STATE OF FLORIDA ei ett AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA fap AGENCY FOR HEALTH CARE . rea ADMINISTRATION, Petitioner, AHCA No: 2003005327 vs. Return Receipt Requested 7002 2410 0001 4236 9076 NATIONAL HOME HEALTH NURSES, 7002 2410 0001 4236 9083 INC., d/b/a NATIONAL HOME HEALTH NURSES, 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 National Home Health Nurses, Inc., d/b/a National Home Health Nurses, Inc. (hereinafter “National Home Health Nurses” or the “home health agency”) 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 and maintain the Agency’s administrative fine in the amount of $10,500.00, pursuant to Sections 400.474, and 400.484(2) (c), Fla. Stat. 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 Miami-Dade County, pursuant to 120.57, Fla. Stat., and Chapter 28-106.207, F.A.C. PARTIES 4. AHCA 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. National Home Health Nurses is a home health agency located at 1790 W. 49° Street, Hialeah, Florida 33012, and is licensed under Chapter 400, Part IV, Fla. Stat., and Chapter 59A-8, F.A.C.; under license number 299991505. COUNT I NATIONAL HOME HEALTH NURSES FAILED TO MEET ALL REQUIREMENTS FOR PLANS OF CARE: THE HOME HEALTH AGENCY FAILED TO ADVISE THE PRIMARY PHYSICIAN OF CHANGES BEING MADE TO THE PLAN OF CARE AND/OR FAILED TO ENSURE THAT CARE FOLLOWED A WRITTEN PLAN OF CARE AND/OR FAILED TO OBTAIN PHYSICIANS’ OR NURSES’ SIGNATURES FOR THE INITIAL VERBAL ORDERS FOR SERVICES. 400.487, Fla. Stat., and/or 42 C.F.R. 484.18., 484.14 (c) (ACCEPTANCE OF PATIENTS, POC, MED SUPER AND CONFORMANCE WITH PHYSICIANS’ ORDERS) REPEAT CLASS III DEFICIENCY 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. During the Medicare/Medicaid Re-certification and State Re-licensure Survey conducted by the Agency on 10/10/02, and based on interview and record review, the Agency found that National Home Health Nurses failed to meet all requirements for plans of care: the home health agency failed to advise the primary physician of changes being made to the plan of care and/or failed to ensure that care followed a written plan of care and/or failed to obtain physicians’ or nurses’ signatures for the initial verbal orders for services. On 10/10/02, the Agency found that the home health agency failed to establish and follow a written Plan of Care in 14 out of 14 Sampled Patients. The findings include the following, to wit: (a) Review of the Plan of Care for Sampled Patient #1 revealed that the Start of Care date, Certification Period, Onset Date of Diagnosis, Verbal Start of Care Date, and Physician's Signature were missing. (b) Review of the Plan of Care for Sampled Patient #2 revealed that the Start of Care date, Certification Period, Verbal Start of Care Date, and Physician's Signature were missing. (c) Review of the Plan of Care for Sampled Patient #3 revealed that the Onset Date of Diagnosis, DME and Supplies, Safety Measures, Nutritional Requirements, Allergies, Mental Status, Goals, Verbal Start of Care Date, and Physician's Signature were missing. (d) Review of the Plan of Care for Sampled Patient #4, revealed that the Start of Care date, Certification Period, Onset Date of Diagnosis, DME and Supplies, Safety Measures, Nutritional Requirements, Allergies, Functional Limitations, Activities Permitted, Mental Status, Prognosis and Verbal Start of Care Date, and Physician's Signature were missing. (e) Review of the Plan of Care for Sampled Patient #5 revealed that the Start of Care date, Certification Period, Onset Date of Diagnosis, DME and Supplies, Safety Measures, Nutritional Requirements, Allergies, Functional Limitations, Activities Permitted, Mental Status, Prognosis, Verbal Start of Care Date, and Physician's Signature were missing. (f) Review of the Plan of Care for Sampled Patient #7 revealed that the Onset Date of Diagnosis, Safety Measures, Nutritional Requirements, Allergies, Activities Permitted, Mental Status, Prognosis, Verbal Start of Care Date, and Physician's Signature were missing. (g) Review of the Plan of Care for Sampled Patient #8 revealed that the Start of Care Date, Certification Period, Onset Date of Diagnosis, DME and Supplies, Safety Measures, Nutritional Requirements, Allergies, Functional Limitations, Activities Permitted, Mental Status, Prognosis and Verbal Start of Care Date, and Physician's Signature were missing. (h) Review of the Plan of Care for Sampled Patient #9 revealed that the Start of Care date, Certification Period, Primary Diagnosis, Onset Date of Diagnosis, DME and Supplies, Safety Measures, Nutritional Requirements, Allergies, Functional Limitations, Activities Permitted, Mental Status, Prognosis, Goals, Verbal Start of Care Date, and Physician's Signature were missing. (i) Review of the Plan of Care for Sampled Patient #10 revealed that the Start of Care Date, Certification