice Home 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 records reviewed and interviews the agency failed to provide services as ordered by the physician or as indicated in the plan of care for 2 of 7(#1 & #2) patient’s whose records were reviewed. In that the agency failed to: 1) Provide Home Health Aide services to Patient #1 for the initial episode of service (08/15/2024 – 10/13/2024) and first half of the second episode of services (10/14/2024 – 12/12/2024) as ordered by the physician. 2) Provide PT services for second episode of service (10/14/2024 – 12/12/2024) as ordered by the physician 3) LVN A failed to assess patient #2’s skin for breakdown during each visit as ordered by the physician in the plan of care. These failures placed the agency’s patients at increased risks for poor health outcomes. Patient #2: Record review of Patient # 2’s ECR included a form titled “Home Health Certification and Plan of Care” (POC) for the period of 02/09/2024 - 04/08/2024, 04/09/2024-06/07/2024 and 06/08/24 - 08/06/24 revealed a SOC date on 02/09/2024 with the following diagnoses: atrial fibrillation (irregular and often very rapid heart rhythm), presence of cardiac pacemaker (small device that’s placed (implanted) in the chest to help control the heartbeat), long term (current) use of anticoagulants (medicines that helps prevent blood clots), chronic kidney disease (when your kidneys are damaged and lose their ability to filter waste and fluid out of your blood ) and indicated the agency was to provide skilled nurse visits once a week for nine weeks. Record review of the POC’s dated 02/09/2024 - 04/08/2024, 04/09/2024- 06/07/2024 and 06/08/24 - 08/06/24 for Patient # 2 physician orders included the following, in part:”... SN Interventions-... SN to assess skin for breakdown at each visit. SN to instruct the BOTH to pad all bony prominences. SN to perform inspection of patient’s lower extremities every visit and report any alteration in skin integrity to physician. SN Goals: ASSESS SKIN AT EVERY VISIT. The BOTH will verbalize an understanding of skin conditions that must be reported to SN or physician immediately. Review of patient #2’s clinical records revealed a physician’s order for SN to assess for skin breakdown at every visit and to report any alteration in skin integrity to the physician. Clinical record also revealed visit notes from HHA A on 2/22/24 and 2/24/24 which stated that the skin is sore on open skin on both dates assessed. During an interview with HHA A on 1/31/25 at 10:55 a.m., HHA A stated that there were some open sore areas on Patient #2’s bottom, and that HHA A documented this in her notes for dates 2/22/24 and 2/24/24. HHA A stated that she also reported this to a nurse but did not remember which nurse it was verbally reported to. HHA A stated that patient #2 did not have any open sore areas on her bottom prior to HHA A’s initial visits with patient #2. During an interview with Patient #2 on 1/31/25 at 11:10 a.m., Patient #2 stated that she had open wounds on her tailbone that were sore and that these wounds were observed by HHA A when HHA A assisted Patient #2 with their bath. Patient #2 stated that LVN A was not treating her tailbone wounds when they came to visit and Patient #2 did not know if the doctor had ordered anything for the wounds. Patient #2 did not think that LVN A had looked at the wounds. During an interview with LVN A on 1/31/25 at 11:35 a.m., LVN A stated that they were the assigned nurse for Patient #2. LVN A stated that they would review the POC and look at the doctor’s orders before going to see any patients. LVN A stated that they did not recall seeing any wounds on Patient #2’s bottom. When asked if Patient #2 was at risk for pressure ulcers, LVN #2 stated that all patients are at risk for pressure ulcers if they are dependent on the use of a wheelchair. LVN A Stated that skin assessments were performed on Patient #2 head to toe and documented on every visit in the ECR, but that they were not documented because LVN A did not remember seeing anything on Patient # 2’s bottom. LVN A stated that he did not communicate or review HHA A visit notes for Patient #2 because it was the RN’s responsibility to review visit notes and communicate with HHA A and Patient #2’s doctor. When asked to review Patient #2’s visit notes from HHA A, LVN A stated that they were now able to see where HHA A documented about open sores on Patient #2’s skin on 2/22/24 and 2/24/24. LVN A stated that the risk of not performing the ordered skin assessments and not communicating with Patient #2’s physician after HHA A documented the observations of open areas on Patient #2’s skin was that Patient #2 could have developed a skin infection. During an interview with the DON on 1/31/25 at 2:44 p.m., the DON stated that she