STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, x. ~ Petitioner, 2) > 3B O0CO AHCA No: 2003002187 vs. Return Receipt Requested 7002 2410 0001 4236 7614 NURSING UNLIMITED 2000, INC., d/b/a NURSING UNLIMITED 2000, INC., Respondent / ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA” or the “Agency”), by and through the undersigned counsel, and files this Administrative Complaint against medical Nursing Unlimited 2000, Inc., d/b/a Nursing Unlimited 2000, Inc. (hereinafter “Nursing Unlimited 2000”) pursuant to 28-106.111, Florida Administration Code (2000) (hereinafter “F.A.C.”), and Chapter 120, Florida Statutes (2002) (hereinafter “Fla. Stat.”), and alleges: NATURE OF ACTION 1. This is an action to impose an administrative fine in the amount of $6,000.00, pursuant to Sections 400.474, and 400.484(2) (b), Fla. Stat. Bhd “AY JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Section 120.569 and 120.57, Fla. Stat., and Chapter 28-106, F.A.C. 3. Venue lies in Dade County, pursuant to 120.57, Fla. Stat., and Chapter 28-106.207, F.A.C. PARTIES 4.° BHCA is the enforcing authority with regard to home health agencies licensure law, pursuant to Chapter 400, Part IV, Fla. Stat., and Rules 59A-8, F.A.C. 5. Nursing Unlimited 2000 is a home health agency located at 4953 S.W. 74°* Court, Miami, Florida 33155, and is licensed under Chapter 400, Part IV, Fla. Stat., and Chapter 59A-8, F.A.C.; license number 299991242. COUNT I NURSING UNLIMITED 2000 FAILED TO PROVIDE SERVICES TO MEET THE NEEDS OF PATIENTS ACCEPTED FOR TREATMENT, AS DEFINED IN A SPECIFIC PLAN OF CARE, AND/OR FAILED TO DOCUMENT THE CLINICAL RECORD TO EVIDENCE THAT SERVICES WERE PROVIDED TO MEET THE NEEDS OF PATIENTS ACCEPTED FOR TREATMENT, AS DEFINED IN A SPECIFIC PLAN OF CARE. 59A-8.020(1), and/or 59A-8.025(2), and/or 59A-8.022(5) (g), and/or 59A-8.022(1), F.A.C., and/or 400.487(6), Fla. Stat., and/or 42 C.F.R. 484.18. (ACCEPTANCE OF PATIENTS, POC, MED SUPER) REPEAT CLASS II DEFICIENCY 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. During the complaint investigation conducted by the Agency on 10/10/02 and based on review of the record of sample patient #1, the Agency found that Nursing Unlimited 2000 failed to provide services to meet the needs of patients accepted for treatment, as defined in a specific plan of care, and/or failed to document the clinical record to evidence that services were provided to meet the needs of patients accepted for treatment, as defined in a specific plan of care. Findings include the following, to wit: 8. Patient #1’s record revealed that the patient’s blood sugar was to be tested twice a day and insulin given. The patient’s blood sugar was documented at the twice-daily visits as over the normal range of 60-110 since the start of care. The blood sugars ranged from 118-190. There was no evidence of documentation of the nurse having reported the abnormal blood sugars to either the Director of Nurses or the physician. Interview with the ADON confirmed the lack of documentation. 9. Review of the record of sample patient #2 revealed that the patient had been hospitalized and upon discharge the medication had been changed. The plan of care from the physician did not include evidence of a modification order for the patient to be taking the new medications. Interview with the ADON confirmed the lack of documentation. 10. Review of the record of sample patient #3 revealed that there were orders for an RN evaluation and 3 LPN visits to follow. There was a subsequent order for 11 additional wound care visits. There was no documentation to indicate the status of the wound at any of the visits. There was no description of the wound, i.e. measurement or condition of the skin. There was no documentation in the visit’s notes too indicate improvement or worsening of the wound. There was no evidence of documentation of the nurse having reported the wound condition to either the Director of Nursing or the physician. Interview with the ADON confirmed the lack of documentation. 11. Review of the record of sample patient #4 revealed that there were orders for a RN evaluation, physical therapy evaluation and 3 physical therapy visits to follow. The record documents the nurse and the therapist evaluations and the 3 physical therapy visits. However, there were no orders for a home health aide to visit and there were 3 visits made by a home health aide. There was a second physical therapy evaluation in the record with 2 visits after the evaluation. There was no evidence in the record to indicate that any modification to the physicians order had been made. Interview with the ADON confirmed the lack of documentation. 