Period, Onset Date of Diagnosis, DME and Supplies, Safety Measures, Nutritional Requirements, Allergies, Activities Permitted, Mental Status, Prognosis and Verbal Start of Care Date, and Physician's Signature were missing. (J) Review of the Plan of Care for Sampled Patient #11 revealed that the Medications, Verbal Start of Care Date, and Physician's Signature were missing. (k) Review of the Plan of Care for Sampled Patient #13 revealed that the Start of Care Date, Certification Period, Onset Date of Diagnosis, Medications, DME and Supplies, Safety Measures, Nutritional Requirements, Allergies, Activities Permitted, Mental Status, Prognosis and Verbal Start of Care Date, and Physician's Signature were missing. {1) Review of the Plan of Care for Sampled Patient #14 revealed that the Onset Date of Diagnosis, Safety Measures, Nutritional Requirements, Allergies, Functional Limitations, Activities Permitted, Mental Status, Prognosis, Verbal Start of Care Date, and Physician's Signature were missing. (m) Review of the Plan of Care for Sampled Patient #15 revealed that the Start of Care Date, Certification Period, Onset Date of Diagnosis, DME and Supplies, Safety Measures, Nutritional Requirements, Allergies, Activities Permitted, Mental Status, Prognosis and Verbal Start of Care Date, and Physician's Signature were missing. (n) Review of the Plan of Care for Sampled Patient #16 revealed that the Start of Care Date, Certification Period, Onset Date of Diagnosis, DME and Supplies, Safety Measures, Nutritional Requirements, Allergies, Activities Permitted, Mental Status, Prognosis and Verbal Start of Care Date, and Physician's Signature were missing. 8. There was no evidence of completed Assessments, or Clinical Notes contained in the clinical records. 9. Interview with the Administrator on 10/08/02, 10/09/02, and 10/10/02 revealed that these were the only Plan of Care documents available for these patients. 10. In addition, and based on interview and record review, the Agency found that the home health agency failed to document verbal orders in writing in 14 out of 14 Sampled Patients. The findings include the following, to wit: (a) Review of the clinical record of Sampled Patient #1 revealed that there were no verbal orders present in the record, and box #23 on the Plan of Care was blank. (b) Review of the clinical record of Sampled Patient #2 revealed that there were no verbal orders present in the record, and box #23 on the Plan of Care was blank. (c) Review of the clinical record of Sampled Patient #3 revealed that there were no verbal orders present in the record, and box #23 on the Plan of Care was blank. (d) Review of the clinical record of Sampled Patient #4 revealed that there were no verbal orders present in the record, and box #23 on the Plan of Care was blank. (e) Review of the clinical record of Sampled Patient #5 revealed that there were no verbal orders present in the record, and box #23 on the Plan of Care was blank. (f) Review of the clinical record of Sampled Patient #7 revealed that there were no verbal orders present in the record, and box #23 on the Plan of Care was blank. (g) Review of the clinical record of Sampled Patient #8 revealed that there were no verbal orders present in the record, and box #23 on the Plan of Care was blank. (h) Review of the clinical record of Sampled Patient #9 revealed that there were no verbal orders present in the record, and box #23 on the Plan of Care was blank. (i) Review of the clinical record of Sampled Patient #10 revealed that there were no verbal orders present in the record, and box #23 on the Plan of Care was blank. (j) Review of the clinical record of Sampled Patient #11 revealed that there were no verbal orders present in the record, and box #23 on the Plan of Care was blank. (k) Review of the clinical record of Sampled Patient #13 revealed that there were no verbal orders present in the record, and box #23 on the Plan of Care was blank. (1) Review of the clinical record of Sampled Patient #14 revealed that there were no verbal orders present in the record, and box #23 on the Plan of Care was blank. (m) Review of the clinical record of Sampled Patient #15 revealed that there were no verbal orders present in the record, and box #23 on the Plan of Care was blank. (n) Review of the clinical record of Sampled Patient #16 revealed that there were no verbal orders present in the record, and box #23 on the Plan of Care was blank. Based on all the foregoing, the Agency cited the home health agency with a Class III deficiency and assigned a mandated correction date of October 24, 2002. 