Tlc Home Healthcare Services Inc.

“Assure patient needs are continually assessed CFR(s): 484.105(c)(4) Assuring that patient needs are continually assessed, and This Element is not met as evidenced by: Based on record review and interview, the clinical manager failed to ensure Patient #1’s needs were continually assessed in that an assessment of Patient #1’s needs was not conducted when Patient #1 notified the Agency of a change in status related to complications involving her wound vacuum (wound vac) (Wound management method which assists in the healing process of the wound) and wound vac dressing. This failure had the potential to place Patient #1 at risk of further wound deterioration and hospitalization. Findings included: Review of the clinical record of Patient #1 revealed a start of care date of 08/06/2024 for a primary diagnosis of Disruption of external operation (surgical) wound (A surgical complication, where the surgical incision reopens) and secondary diagnoses which included Infection following a procedure, other surgical site (Infection acquired after surgery to the surgical site). Further review of the clinical record of Patient #1 revealed a post-hospital order, dated 08/17/2024 which revealed the following Physician Orders: “SN: 1w1 (Once a week for one week), 3w7 (Three times a week for seven weeks). 1-4 SN PRN visits for changes in status/condition, falls, injury, medication changes, labs, abnormal vital signs/glucose readings… SN to cleanse wound with normal saline prepare peri wound, cover with white sponge follow by black sponge, cover with drape and vacuum dressing…SN to assess/evaluate wound(s) at each dressing change and PRN for signs/symptoms of infection.” Review of the Agency’s after hours/on call log for the time-period requested of 09/22/2024 to 09/30/2024 revealed the Agency received two calls from Patient #1 on 09/29/2024 (Sunday). The calls were received at 9:58 AM and 4:29 PM and both calls were regarding “Wound vac issues.” Review of the clinical record of Patient #1 revealed a document titled “Patient Communication,” dated 09/29/2024, documented by the Alternate Administrator/Alternate Supervising Nurse which read in part, “Time: 1630 (4:30 [RG(2] PM)…Patient contacted answering service around approximately 16:30 (4:30 PM). Patient stated that wound vac became loose. Patient indicates that she spoke with what sounds like a DME agent who told her there is nothing wrong with the machine and that it is the dressing itself. Midway through conversation skilled nurse notified patient the dressing becoming unhinged nearly every day is unusual and that she has ran out of PRN visits. Patient has been made aware previously by assigned nurse that PRN visits were exceeded. Live recording and audio transcript shows that patient suggested going to the hospital and skilled nurse indicated that it is possible if dressing fails daily that patient needs a different type of wound care and skilled nurse recommended calling ambulance. Live transcript and audio recording shows that patient was also given option to wait until the following day for dressing change as at the time of phone call nurse had noted a visit was scheduled for the following day for wound care. Recording and transcripts indicate patient asked nurse if it would increase the risk of infection. Skilled nurse stated that he could not answer such a question. Although skilled nurse recommended patient call ambulance, patient indicated that she was okay waiting for wound dressing the following day by her assigned nurse, but that she would contact her son presumably for legal advice.” Review of documentation provided by the Agency revealed a transcript of the call between the Alternate Administrator/Alternate Supervising Nurse. The transcript revealed Patient #1 informed the Alternate Administrator/Alternate Supervising Nurse of the wound vac not functioning properly. The transcript further revealed the Alternate Administrator/Alternate Supervising Nurse informed Patient #1 she did not have further PRN visits and could contact Emergency Medical Services. Review of the clinical record of Patient #1 for the time-period reviewed of 08/06/2024 to 09/30/2024 did not include documentation that a PRN visit was completed on 09/29/2024. Further review of the clinical record of Patient #1 revealed that although 1-4 PRN visits were ordered by the MD, only 2 PRN visits had been conducted during the time-period reviewed of 08/06/2024 to 09/30/2024 . The PRN visits were on 08/22/2024 and 08/25/2024. There was no further documentation of PRN visits completed for Patient #1. Further review of the clinical record of Patient #1 revealed a document titled “Patient Communication,” documented by the Intake Coordinator, dated 09/30/2024 which read in part, “Patient called office to complain about her wound vac not functioning properly. Patient stated she was going to call 911 because no one was paying attention to her about wound vac not functioning…I told her not to exhaust emergency response resources unless it is an emergency. Patient was told she was due for recertification, [Registered Nurse] was going to be out there to perform wound care/change wound vac for her services to continue. Patient continued to state she was calling 911 regarding the circumstances.” Further review of the clinical record of Patient #1 revealed a Transfer Summary, documented by the Registered Nurse B, dated 10/01/2024, which revealed Patient #1 was hospitalized on 09/30/2024 due to “as per patient report c/o (complaints of) issues with wound vac.” A telephone interview was conducted with the Licensed Vocational Nurse A on 10/04/2024 at 1:59 PM. The Licensed Vocational Nurse A stated that when Patient #1 was first admitted, she would frequently find the wound vac dressing to be dislodged and believed it may be due to the clutter in Patient #1’s home and Patient #1 having difficulty moving around the home with the wound vac. The Licensed Vocational Nurse A stated that in subsequent visits she realized that Patient #1 was noncompliant with the wound vac and dressing. The Licensed Vocational Nurse A stated that she provided education to Patient #1 and the importance of Patient #1 being compliant with the wound vac for the wound to heal. The Licensed Vocational Nurse A stated that recently, she had developed rapport with Patient #1 and Patient #1’s surgical wound had been showing progress and the behavior of removing the wound vac dressing and turning off the wound vac had decreased. A telephone interview was conducted with the Alternate Supervising Nurse/Alternate Administrator on 10/04/2024 at 4:02 PM. The Alternate Administrator/Alternate Supervising