——— eet ee STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION(; AGENCY FOR HEALTH CARE Cig ADMINISTRATION, Be Mas Petitioner, vs. AHCA NO. 2005008407 SENIOR HOME CARE, INC. Respondent. . ey f ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “Agency”), by and through its undersigned counsel, and files this. _ Administrathve Complaint against Respondent, SENIOR HOME CARE, INC, (hereinafter “Respondent”) pursuant to Sections 120.569 and 120.57, Florida Statutes (2004), and as grounds therefore, alleges the following: NATURE OF THE ACTION 1. This is an action to impose an administrative fine in the total amount of three thousand dollars ($3000.00) against SENIOR HOME CARE, INC. pursuant to Sections 400.474(2)(a) and 400.484(2)(b), Florida Statutes (2004) based on two (2) uncorrected class III deficiencies cited at a Survey on or about March 7, 2005. JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes (2004), . ——_— eee ee oe At SE AS TMG Weel 3. The Agency has jurisdiction over Respondent pursuant to Chapter 400, Part IV, Florida Statutes (2004). | 4, Venue shail be determined pursuant to Rule 28-106.207, Florida Administrative Code (2004). | PARTIES 5. Pursuant to Chapter 400, Part IV, Florida Statutes, and Chapter 59A-8, Florida Administrative Code, the Agency Is the regulatory agency responsible for the licensure of home health agencies and for the enforcement of all applicable state laws and rules governing home health agencies, ; 6. At all times material hereto, SENIOR HOME CARE, INC, was a home health agency located at 4048 Evans Ave., Suite 204, Fort Myers FL. 33901. 7. At all times material hereto, Respondent was licensed by the ‘Agency to operate a home health agency In Lee County having been issued license number 21830096 by the Agency. 8. At all times relevant hereto, SENIOR HOME CARE, INC. is and was a licensed home health agency required to comply with Chapter 400, Part IV, Florida Statutes, and Chapter 59A-8, Florida Administrative Code. COUNTI THE AGENCY FAILED TO ENSURE THAT A PATIENT WITH HOME HEALTH AIDES RECEIVED CARE AND SERVICES AS ORDERED IN THE PLAN OF CARE ESTABLISHED BY THE REGISTERED NURSE, in violation of Coda nll ed Fe ale DO PIT Rule 59A-8.0095(5), Florida Administrative Code (2004) CLASS IIT DEFICIENCY 9. The Agency re-alleges and incorporates by reference paragraphs one (1) through eight (8) above as if fully set forth herein. 10. Rule 59A-8.0095(5), Florida Administrative Code (2004) reads in part: (5) Home Health Aide and Certified Nursing Assistant. = (a) A home health aide or a certified nursing assistant (CNA) shall provide personal care services assigned by and under the supervision of a registered nurse. When only physical, speech, or occupational therapy is furnished, in addition to home health alde or CNA services, supervision can be supplied by a licensed therapist directly employed by the home health agency or by an independently contracted employee. (b) Supervision of the home health aide and CNA by a registered nurse in the home will be In accordance with Section 400.487(3), F.S. Home health - agencies will need to obtain the patient’s verbal permission to send a registered nurse into the home to conduct supervisory visits. 11. In a Survey conducted on or.about March 7, 2005, the " following deficiency in violation of the preceding provision was found by agency Surveyors: Based on clinical record review, the agency failed to ensure 1 (#32) patient, with home health aides (HHA) received care and services as ordered in the plan of care and per care plan established by the registered nurse. Finding include Patient #32 was admitted to the agency on 2/19/05 with physiclan orders, which included Home Health Aide. Review of the care plan established by the registered nurse dated 2/19/05 revealed the Aide was to perform "Nail Care" with each visit. The alde made Cot te ed Pe MOLI Lee fie vc PTT a visitation on 2/25/05 and did not perform nail care or contact the agency Office to seek guidance. 