was responsible for overseeing that care plans are being followed per physician orders. The DON stated that they monitor staff by having a case conference every week to go over the care plans. The DON stated that all staff had to perform skin assessments from head to toe on every visit when ordered on the POC and all staff had to document it in the ECR and report any concerns immediately to the DON and the physician. The DON stated that the skin assessments for Patient #2’s open sores was not documented by LVN A or reported to the physician because it had fallen through the cracks. The DON stated the risk was that Patient #2 could have gotten an infection or died from sepsis. During an interview with the Adm and Alt Adm. On 1/31/25 at 3:19 p.m. regarding the failure to report open sores to Patient #2’s physician they stated that staff had to follow agency policies and procedures regarding the plan of patient care. Review of agency’s administrative policy revised date 01/09/25 titled, “Plan of Care-CMS 485 and Physician Orders” reads in part, “… Policy: Skilled nursing and other home health services will be in accordance with a plan of care based on the patient’s diagnosis and assessment of immediate and long-range needs and resources. Procedure: 1. Patients are accepted for treatment on the reasonable expectation that agency can meet the patient’s medical, nursing, rehabilitative and social needs in his or her place of residence. Findings include: Patient #1 Review of patient #1’s clinical record revealed Physician initial Home Health Services referral orders that was faxed to Agency on 08/12/2024. Review of the initial Home Health referral document revealed patient was bedbound, had high blood pressure, nerve pains, fungal skin infection, and red rashes all over her skin that made her itch. Further review of the initial Home Health orders for the initial episode (from 08/15/2024 – 10/13/2024) also revealed that patient #1’s physician ordered for Home Health Aide (bath Aide) to help patient with personal grooming needs. Review of the RN A’s initial comprehensive assessment document dated 08/15/2024 RN A documented that she had developed patient #1’s plan of care for nursing, home health aide, and therapy services but did not indicate the frequencies for these services. Review of the patient #1’s clinical records for episode that started from 08/15/2024 – 10/12/2024 showed that patient #1 did not receive any Home Health aide services during the entire certification period. Review of another Physician’s orders dated 10/21/2024 for certification period from 10/14/2024 -12/12/2024 showed that patient #1’s Physician ordered Home Health Aide Services twice a week for 8 weeks and PT to evaluate and treat patient effective 10/21/2024. However, review of patient’s clinical records showed patient did not receive Home Health Services for the entire first episode (08/15/2024 -10/13/2024) and the first 4 weeks of the second episode (10/14/2024 – 12/12/2024). During interview with the Alternate Administrator on 01/29/2025 at 2:20p.m., the administrator stated they tried to provide home health aide services to patient #1, but the aide could not provide services because she was afraid of the patient’s dog. The administrator was asked why the agency did not send another staff who could work around the dog. The administrator did not respond to that inquiry. During interview with RN A on 01/29/2025 at 3:20p.m. on why the patient did not receive Home Health Aide Services as was ordered by patient’s physician? The Nurse stated that the home health aide that was assigned to provide services to patient could not provide care because she was afraid of patient’s dog. And regarding the second episode, the RN A stated that the home health aide kept having missed visits because patient’s door was always locked whenever the aide went to provide service because patient could not get up to open the door for the Aide. The RN A was asked how she got to perform the initial comprehensive assessment. The RN A Nurse stated that she had called the evening before and made arrangements with Patient #1 and so the patient had her son to be there to open the door for the nurse, and at other times the patient asked her son to leave the key under the door mat so RN A could let herself in during home visit. RN A was asked why she did not communicate with other agency staff about the patient #1’s situation. The nurse responded, “company policy is to call patients the night before they go out to visit patients. Everyone knows that.” RN A was asked how often the home health aide was supposed to visit patient to provide services as the frequency of service was not indicated in the patient#1’s Home Health Aide’s Plan of Care. The Nurse stated that home health aide was supposed