Nurse stated the Agency utilized an individual for after hours on call services. The Alternate Administrator/Alternate Supervising Nurse stated the individual would transfer calls to either the Administrator on call, if the issue is related to administration, or the Registered Nurse on call if the call is nursing related. The Alternate Administrator/Alternate Supervising Nurse stated a visit is conducted on a case-by-case basis. The Alternate Administrator/Alternate Supervising Nurse stated Patient #1 had a history of removing the wound vac dressing and had exhausted her PRN nursing visits. The Alternate Administrator/Alternate Supervising Nurse was asked what was meant by this and was asked to verify when PRN visits were completed for Patient #1 during the time-period reviewed of 08/06/2024 to 09/30/2024. The Alternate Administrator/Alternate Supervising Nurse stated this was a technicality on scheduling’s behalf because there were visits that had been made by the assigned nurse Licensed Vocational Nurse A and the Licensed Vocational Nurse B to change the dressing and this was how he was notified of the excess usage of Patient #1’s allotted visits and PRN visits. A telephone interview was conducted with the Clinical Manager on 10/04/2024 at 4:18 PM. The Clinical Manager stated the Agency utilized a third-party service to answer phone calls After Hours. The Clinical Manager stated the Agency had two Registered Nurses on call for Triage, and an on-call Licensed Vocational Nurse for back up. The Clinical Manager stated if a visit is requested or information is provided by the patient/individual calling which references a patient care concern, the Triage nurses will triage the concern and determine if a visit needs to be conducted. The Clinical Manager stated in Patient #1’s case, this was a patient who had a certain amount of visits authorized, which was 2 to 4 PRN visits and was calling in frequently to request a PRN visit. The Clinical Manager stated Patient #1 had exceeded her PRN visits. The Clinical Manager was asked if PRN visits conducted on 08/22/2024 and 08/25/2024 were the only PRN visits conducted for Patient #1 during the time-period reviewed of 08/06/2024 to 09/30/2024. The post-hospital order, dated 08/17/2024 referencing 1-4 PRN visits was reviewed with the Clinical Manager. The Clinical Manager stated that he would check with the biller to see when PRN visits were completed for Patient #1. On 10/04/2024 at approximately 4:38 PM, the Clinical Manager provided a handwritten note indicating that PRN visits were completed for Patient #1 on 08/22/2024, 08/24/2024 and 08/25/2024. The Clinical Manager stated the visit completed on 08/24/2024 was not documented as a PRN visit as it would impact the Skilled Nursing frequency for the week of 08/18/2024 to 08/24/2024. During the exit conference on 10/04/2024 at approximately 5:00 PM, the Clinical Manager verified there were no additional PRN visits completed for Patient #1. After discussing the preliminary findings, the Clinical Manager stated, “We told [Patient #1] to go to the hospital.” Review of the Agency’s policy and procedure manual revealed a policy titled “On Call for Patient Care,” dated 06/01/2013, which read in part, “To provide a process to meet patient care needs after Agency operating hours, during weekends and holidays….A. Agency will assign appropriate qualified staff for visits that need to be made after Agency operating hours, on weekends and holidays. B. A Registered Nurse is scheduled for availability 24 hours a day, 7 days a week to respond to calls from patients and Licensed Vocational Nurses…The On Call nurse will utilize standards for practice/best practices in making clinical judgements.””

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on interview, record review and observation, the Agency failed to enforce written policies addressing infection control including the prevention of the spread of infectious and communicable diseases involving Bag Technique policy in 1 (Client #7) of 7 clients who received home visits. The LVN failed to follow proper bag technique when providing wound care to Client #7. Failure of the Agency to enforce its policy on Equipment Bag Technique has the potential to result in the spread of bacteria and may lead to infections amongst clients. Findings included: Review of Agency’s policy and procedure manual provided a policy entitled “IC.12 Equipment Bag Technique” dated 11/15/21. Purpose read, “To describe the procedure for maintaining a clean equipment/clinical bag and prevention cross contamination.” Policy read, “A. As part of the infection/ exposure control plan, the Agency clinical staff consistently implement principles to prevent the spread of infection and maximize the efficient use of the bag. Bag Technique read in part … “C. Identify a clean, firm surfc1ce and safe area for the equipment bag with adequate workspace and 1s kept away from children and pets. D. Place the bag on a clean surface in the home with a barrier (i.e., waterproof barriers, blue pad, wax paper, small trash bag, etc.) to be placed under the bag.” Record review conducted on 11/07/2023 of Client #7 chart. Client #7 was a 73-year-old female with diagnoses of pressure ulcer to left ankle, type 2 diabetes, heart failure and kidney disease. Start of care was on 04/21/2023 and had skilled nursing services once a week for 8 weeks per certification period. Wound care provided to pressure ulcer to left ankle each visit per skilled nurse weekly. Observation conducted on 11/08/2023 at 08:30 AM of Client #7. LVN A placed work bag on Client A’s side table. Noted not to clean side table or place a barrier. LVN A continued to conduct wound care treatment. Record review of LVN A personnel training record on 11/09/2023. Record revealed training check off (undated) on Bag Technique & Hand Washing show as completed and met standard. Interview conducted on 11/08/2023 at 09:25 AM with LVN A. LVN A verbalized proper bag technique when conducting client treatment to include providing a barrier between bag and client’s side table. She verbalized that she had her barrier present and showed wax paper. LVN A stated she forgot to place it down prior to placing bag. LVN A verbalized understanding the bag technique policy. She was aware the purpose to keep work bag from client’s tray table. LVN A said the importance was to maintain a clean field and prevent cross contamination. Interview conducted on 11/09/2023 at 2:25 PM with Supervising Nurse. Verbalized nurses were trained on bag technique prior to providing care to clients. Supervising Nurse explain the need for barrier to prevent infection control issues for clients.”