12. This was an uncorrected deficiency as, on or about January 13, 2005, Agency surveyors found the same deficiency. Based on clinical record review, the agency failed to ensure 4 of 6 patients with home health aides (HHA) received care and services as ordered in the plan of care and per care plan established by the registered nurse, Findings include; 1, Patient #13 was admitted to the agency on 12/17/04 with physiclan orders, which included home health alde 2 times per week for 3 weeks. The HHA was to take the patient's temperature, pulse and respirations, assist with bathing, oral hygiene, dressing and activities of daily living along with transfers and ambulation. Review of the care plan established by the registered nurse dated 12/17/04 revealed the following: ‘ - All personal care is per patient request including vital signs, - There was no direction to the HHA as to what type of bath to give. ~ The only activity checked was " walker. " - The nurse did not instruct the HHA to transfer or ambulate the patient, - Review of the HHA visit notes revealed the HHA was assisting with transfer and ambulation and was performing chores. - The care plan as established by the registered nurse was not being followed the HHA. - The care plan established by the registered nurse did not reflect the orders from the Physician. , 2. Patlent #14 was admitted to the agency on 12/19/04 with a primary diagnosis of Malignant Neoplasm of the ovary. The patient was to have the services of skilled nurse and a home health aide. Per the aide assignment sheet, the aide was to provide the patient with a shower, vital signs and reminding of the patlent to weigh herself daily. The aide made visits on 12/21/04, 12/22/04, 12/28/04 and 12/29/04, On each of these visits, the aide gave the patient a sponge bath. The aide assignment sheet did not reflect the change to a sponge bath and it could not be seen In the record that the aide contacted the agency office to seek guidance for the change from a shower to a sponge bath, - Poet ——— i ee Reem ee ee elie 3. Patlent #22 was admitted to the agency on 12/15/04 with physician orders that included the HHA to take the patient ‘ s temperature, pulse and respirations, assist with bathing, oral hygiene, dressing and activities of daily ~ living along with transfers and ambulation. The HHA was to assist the patient with the exercise program as Instructed by the Therapist. The care plan established by the registered nurse on 12/15/04 did not include the instructions to assist the patient with home exercise, or ambulation. Assistive devices include a walker only. Review of the HHA visit notes revealed the HHA was using a wheelchair with the patient. The HHA was assisting with ambulation even though this was not on the care plan. In addition, the aide was not assisting with hair care oral hygiene, nail or skin care as assigned on the plan of care. 4, Patient #24 was admitted on 11/27/04 with physician orders which included HHA to take temperature, pulse and respirations each visit and assist with bathing, oral hygiene, dressing and activities of facility living. The care plan established by the registered nurse instructed in the plan of care reflects physician orders. A review of the home health aide visits revealed that the home health aide was not assisting the patient with hair or nail care and was not assisting with the changing of the bed linens, light housekeeping or laundry. 13. The original mandated correction date for this deficiency was .February 13, 2005. This date of correction was not met as indicated by Paragraph 11 above, 14, This is characterized as an uncorrected class III deficiency for which an administrative fine in the amount of five hundred dollars ($500.00) is appropriate pursuant to Section 400.484(2)(c), Florida Statutes (2004) which provides: Steet att haere Py ee P et tl eed Fe ete ee 400.484 Right of inspection; deficiencies; fines.— (2) The agency shall Impose fines for various classes of deficiencies in accordance with the following schedule: (c) A class III deficlency is any act, omission, or practice that has an indirect, adverse effect on the health, safety, or security of a patient, Upon finding an uncorrected or repeated class III deficiency, the agency may Impose an administrative fine not to exceed $500 for each occurrence and each day that the uncorrected or repeated deficlency exists. COUNT II THE AGENCY FAILED TO PROVIDE CARE THAT FOLLOWED THE PLAN OF TREATMENT FOR PATIENTS, in violation of Section 400.487, Florida Statutes (2004) CLASS ITI DEFICIENCY 15. * The Agency re-alleges and incorporates by reference ° Paragraphs one (1) through eight (8) above as If fully set forth herein. (2) ae 16, Section 400.487, Florida Statutes (2004) provides in part: When required by the provisions of chapter 464; part I, part ITI, or part V of chapter 468; or chapter 486, the attending physician, physician assistant, or advanced registered nurse practitioner, acting withIn his or her respective scope of practice, shall establish treatment orders for a patient who Is to receive skilled care. The