11. During the Re-Certification and Re-licensure survey conducted by the Agency on 7/21-23/03 and based on record review and interview, the Agency again found that National Home Health Nurses failed to meet all requirements for plans of care: the home health agency failed to advise the primary physician of changes being made to the plan of care and/or failed to ensure that care followed a written plan of care and/or failed to obtain physicians’ or nurses’ signatures for the initial verbal orders for services. The Agency found that the home health agency failed to advise the primary physician of changes being made to the plan of care for 5 of 11 sampled patient records reviewed (for patients #4, #5, #7, #8 & #10). The findings include the following, to wit: (a) Review of the record for patient #4 revealed a Plan of Care (POC) requesting skilled nurse visits to be performed "1 x week x 60 days to monitor vital signs and supervise medications. Review of the clinical documentation showed the nursing staff making more than 1 visit weekly. Skilled nursing visits were made from May 27 through June 2, 2003 consecutively, and in addition from June 4 through June 6, 2003. (b) Review of sampled case #5 determined that the Plan of Care (PoC) dated 5/31/03 called for skilled nursing visits to be conducted three times a week and home health aide visits to be done 10 times a week. Review of the record determined that home health aide visits were documented as being made five times a week from 5/31 thru July 3, 2003. Furthermore, during a home visit, the patient stated that the aide comes to her home during the week Monday thru Friday, only once a day. (c) Review of sampled case #7 revealed that the agency provided home health aide services to the patient prior to the start of care (SoC) date. Home health services with an aide were provided from 6/22/03 through 6/28/03. (d) Review of sampled case #8 determined that the Plan of Care (PoC) dated 4/1/03 called for skilled nursing visits to be conducted twice a week. Review of the record revealed that visits were made once per week from April 27, 2003 thru July 11, 2003. (e) Record #10 revealed a POC requesting skilled nursing visits to be performed "4 (four) times daily x 60 days", and home health aide services to be performed, "7 days 10 a week for 60 days." Examination of the record indicated less than the specified number of skilled nursing visits as ordered by the physician on 20 (twenty) days. There was skilled nursing documentation missing from the record and none was documented or observed from May 25, 2003 through June 13, 2003. 12. During discussion with the administrator on 07/21/03 about the inconsistencies in the visits as compared to what is ordered in the Plan of Care, the administrator stated that many times after the Plan of Care has been developed, the nurses may find that there is a need for a change in the frequency of the visits, but that they have not been getting orders from the physician for these changes. 13. In addition, and based on record review and interview, the Agency found that home health aide services were not provided as per the PoC in 1 of 11 clinical records (for patient #2). The findings include the following: (a) Review of the sampled patient case #2 revealed that the PoC, dated 6/13/03, called for home health aide to assist with Activities of Daily Living (ADL's). Review of home health aide documentation, from 6/16 through 7/08/03, failed to document the prescribed ordered ADL's. il Interview with the administrator confirmed the absent documentation, and the administrator offered no explanation as to the omission or possible lack of care. 14. Also, based on review of records and interview, the Agency found that facility was not dating or having the physician sign the initial verbal orders for the initiation of services, in 6 of 11 cases (for patients #1, #2, #3, #5, #6, and #7). The findings include the following: 15. Review of the records revealed that the facility documents the initial verbal order for services on a form titled Physician's Order. For patients #1, #2, #3, #5, #6, and #7, the area for the date was blank. As a result, it was not possible to evaluate if the initial evaluation visit was conducted in a timely manner. Also, the orders were not counter-signed. 16. During discussion with the administrator on 07/22/03, the administrator stated that the forms were indeed not completed, as they were not dated, and that it is not their policy to have the initial orders for services counter- signed by the physician. 17. Based on the foregoing, National Home Health Nurses violated 400.487, Fla. Stat., and/or 42 C.F.R. 484.18, and 484.14 (c), herein classified as a repeated Class III deficiency, pursuant to Section 400.484(2)(c), Fla. Stat., 12 which carries a fine of $500.00 per patient/occurrence, x 9, for a total fine of $4,500.00. COUNT II NATIONAL HOME HEALTH NURSES FAILED TO ENSURE THAT THE REGISTERED NURSE MADE THE ONSITE VISITS EVERY TWO WEEKS. 42 C.F.R. 484.36(d) (2) and/or 59A-8.0095(1),(3), F.A.C. (SUPERVISION) REPEAT CLASS III DEFICIENCY 18. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 19. During the Medicare/Medicaid Re-certification and state Re-licensure survey conducted by the Agency on 10/10/02, and based on record review and interview, the Agency found that National Home Health Nurses failed to ensure that the registered nurse made the onsite visits every two weeks. The home health agency did not ensure that the HHAs providing patient care in the field were supervised every 2 weeks, as per regulation. The findings include the following, to wit: (a) Record review of all 15 sampled residents clinical records receiving SN, HHA and PT (when needed) PRN, did not contain any evidence that a supervisory visit was conducted in order to evaluate the Aide performance while providing care in the home setting. During interview with the Administrator, who is also a Registered Nurse, the Administrator stated that the supervisory visits are conducted while the HHA is providing the care, and the notes are mailed into the office. However, the Administrator was unable to produce the supervisory notes for the Agency’s surveyor’s review. Based on all the foregoing, the Agency cited the home health agency with a Class III deficiency and assigned a mandated correction date of October 24, 2002. 20. During the Re-certification and Re-licensure survey conducted by the Agency on 7/21-23/2003 and based on record review and interview, the Agency again found that National Home Health Nurses failed to ensure that the registered nurse made the onsite visits every two weeks. The Agency found that the registered nurse did not make onsite supervisory visits every two weeks for 7 of 11 records reviewed (for patients #2, #3, #5, #6, #8, #10, and #11). The findings include: (a) Review of patient record sample #2 revealed a patient receiving skilled nursing and home health aide services with a start of care date (SOC) of 6/16/03. Review of the record for care provided from 6/16 through 7/06 showed only one supervisory visit documented. Home health aide notes after 7/6 were not available or reviewed. Furthermore, review of the sampled patient case #2 revealed that the Poc, dated 6/13/03, called for home health aide to assist with Activities of Daily Living (ADL's). Review of home health aide documentation, from 6/16 through 7/08/03, failed to document M4 the prescribed ordered ADL's. Interview with the administrator confirmed the absent documentation, and the Administrator offered no explanation as to the omission or possible lack of care. (b) Review of patient record sample #3 revealed a patient receiving skilled nursing and home health aide services with start of care date (SOC) of 6/06/03. Review of the record for care provided from 6/06 through 7/10 did not reveal evidence of supervisory visit documentation. Home health aide notes after 7/10 were not available or reviewed. (c) Review of patient record sample #5 revealed a patient receiving skilled nursing and home health aide services with start of care date (SOC) of 5/31/03. Review of the record for care provided from 5/31 through 7/04 revealed only one supervisory visit. Home health aide notes after 7/04 were not available or reviewed. (a) Review of patient record sample #6 revealed a patient receiving skilled nursing and home health aide services with start of care date (SOC) of 6/16/03. Review of the record for care provided from 6/16 through 7/09 did not reveal evidence of supervisory visit documentation. Home health aide notes after 7/09 were not available or reviewed. (e) Review of patient record sample #8 revealed a patient receiving skilled nursing and home health aide 15 services with start of care date (SOC) of 4/01/03. Review of the record for care provided from 4/26 through 7/11 failed to document nursing supervisory visits for home health aides. There was absent documentation from 4/1 through 5/25. (f) Review of patient record sample #10 revealed a patient receiving skilled nursing and home health aide services with start of care date (SOC) of 4/15/03. Review of the record for care provided from 4/15 through 5/24 did not reveal evidence of supervisory visit documentation. Skilled nursing and home health aide notes after 5/24/03 were not available or reviewed. (g) Review of patient record sample #11 revealed a patient receiving skilled nursing and home health aide services with start of care date (SOC) of 3/19/03. Review of the record for care provided from 3/19 through 5/18 did not reveal evidence of supervisory visit documentation. 20. During discussion on 7/22/03, the administrator stated that the home health agency had identified this as a problem and has provided verbal reminders to staff to conduct supervisory visits. This is a repeat Class III deficiency. 