to visit patient twice weekly. During interview with HHA A (The Home Health Aide that was assigned during the second episode of service) on 01/30/2025 at 3:44p.m., the staff was asked the reason she had so many missed visits during the second episode of service for patient#1. The Aide stated that she had requested the scheduler to take her off patient #1’s case because she could not continue to provide services to patient #1 in such deplorable living conditions. Home Health Aide stated that she had tried several times to notify the agency’s administration about patient #1’s deplorable living conditions and eventually she was able to talk to the New Supervising Nurse, the Alternate and the CEO of the agency about the situation. Review of patient #1’s clinical records also revealed that Patient #1 did not receive physical Therapy service during the entire certification period from 10/14/2024 – 12/12/2024. Review of patient #1’s Physical Therapy tab in agency’s electronic clinical record showed no PT visit notes for the entire certification period from 10/14/2024 – 12/12/2024. During interview with the alternate administrator on 01/29/2025 at 2:33p.m., the administrator stated that agency provided PT services to patient #1 after patient was discharged from the hospital during the first episode of service. Surveyor noted that PT discharged the patient after just three weeks of services and the during the second episode patient did not receive any PT services. The Administrator stated that she was not sure why patient did not receive PT services during the 2nd episode, and she admitted that there were a few things that fell through the cracks due to poor management oversight of the previous administrative staff.”

“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: Based on records reviewed and interviews the agency’s personnel failed to communicate with all physicians involved in the plan of care and other health care practitioners involved in the care of the patient for 2 of 7 (#1 & #2) patients whose clinical records were reviewed. In that, 1) PTA A failed to notify patient #1’s of patient’s refusal of PT service due to pain on the legs and feet. 2) LVN C failed to notify patient #1’s physician about patient #1’s complaint of pain during urination. 3) LVN A failed to notify patient #2’s physician of the pressure ulcer on patient’s buttocks. These failures placed agency’s patients at increased risk of poor health outcome. Patient #2: Record review of Patient # 2’s ECR included a form titled “Home Health Certification and Plan of Care” (POC) for the period of 02/09/2024 - 04/08/2024, 04/09/2024-06/07/2024 and 06/08/24 - 08/06/24 revealed a SOC date on 02/09/2024 with the following diagnoses: atrial fibrillation (irregular and often very rapid heart rhythm), presence of cardiac pacemaker (small device that’s placed (implanted) in the chest to help control the heartbeat), long term (current) use of anticoagulants (medicines that helps prevent blood clots), chronic kidney disease (when your kidneys are damaged and lose their ability to filter waste and fluid out of your blood ) and indicated the agency was to provide skilled nurse visits once a week for nine weeks. Record review of the POC’s dated 02/09/2024 - 04/08/2024, 04/09/2024- 06/07/2024 and 06/08/24 - 08/06/24 for Patient # 2 physician orders included the following, in part:”... SN Interventions-... SN to assess skin for breakdown at each visit. SN to instruct the BOTH to pad all bony prominences. SN to perform inspection of patient’s lower extremities every visit and report any alteration in skin integrity to physician. SN Goals: ASSESS SKIN AT EVERY VISIT. The BOTH will verbalize an understanding of skin conditions that must be reported to SN or physician immediately. Review of patient #2’s clinical records revealed a physician’s order for SN to assess for skin breakdown at every visit and to report any alteration in skin integrity to the physician. Clinical record also revealed visit notes from HHA A on 2/22/24 and 2/24/24 which stated that the skin is sore on open skin on both dates assessed. During an interview with HHA A on 1/31/25 at 10:55 a.m., HHA A stated that there were some open sore areas on Patient #2’s bottom, and that HHA A documented this in her notes for dates 2/22/24 and 2/24/24. HHA A stated that she also reported this to a nurse but did not remember which nurse it was verbally reported to. HHA A stated that patient #2 did not have any open sore areas on her bottom prior to HHA A’s initial visits with patient #2. During an interview with Patient #2 on 1/31/25 at 11:10 a.m., Patient #2 stated that she had open wounds on her tailbone that were sore and that these wounds were observed by HHA A when HHA A assisted Patient #2 with their bath. Patient #2 stated