treatment orders must be signed by the physiclan, physician assistant, or advanced registered nurse practitioner before a claim for payment for the skilled services is submitted by the home health agency. If the claim is submitted to a managed care organization, the treatment orders must be signed within the time allowed under the provider agreement. The treatment orders shall be reviewed, as frequently as the patient's illness requires, by the physician, physician assistant, or advanced registered nurse practitioner in consultation with the hame health agency. , Ae Ae Pe Feu we eo ee LT eT : (6) The skilled care services provided by a home health agency, directly or under contract, must be supervised and coordinated in accordance with the plan of care. 17. Ina survey conducted on or about March 7, 2005, the following deficiency in violation of the preceding statute was found by agency surveyors: Based on a review of 10 clinical records, the agency failed to provide care that followed the plan of treatment in 5 (Patients #26, #27, #31, #33 and #34) cases. The findings include: 1. Patient #26 was admitted to the agency on 2/14/05. Per the plan of treatment (POT), skilled nursing was to “instruct the patient to use an incentive spirometer 4x day for 10 reps." The only documentation in the _ Clinical record was dated 2/17/05 with no evaluation of patient's competency recorded. Fhere was no documentation of teaching having been completed at start of care or after 2/17/05, Physician's telephone order dated 2/21/05 Stated, "at each visit the Home Health Aide (HHA) to assist with bathing, oral hygiene, dressing and activities of daily living." The HHA care plan prepared by the registered nurse provided this care on an “as needed" basis rather than at each visit per physician's order, 2, Patient #27 was admitted to the agency with 2/24/05 as a start of care date. Per the POT, skilled nursing was to provide wound/incision care and perform wound care as follows: "Patient to wash incislon dally with antibiotic soap and water and apply dry sterile dressing and tape as needed for drainage only." There was no documentation in the clinical record of the patlent having been taught wound care or any evaluation of the patient's competency in performing this procedure, . 3. Patient #31 was admitted to the agency on 2/15/05 with a POT for occupational therapy -to visit the patient 1 time per week x 1 week and 2 times per week for 3 weeks. Review of the clinical record revealed documentation the physical therapist visited the patient 1 time during week of 2/25/05. There was no explanation in the record for the missed visit. Per a physician's telephone order dated 3/4/05, the following orders were received: “Patient discharge from nursing service goal met and remain on physical therapy only." Documentation in the clinical record revealed a te ee oh toe Pw NET Rd FINE Ce Te skilled nursing visit was made to the patient's hame on 3/5/05 without a physician's order. : 4, Patient #34 was admitted on 2/9/05 with physician's orders that include "Instruct in medications." Review of the record revealed the Patient #34 was prescribed only 3 medications. On 2/23/05, after five nursing visits had been made and no medication had been done, the agency obtained a physician's order to extend nursing services for 2 weeks to "teach meds." As of 3/7/05, the date of this survey, there still had not been any medication teaching for this patient. 5. Patient #33 had-a start of care date of 1/30/05 with a certification period of 1/30/05 through 2/30/05. Per the POT, physical therapy was to visit the patient 3 times’ per week for 4 weeks, effective 1/31/05 and 2/7/05. Review of the clinical record revealed documentation the physical therapist visited the patient 1 time during week of 2/23/05. There was no explanation in the record for the missed visit, 18. This was an uncorrected deficiency as, on or about January 13, 2005, Agency surveyors found the same deficiency. Based on Clinical record review, interview with the agency 's Director of Clinical Services (DCS) and agency administrator, and review of the agency ' § policies and procedures, the agency failed to ensure 11 of 25 sampled patients (#3, #6, #8, #14, #17, #18, #19, #21, #22, #23, and #24) . received services as ordered by the attending physician, nor was the physician notifled of these deviations from the plan of treatment. In addition, two Plan of Treatments were not signed by the physician within the 30 days time frames (#'s 2 & 4) Findings include: 1. Patient #3 was admitted to the agency on 10/6/04, for diagnoses that included decubitus ulcer buttocks, paraplegia, and protein-calorie malnutrition, Per the POT (Plan of Treatment) dated 12/5/04, nursing was to see this patient 3 tlmes per week for 2 weeks, The POT had orders for skilled nursing to cleanse buttock wound with normal saline, pat dry, pack with foam, use skin prep around wound, and apply wound vac. Documentation in the nursing clinical note for 12/6/04 and 12/8/04 revealed the nurse used adaptic dressing to edge of wound. There was no physician ' s order in the POT for skilled nursing to apply this wound dressing. The physician was not notified in this deviation from the POT or the need for the possible need to change the orders, © 2, Patient #4 was admitted to the agency on 11/13/04 with physician orders for Skilled nursing, Physical Therapy, Occupational Therapy, Speech ’ Therapy, a Home Health Aide and a Medical Social Service Worker. Per the POT (Plan of Treatment), the physical therapist was to see the patient 3 times a week for 4 weeks, effective 11/16. The physical therapist saw the patient on 11/15/04 for an evaluation. There was no order for that visit. Between 11/16/04 and 12/5/04, the therapist only saw the patient twice a week. During the 4th week of service, the physical therapist saw the patient 3 times. On 12/9/04, a new order was received from the physician that instructéd the therapist to continue to treat the patient 3 times a week for another 4 weeks effective 12/13/04. During the weeks of 12/13/04 and 12/20/04, the physical therapist only saw the patient twice a week. The physician was not made aware of the need of additional therapy orders. The plan of treatment for this patient was signed on 12/20/04, 37 days after the patient was admitted to the agency. The Occupational theraplst was to see the patient for an evaluation. The OT did not see this patient until 11/22/04 (9 days after the start of care). The OT then proceeded to see the patlent 3 times a week for the next 4 weeks without the benefit of physician's orders. On 12/13/04, the OT received orders to continue services 3 times a week for 3 weeks and 1 time a week for 1 week (from 12/20/04 thru 1/11/05). .3. Patient #8 most recent recertification date is 12/19/04. The patient was being rated for an open wound to the right leg. Physician orders included applying antibiotic cream to the wound. Observation during a home visit on 1/11/05 revealed the nurse applied antibiotic ointment instead of the cream. The physician was not contacted - for the change from the cream to the ointment. 4, Record review for Patient # 17 conducted on 1/11/05 revealed the patient was admitted to the agency 's service on 6/21/04 with a diagnosis of Urinary incontinence requiring an indwelling catheter. Physician orders for the certification period 6/21/04-8/19/04, and 8/20/04-10/18/04 was for SN (Skilled Nursing) to insert Foley catheter, change every month, and prn (as needed) for displacement, occlusion or leakage of Foley, and Irrigate Foley with 100 cc's of NS (Normal Saline) prn. Assess and instruct s/s (signs and symptoms) of UTI (urinary tract infection), catheter care and emergency removal. , . i Bee bbe Co een” The Certification Period for 10/18/04-12/19/04 added a diagnosis of constipation, and added ta the orders, assess and instruct patient of catheter, and catheter care and emergency removal. Patient has history of constipation. Caregiver follows.bowel regime per M.D, (Medical Doctor). Nursing narrative notes dated 6/21/04 listed a nursing diagnoses of altered skin integrity due to incontinence, superficial wounds scabbed on left groin and hip area. These wounds were not addressed in the section of the’ Nursing Clinical Note for the assessment of skin. There was no documentation that the spouse was instructed in the s/s of UTI, catheter care or emergency removal. On 6/25/04, the Nurse checked for impaction and applied Bag Balm to reddened area in the perineal and buttocks area. On 6/29/04, the Nurse indicated the patient had reddened areas in the groin area, continues with medication 4 times a day for back pain, also mentioned the patient was checked for impaction, and some stool was removed. Bag Balm applied to reddened bottom and groin. On 9/13/04, notes Indicated Lab work was done, A & D ointment used, On 1/3/05, the spouse reported "2 sores" on the right side; the nurse cleaned with normal Saline and applied hydrocolloid. There was no documentation to support the order for the Nurse to check for impaction, skin