31. Based on the foregoing, National Home Health Nurses violated 42 C.F.R. 484.36(d) (2), and/or 59A-8.0095(1), (3), F.A.C., herein classified as a repeated Class III deficiency, pursuant to Section 400.484(2) (c), Fla. Stat., which carries a 16 fine of $500.00 per patient/occurrence, xX 7, for a total fine of $3,500.00. COUNT III NATIONAL HOME HEALTH NURSES FAILED TO MAINTAIN ACCURATE AND COMPLETE CLINICAL RECORDS. 42 C.F.R. 484.48, Chapter 400.491, Fla. Stat. and/or 59A- 8.022, F.A.C. (CLINICAL RECORDS) REPEAT CLASS III DEFICIENCY 32. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 33. During the Medicare/Medicaid Re-certification and State Re-licensure survey conducted by the Agency on 10/08- 10/02, and based on interview and record review, the Agency found that National Home Health Nurses failed to maintain accurate and complete clinical records. The home health agency failed to maintain a complete clinical record for each patient receiving care in 14 out of 14 sampled patients. The findings include: (a) Review of sampled patients #1, #2, #3, #4, #5, #7, #8, #9, #10, #11, #13, #14, #15 and #16 revealed there was no evidence of documentation of evaluations, clinical notes, or case conferences in order to provide for coordination of services and supervision according to the Plan of Care to occur. The Agency cited the home health agency with a Class 17 III deficiency and assigned a mandated correction date of October 24, 2002. 34. During the Re-certification and Re-licensure survey conducted by the Agency from 7/21/-23/2003 and based on record review and interview, the Agency found that National Home Health Nurses failed to maintain accurate and complete clinical records. The home health agency failed to ensure the maintenance of clinical records and/or that correction to documentation was accomplished appropriately in 5 of Il records reviewed (for patients #2, #4, #6, #7 and #8). The findings include the following: (a) Review of the clinical record for sampled case #2 revealed numerous corrections made in various records including home health aide notes and skilled nursing notes. The changes were made to incorrect dates that were documented in the notes. For example, the home health aide care plan had a date of 6/13/03 that was written over twice to reflect 6/16/03 and the wound care note for 6/16/03 had an unaltered date of 6/13/03 that had been written over with 6/16/03. (ob) Sampled patient record #4 failed to document appropriately the correct dates of skilled nursing encounters. The nurse's progress notes and home health aide note’s dates were altered on 5/21, 5/29, and 6/30. In addition, some of the clinical progress notes were absent. 18 (c) Sampled patient #6’s record failed to document appropriately the correct dates of skilled nursing encounters. Examination of the clinical record indicated alteration of the dates written. Additionally, some of the clinical progress notes were absent. (ad) The clinical record for sampled patient #7 failed to demonstrate documentation by skilled nursing from 7/6 to 7/20. In addition, the record failed to show evidence of home health aide documentation from 7/8 through 7/20. (e) Review of the clinical record for sampled case #8 revealed numerous corrections made in various records including home health aide notes and skilled nursing notes. The changes were made to incorrect dates that were documented in the notes. For example, nurse's note for 7/4/03 had the date written over several times. 35. During interview with the administrator on 07/21/03the administrator stated that she, "meets with the staff weekly and has discussed the need for accurate documentation, and that this is an ongoing area of improvement." This statement was confirmed by reviewing meeting minutes and quality assurance documentation. This is a repeat deficiency. 36. Based on the foregoing, National Home Heaith Nurses violated 42 C.F.R. 484.48, and/or 400.491, Fla. Stat., 19 and/or 59A-8.022, F.A.C., herein classified as a repeated Class III deficiency, pursuant to Section 400.484 (2) (c), Fla. Stat., which carries a fine of $500.00 per patient/occurrence, x 5, for a total fine of $2,500.00. 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 through III. B. Assess and maintain the Agency’s administrative fine totaling $10,500.00 against National Home Health Nurses, in accordance with §400.484(2)(c), Fla. Stat. C. Award the Agency for Health Care Administration reasonable attorney’s fees, expenses, and costs, if the Court finds that costs are applicable, and 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 20 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 21 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 Maida Bacondelmar, Administrator, National Home Health Nurses, Inc., 1790 W 49" Street, Hialeah, Florida 33012 and to Margarette Abelard, Registered Agent, 1800. W. 49°* Street, Hialeah, Florida 33012, on fy : as , 2003. Kaghryn F. Fenske, Esq. 22

Docket for Case No: 03-003854