that LVN A was not treating her tailbone wounds when they came to visit and Patient #2 did not know if the doctor had ordered anything for the wounds. Patient #2 did not think that LVN A had looked at the wounds. During an interview with LVN A on 1/31/25 at 11:35 a.m., LVN A stated that they were the assigned nurse for Patient #2. LVN A stated that they would review the POC and look at the doctor’s orders before going to see any patients. LVN A stated that they did not recall seeing any wounds on Patient #2’s bottom. When asked if Patient #2 was at risk for pressure ulcers, LVN #2 stated that all patients are at risk for pressure ulcers if they are dependent on the use of a wheelchair. LVN A Stated that skin assessments were performed on Patient #2 head to toe and documented on every visit in the ECR, but that they were not documented because LVN A did not remember seeing anything on Patient # 2’s bottom. LVN A stated that he did not communicate or review HHA A visit notes for Patient #2 because it was the RN’s responsibility to review visit notes and communicate with HHA A and Patient #2’s doctor . When asked to review Patient #2’s visit notes from HHA A, LVN A stated that they were now able to see where HHA A documented about open sores on Patient #2’s skin on 2/22/24 and 2/24/24. LVN A stated that the risk of not performing the ordered skin assessments and not communicating with Patient #2’s physician after HHA A documented the observations of open areas on Patient #2’s skin was that Patient #2 could have developed a skin infection. During an interview with the DON on 1/31/25 at 2:44 p.m., the DON stated that she was responsible for overseeing that care plans are being followed per physician orders. The DON stated that they monitor staff by having a case conference every week to go over the care plans. The DON stated that all staff had to perform skin assessments from head to toe on every visit when ordered on the POC and all staff had to document it in the ECR and report any concerns immediately to the DON and the physician. The DON stated that the skin assessments for Patient #2’s open sores was not documented by LVN A or reported to the physician because it had fallen through the cracks. The DON stated the risk was that Patient #2 could have gotten an infection or died from sepsis. During an interview with the Adm and Alt Adm. On 1/31/25 at 3:19 p.m. regarding the failure to report open sores to Patient #2’s physician they stated that staff had to follow agency policies and procedures regarding coordination of patient care. Review of agency’s administrative policy dated 03/12/2021 titled, “Coordination of Patient Care” reads in part , “…To ensure that quality services are being provided to patients; to provide a mechanism for representatives from various disciplines to discuss patient care in a group meeting…The agency must assure communication with all physicians involved in the plan of care…” Findings include: Patient #1 … Review of patient #1’s clinical records revealed a PTA’s missed visit communication document dated 10/08/2024 where patient declined PT session due to pain on her legs and feet. There was no record of PTA’s called to notify patient’s physician about patient complaint of pains. During interview with PTA A on 01/31/2025 at 11:39a.m., the staff was asked if he called patient #1’s physician to notify him and get pain medication for patient. PTA A stated that he notified patient’s physician about patient’s complaint of pain, but he may have forgotten to document it in patient’s records. Review of a skilled nurse’s visit note dated 08/29/2024 showed LVN C’s documentation that patient informed LVN C that she feels pain during urination and patient rated the pain 8/10. Further review of the visit note showed no documentation that staff notified patient #1’s physician of patient complaint. Surveyor was unable to speak with LVN C about the issue. During interview with agency’s Supervising Nurse on 01/29/2025 at 3:25p.m., the nurse stated it was agency’s policy that staff call the clinical supervisors/Supervising Nurse to report any changes in patients’ condition and the nurses as well as the therapists are required to call the patient’s physicians to notify them of changes in patients’ condition and get orders”