care or wound care. In an interview with the Administrator and the Director of Clinical Services on 1/12/05 at approximately 4:00 P.M, confirmed there were no orders for the nurse to check for and remove impaction, and for the skin or wound care. ; After surveyor intervention a Physician's Telephone Order Confirmation was initiated to include SN may check for impaction prn and may dis-impact prn. 5. Patient #18 had a start of care dated 11/14/04 with a certification period from 11/14/04 through 1/12/05 for diagnoses that included Alzheimer's ‘ disease and fitting urlnary devices due to incomplete bladder emptying. The patient was receiving care from skilled nursing and occupational therapy. Per POT dated 12/13/04, skilled nursing was to vislt this patient 1 time per week for 1 week to recheck the Protime with INR. There was no documentation this order was followed. Clinical records revealed patient was totally discharged from skilled nursing on 12/14/04 with a notation that " goals were met and maximum potential achieved." Further review of 10 Cl tte let cate fT ———————— a =o © record on 12/14/04 revealed documentation that skilled nursing changed the Foley catheter without an order from the physician. A physician's telephone order was received by nursing on 1/10/05 that read, " May recertify patient for home health." The order was incomplete as it did not have any discipline, treatments for specific care, or any frequency of visits, 6. Patient #19 start of care was dated 12/23/04 with a diagnosis of fitting cardiac pacemaker. Skilled nursing was to assess vital signs and integumentary and cardiovascular Status. Instruct In medications, diet, disease process, s/s of complications and home safety. Documentation in the skilled nursing notes for 12/31/04 revealed on 12/27/04 " removal of sutures left upper chest wall." . There was no order in the POT for skilled . nursing to remove these sutures, 7. Patient #21 had a start of care date of 10/20/04 with a recertification of | 12/19/04 through 2/16/05. Services provided per the POT included home health aide, skilled nursing, and speech therapy. Speech therapy was to visit the patient 1 times a week for 1 week, and 3 times a week for 7 weeks, Review of the clinical record revealed no speech therapy notes or visits after 12/16/04 with no explanation provided. ; 8. Patient #22 was admitted on 12/15/04 with physician orders including physical therapy 3 times per week times 4 weeks Review of clinical record revealed the physical therapist did not start treatment until the second week of the certification. There was no documentation as why the physical therapist did not start treatment the first week. The clinical record also revealed the occupational therapist (OT) is seeing the patient. However, there were no physician orders for the OT to see this patient, 9. Patient #24 was admitted to the agency on 11/27/04 with an open wound to the foot and peripheral vascular disease, Physiclan orders included skilled nursing care, physical (PT) and occupational therapy (OT) treatment, Review of the clinical record reveals the following. - Anurse's note dated 11/27/04 revealed the nurse applied Telfa to a groin wound. There were no physician orders for this treatment. ~ A nurses note dated 12/3/04 revealed the nurse applied a DuaDerm to the patient's hip. There were no physician orders for this treatment. - A nurse note dated 1/2/05 revealed the nurse applied a wet to dry dressing, Physician orders were to apply Silvadene cream to the wound, : ee KT et a Peete eat Netter tent I Eee Review of physical therapy notes revealed the therapist was to see the ; patient 3 times per week. Review of the clinical record revealed the PT saw the patlent only 2 times per week, the week of 11/30/04 and 12/6/04. New orders were obtained for an occupational evaluation 12/30/04. The record lacked any OT visits after 1/30/05. 10. Patient #14 was admitted to the agency on 12/19/04 for nursing and personal care services. The patient was noted to be Oxygen dependent and the orders on the POT included orders for the nurse to do a daily pulse ox (the patient was to be seen daily by the nurse for 11 days) on the patient,. and titrate the Oxygen liters according to the pulse ok results when it was: tested. On the day of admission, the pulse ox reading was 88%. The ~ clinical record contained no visit for 12/26/04 or any reason for the missed visit. The patient was seen the next day but no Pulse ox reading was documented for that date, It could not be determined that the physician was notified of these omissions. 