12. Review of the record of sample patient #6 revealed that there were orders for an RN evaluation and 3 LPN visits to follow. There was no evidence in the record to indicate that any visits had been made after the initial assessment. Interview with the ADON confirmed the lack of documentation. 13. Review of sample record #7 revealed that that there were orders for an RN evaluation and 6 LPN visits to follow, a physical therapy evaluation with 2 visits to follow and an occupational therapy evaluation. There was no evidence of any follow-up visits for nursing or physical therapy. Interview with the ADON confirmed the lack of documentation. 14. Review of the record of sample patient #9 revealed the patient had been receiving wound care for 14 days. There is no documentation to indicate the status of the wound at any of the visits. There is no description of the wound, i.e. measurement or condition of skin. There is no documentation in the visit notes to indicate improvement or worsening of the wound. There is no evidence of documentation of the nurse having reported the wound condition to either the Director of Nurses or the wn physician. Interview with the ADON confirmed the lack of documentation. This deficiency was cited as a Class II deficiency and found to be corrected when the Agency conducted a follow-up survey on 12/09/02; however, the deficiency was found to be repeated during a complaint investigation survey conducted by the Agency on 3/13/03. 15. During another complaint investigation conducted by the -Agency on 3/13/03 and based on record review and interview, the Agency again found that Nursing Unlimited 2000 failed to provide services to meet the needs of patients accepted for treatment, as defined in a specific plan of care, and/or failed to document the clinical record to evidence that services were provided to meet the needs of patients accepted for treatment, as defined in a specific plan of care. The Agency found that Nursing Unlimited 2000 failed to adequately meet the needs of the patients who were accepted for treatment in 5 out of 5 sampled patients. The findings include the following, to wit: 16. Review of sampled record #1 indicated that the patient was admitted to home health services on January 11, 2003 with a diagnosis of acute ill-defined cerebrovascular disease. The patient was ordered to receive skilled nursing, physical therapy and home health aide. The initial nursing assessment identified that the patient needed assistance with activities of daily living and the patient was on 6 new medications following a recent hospitalization. The physician treatment orders were for the nurse to evaluate the patient's needs and make a second visit for teaching on disease process and medication regimen. The physician also ordered a home health aide to visit the patient 3 times, to assist with personal care. There is no evidence in the record of a second nursing visit having been provided. The home health aide note revealed that the home health aide did not visit the patient until January 29, 2003, 18 days after the start of care. There was no evidence in the record of why the physician's orders were not carried out in a timely manner. Interview with the Administrator and Acting Director of Nursing acknowledged the delay in services, provided no explanation for the delay in provision of services to the patient, and did not produce a second nursing visit note. 17. Review of sampled record #2 indicated that the patient was admitted to home health services on January 20, 2003 with a diagnosis of Parkinson's disease. The patient was ordered to receive skilled nursing, physical therapy and home health aide. The initial referral included orders for the patient to receive 3 physical therapy visits. The plan of care does not include those orders. The plan of care ordered the patient to receive 3 home health aide visits. The initial nursing assessment recommends that the patient receive physical therapy and home health aide services for personal care, however, there is no documentation in the record to explain why therapy was not provided to the patient as ordered. The record revealed that only 2 of 3 home health aide visits were performed. Interview with the Administrator and Director of nursing revealed that they did not know why the patient did not receive physical therapy and did not offer any further documentation to explain the omission of therapy services or lack of a third home health aide visit (as ordered). 