“Coordinate patient care CFR(s): 484.105(c)(2) Coordinating patient care, This Element is not met as evidenced by: This failure to adopt and enforce the agency’s written policy regarding coordination of client services with other health services providers, this failure places agency patients at risk of not receiving care as ordered and at risk of poor outcomes. Review of complaint case #447801 indicating an Adult Protective Services (APS) report dated 8/30/23 referral for suspected neglect by a provider for patient. The APS report revealed the HHA agency never sees the provider at the home, no food or water in the home. Concerns detailed included providers has not been showing up to the home for weeks at a time but stating she is there. APS Specialist reached provider who stated she was not there this past week because of sickness but will go back 8/29/23. Patient #6 reported to APS Specialist that provider did not show up. On 8/30/23 the provider left for the store at 1:30pm with patient #6’s debit card and did not return. Patient #6 called provider at 4:30pm and provider stated that she was checking on her grandson and will be back tomorrow to bring card and things. An agency policy review on 01/28/25 of the agency’s “Coordination of Patient Care” read in part: The agency must: Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and coordination of care provided by all disciplines. Care will be coordinated with other involved external organizations, e.g., home medical equipment providers, infusion therapy/pharmacy companies and community agencies. Staff will: · Understand Agency and organization’s responsibilities in providing care or services. · Communicate with other individuals or organizations involved in the patient’s care when significant changes occur in the patient’s overall care. · Share relevant information to facilitate appropriate continuity and care coordination. Review on 01/28/2025 of patient #6‘s records noted SOC of 07/19/23 with certification period reviewed 07/19-23 – 09/16/23. Diagnosis noted: Spondylosis of cervical region, Chronic pain syndrome, Osteoarthritis, Radiculopathy, Major Depressive Disorder and Repeated Falls. Initial start of care orders included: Skilled nurse frequency one visit weekly for nine weeks, Physical Therapy frequency two times for four weeks and one time for 1 week with a social worker order once per one week ordered 8/22/23. Further review noted a skilled nurse visit dated 07/26/23 by LVN B Patient #6 stated that her provider had not come yet, she always has excuses that she cannot make it because she stop to help someone else. Pt stated that she was going to call her provider service company and again a 08/03/23 dated skilled nurse visit to patient #6 stated that her provider never came, and she needed help with her ADL’s, someone to take her to her doctor’s appointment and someone to buy her groceries. During an interview with LVN B on 1/29/25 at 1:16pm the LVN B stated that she saw the PAS provider once or twice, LVN B further stated she spoke to patient #6’s provider agency and called the office to see if they would send someone out, she called the provider company and called her company, it was 2023 I don’t remember but they said they would send someone. An interview with the Sup. Nur 0n 1/29/25 at 11:30am surveyor asked policy for coordinating services with other entities who are providing services for patients. Sup. Nur stated, “my policy is for if we have patient with other services, we are supposed to send a coordination of services form to the other entity and we have them complete it, it is like hey we are providing services to this patient, I do know when I get the admission, I give them a call and let them know” When asked was this completed for patient #6 as there is no evidence documented that the agency coordinated care with the PAS agency, the Sup. Nur stated “this is something that we are working on, I was not here until 10/15/2024, I don’t know if they have a sheet, it would be in the electronic clinical record. In an interview on 01/29/2025 at 2:00pm with the Alt Admin when asked policy for coordination of care and services with other agencies, the alternate administrator stated, “the main one is our wound group, and we coordinate via email”. When surveyor asked about provider services, the alt admin stated, “I reach out, I get the nurse to send me the number on the book the provider has in the home, and I simply call the agency and let them know to make sure so there is not a duplication of services”. In an interview with PAS agency alt admin on 01/29/25 at 12:20pm when asked if the HHA that provided skilled nurse ever contacted their agency regarding coordination of care, PAS agency alt admin stated, “Patient # 6 let us know that she had a nurse there on Wednesdays, no the skilled nurse agency never called us, they never called us regarding this patient or missed provider visits” Surveyor asked PAS agency alt admin about any attempts to coordinate care with skilled nurse agency, alt admin of PAS agency stated, never received anything from Patient #6 or her family, some clients who have skilled we do get those papers from the SN agency and when we do we complete it and return it. No additional information was provided by the end of the survey on 01/31/25.”