11. Patient #23 was admitted to the agency on 12/4-04, with orders for skilled nursing, a home health aide, physical therapy, and occupational therapy. The home health aide was ordered twice a week for three weeks, A review of the record showed that the aide only saw the patient once a week, On 12/22/04, the nurse documented that the patient had fallen that morning. No injuries were noted. On the same day, the physical therapist documented that same day that the patient seemed depressed and out of focus. Nelther of these findings was reported to the physician. On 12/23/04, the therapist documented: “does not focus on task- no interest in activity. Shows symptoms of withdrawal." This was not reported to the physician. 12. Patient #6 was admitted to the agency on 12/3/04 with a primary diagnosis of Drug Abuse. The history given In the clinical record shows that the spouse had been the primary caregiver, however, due to a recent stroke, was in a rehabilitation center. Various family members who did not live locally continued care. It was also documented that the patient's blood sugars had been running in the 140's, On 12/4/04, the nurse documented 2 blood sugars, 543 and 477. The nurse continued to see the patient in the home and recorded blood sugars: 12/7/04-264, 12/10/04-77, 12/13/04- 426,and 12/15/04-351. It could not be seen that the physician ever notified the physician of these elevated blood sugars or sought to obtain orders for extra nursing visits. : 12 wT eee BEE” 13. Patient #2 was admitted to the agency on 8/20/04. The plan of treatment was not signed by the physician until 9/20/04, 40 days after the care of the patient was established. 19, The original mandated correction date for this deficiency was February 13, 2005. This date of correction was not met as Indicated by paragraph 17 above. 20. This Is characterized as an uncorrected class III deficiency for - which an administrative fine in the amount of five hundred dollars ($500,00) ‘per the five patients Impacted is appropriate pursuant to Section 400.484(2)(c), Florida Statutes (2004) which provides: 400.484 Right of inspection; deficiencies; fines.— (2) The agency shall impose fines for various classes of deficiencies in accordance with the following schedule: (c) A class III deficiency is any act, omission, or practice that has an indirect, adverse effect on the health, safety, or security of a patient. Upon finding an uncorrected or repeated class III deficiency, the agency may impose an administrative fine not to exceed $500 for each occurrence and ‘each day that the uncorrected or repeated deficiency exists. CLAIM FOR RELIEF WHEREFORE, the Agency respectfully requests the following relief: 1) Make factual and legal findings in favor of the Agency on Counts Tand II; ) . 2) Impose a fine of five hundred dollars ($500.00) for Count I agalnst Respondent and a fine of two thousand five hundred fans Sethe Sa | Ge VOLT Lan seo dirs PTT peed ot dollars ($2500.00) for Count II for a total fine of three thousand dollars ($3000.00); 3) Enter whatever other relief as this court deems just and appropriate, NOTICE Respondent hereby is notified that it has a right ta request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2004). Specific options for administrative action are set out in the attached Election of Rights form and explained in the attached Explanation of Rights form. All requests for a hearing shall be sent to Richard Shoop, Agency Clerk, Agency for. Health. Care Administration, 2727 Mahan Drive, Building 3, Mail Stop #3, Tallahassee, Florida, 32308. RESPONDENT IS FURTHER NOTIFIED THAT IF THE REQUEST FOR HEARING IS NOT RECEIVED BY THE AGENCY WITHIN TWENTY-ONE (21) ‘DAYS OF RECEIPT OF THIS ADMINISTRATIVE COMPLAINT BY RESPONDENT, A FINAL ORDER WILL BE RENDERED BY THE AGENCY FINDING THE: DEFICIENCY AND/OR VIOLATION CHARGED AND IMPOSING THE PENALTY SOUGHT IN THE ADMINISTRATIVE COMPLAINT, 14 POT Sr dae TTT Bar No.: 3339067 Respondent’s Counsel Assistant Genera] Counsel Agency For Health Care Administration , ; 2295 Victoria Avenue, Room 346C Fort Myers, FL 33901-3884 - (239) 338-3203 (239) 332372 fax CERTIFICATE OF SERVICE u I HEREBY CERTIFY that one original Administrative Complaint has been sent via certified mail return receipt requested (return receipt # 7004 2510 0007 6070 9107) to Marsha Moore, Administrator, SENIOR HOME CARE, INC., 4048 Evans Ave., Suite 204, Fort Myers FL 339010n this_=4/ day of October, 2005. FOWLER Ct ltl eed Tre eat

Docket for Case No: 05-004668