18. Review of sampled record #3 indicated that the patient was admitted to home health services on February 14, 2003 with a diagnosis of Syncope and Collapse. The patient was ordered to receive skilled nursing and physical therapy. The initial nursing assessment revealed that the patient lacked knowledge of the medication regimen and needed continuing assessment of cardio/pulmonary status. The physician treatment orders were for 2 additional nursing visits to instruct on disease process and medication regimen. There is no evidence in the record of the 2 nursing visits having been provided to the patient. Interview with the Administrator and Acting Director of Nursing acknowledged the visit notes were not in the record and did not produce any further documentation or evidence of visits having been made. 19. Review of sampled record #4 indicated that the patient was admitted to home health services on February 7, 2003 with a diagnosis of arthropathy. The patient had a history’ of Guillian-Barre syndrome and a motor vehicle accident. The patient injured his knee due to a fall at home. The patient's prior level of function was that he was ambulating with a 4-wheel walker, lived alone and received assistance from his neighbors and paid help at night. The patient was ordered to receive skilled nursing, physical therapy and occupational therapy. The patient's referral orders for home health service were received by the home health agency on February 6, 2003, however the nursing evaluation and physical therapy evaluation were not provided until February 11, 2003. 20. Review of sampled record #5 indicated that the patient was admitted to home health services on February 24, 2003 with a diagnosis of hypertension and knee joint replacement. A referral order/authorization was received on 2/20/03 for an RN and physical therapy evaluation and occupational therapy evaluation. The plan of care’s physician orders the skilled nurse to assess vital signs and signs and symptoms of complications of the cardiopulmonary systems, Instruct and evaluate understanding of disease process, medication regimen (actions/side/effects), detecting complications. The patient's initial assessment indicates that the blood pressure was 176/140; there is no evidence that the nurse contacted the physician to alert him to the elevated blood pressure and obtain orders. The assessment contains no evidence of any teaching related to disease process or medication management. The patient's medication profile documents the patient is on 10 medications Hyzaar, Verapamil, Singulair, Paxil, Glucophage, Verapamil, methylprednisolone, hydroxyzine, Ranitidine and Premarin. The assessment recommended a physical therapy evaluation and a home health aide for assistance with activities of daily living. The patient ambulates with a walker. The physical therapy evaluation was not done until 2/27/03 and recommended 3 times a week for 4 weeks. The therapist also recommended a CPU device for the affected extremity and the therapy note documents contact with the case manager in the agency to discuss obtaining an order for application of a CPU. On the subsequent therapy visit note, the documentation indicates that the therapist discussed with 10 the agency the need for the CPU device. There is no evidence in the record that the patient ever received the CPU device. Interview with the Administrator and Acting Director of Nursing acknowledged the delay in implementation of the plan of care orders. Interview with the administrator revealed that delays occurred in obtaining equipment because the case management company, who gives the agency the referral, does it. This is a repeat deficiency from the visit of 10/10/02. 21. Based on the foregoing, Nursing Unlimited 2000 violated 59A-8.020(1), and/or 59A-8.025(2), and/or 59A- 8.022(5)(g), and/or 59A-8.022(1), F.A.C., and/or 400.487(6), Fla. Stat., and/or 42 C.F.R. 484.18, herein classified as a repeated Class II deficiency, pursuant to Section 400.484(2) (b), Fla. Stat., which carries a fine of $1,000.00 per patient, x 5, for a total fine of $5,000.00. COUNT ITI NURSING UNLIMITED 2000 FAILED TO REPORT CHANGES IN A PATIENT’S CONDITION TO THE PATIENT’S PHYSICIAN. 59A-8.0095(3), F.A.C. (DUTIES OF REGISTERED NURSE) REPEAT CLASS II DEFICIENCY 22. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 23. During the complaint investigation conducted by the Agency on 10/10/02 and based on record review and interview, the Agency found that Nursing Unlimited 2000 failed to report changes in a patient’s condition to the patient's physician. The home health agency did not inform the physician of a change in the patient’s condition or needs in 4 of 10 records reviewed. The findings include the following, to wit: 24. Review of the record of sample patient #1 revealed that the patient’s blood sugar was to be tested twice a day and insulin given. The patient’s blood sugar was documented at the twice-daily visits as over the normal range of 60-110 since the start of care. The blood sugars ranged from 118-190. There is no evidence of documentation of the nurse having reported the abnormal blood sugars to ither the Director of Nurses or the physician. Interview ‘ the ADON confirmed the lack of documentation. 5. Review of the record of sample patient #3 that there were orders for an RN evaluation and 3 -to follow. There was a subsequent order for 11 nd care visits. There is no documentation to tus of the wound at any of the visits. ‘tion of the wound, i.e. measurement or ere is no documentation in the visit 12 deficiency and found to be corrected when the Agency conducted a follow-up survey on 12/09/02; however, the deficiency was found to be repeated during a complaint investigation survey conducted by the Agency on 3/13/03. 28. During another complaint investigation conducted by the Agency on 3/13/03 and based on clinical record review and interview, the Agency again found that Nursing Unlimited 2000 failed to report changes in a patient’s condition to the patient’s physician. The registered nurse did not inform the physician of the changes in the patient’s condition and needs in 1 of 5 records reviewed. Findings include the following, to wit: 29. Review of sampled patient #5 revealed that physician orders the skilled nurse to assess vital signs and signs and symptoms of complications of the cardiopulmonary systems. Instruct and evaluate understanding of disease process, medication regimen (actions/side/effects), detecting complications. The patient's initial nursing assessment indicates that the patient's blood pressure was 176/140; there is no evidence that the nurse contacted the physician to alert him to the elevated blood pressure and obtain orders. 30. Interview with the Administrator and Acting Director of Nursing at 3:30PM on 3/13/03 acknowledged the 14 deficient practice of the skilled nurse in not contacting the physician in response to the abnormal blood pressure. 31. Based on the foregoing, Nursing Unlimited 2000 violated 59A-8.0095(3), F.A.C., herein classified as a repeated Class II deficiency, pursuant to Section 400.484(2) (b), Fla. Stat., which carries a $1,000.00 fine. PRAYER FOR RELIEF WHEREFORE, the Petitioner, State of Florida Agency for Health Care Administration requests the following relief: A. Make factual and legal findings in favor of the Agency on Counts I and Ii. B. Assess and maintain the Agency's administrative fine totaling $6,000.00 against Nursing Unlimited 2000, in accordance with §400.484(2) (b), Fla. Stat. Cc. Award the Agency for Health Care Administration reasonable attorney’s fees, expenses, and costs, if the Court finds that costs are applicable. D. Grant such other relief as this Court deems is just and proper. Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2002). Specific options for administrative action are set out in the attached Election of Rights and explained in the attached Explanation of Rights. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, Agency Clerk, 2727 Mahan Drive, Building 3, Mail Stop #3, Tallahassee, Florida 32308. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECEIVE A REQUEST FOR A HEARING WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS COMPLAINT, PURSUANT TO THE ATTACHED ELECTION OF RIGHTS, WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. Respectfully submitted, Kathryn F. Fenske, Esq. Assistant General Counsel Agency for Health Care Administration Florida Bar No. 0142832 8355 NW 53°* Street, 1°* Floor Miami, Florida 33166 (305) 499-2165 Copy to: Kathryn F. Fenske, Assistant General Counsel Agency for Health Care Administration Manchester Building 8355 NW 53°° Street Miami, Florida 33166 Elizabeth Dudek, Deputy Secretary Agency for Health Care Administration 2727 Mahan Drive, MS#9 Tallahassee, Florida Diane Lopez Castillo, Field Office Manger Agency for Health Care Administration 8355 NW 53" Street Miami, Florida 33166 Jean Lombardi Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #14 Tallahassee, Florida 32308 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.S. Certified Mail, Return Receipt Requested to Aida Salazar Rebull, Administrator, Nursing Unlimited 2000, Inc., 4953 S.W. 74° Avenue, Miami, Florida 33155, on ped [Y1. 200s, Kathr F. Fenske, Esq. 17

Docket for Case No: 03-002000