STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2006006153 Return Receipt Requested: v. 7002 2410 0001 4234 6930 7002 2410 0001 4234 6947 NANY HOME HEALTH CARE, INC. d/b/a NANY HOME HEALTH CARE INC., Respondent. po a) l ~AISB i) ADMINISTRATIVE COMPLAINT COMES NOW the State of Florida, Agency for Health Care Administration (“AHCA”), by and through the undersigned counsel, and files this administrative complaint against Nany Home Health Care, Inc. d/b/a Nany Home Health Care Inc. (hereinafter “Nany Home Health Care Inc.”), pursuant to Chapter 400, Part IV, and Section 120.60, Florida Statutes, and herein alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine of $1,000.00 pursuant to Section 400.484, Florida Statutes for the protection of public health, safety and welfare. JURISDICTION AND VENUE 2. AHCA has jurisdiction pursuant to Chapter 400, Part IV, Florida Statutes. 3. Venue lies in Miami-Dade County pursuant to Rule 28.106.207, Florida Administrative Code. PARTIES 4. AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing home health agencies, pursuant to Chapter 400, Part Iv, Florida Statutes and Chapter 59A-8 Florida Administrative Code. 5. Nany Home Health. Care Inc. operates a home health agency located at 9010 S. W. 137 Avenue, #111, Miami, Florida 33186. Nany Home Health Care Inc. is licensed as a home health agency under license number 21869096. Nany Home Health Care Inc. was at all times material hereto a licensed facility under the licensing authority of AHCA and was required to comply with all applicable rules and statutes. nw COUNT I NANY HOME HEALTH CARE INC. FAILED TO PROVIDE APPROPRIATE GOALS AS OUTLINED IN THE PLAN OF CARE. RULE 59A-8.0095(3) (a), FLORIDA ADMINISTRATIVE CODE. CLASS III 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. Nany Home Health Care Inc. was cited with two (2) Class III deficiencies due to complaint investigation surveys conducted on April 17, 2006 and May 19, 2006. 8. A complaint investigation was conducted on April 17, 2006. Review of the clinical record for sample patient #3 revealed a Home Health Certification and Plan of Care dated 1/30/06. The diagnoses for the patient included diabetes Mellitus and decubitus ulcer to the right heel. The Plan of Care identified the need for daily skilled nursing visits to administer insulin and provide wound care. The specific instructions for the skilled nurse included a sliding scale for regular insulin administration as follows: a. For blood sugar level 200 to 250 4 units b. 251 to 300 - 6 units c. 301 to 350 - 8 units d. 351 to 400 - 10 units e. For blood sugar more than 401 12 units and call physician. 9. Additionally, the skilled nurse was to evaluate integumentary status, effectiveness of medication regimen and symptomatology related to disease complications. Document client's and caregivers response to learning. Skilled nurse to reinforce diabetic teachings. Skilled nurse to report abnormal findings to physician every visit. 10. Review of the skilled nurse's noted dated 1/31/06 revealed that the patient's wound measured 4.5 X 4.5 X 0.5. The skilled nurse documented cleaning the wound with normal saline, applied Granulex spray, covered with 4 xX 4 gauze and applied boot, no distress noted. There was no documentation in the note of the wound appearance, drainage, signs and symptoms of infection. 11. Review of the discharge assessment dated 1/31/06 revealed that the patient was admitted to an acute hospital for urgent care. The discharge assessment revealed that the reason for hospitalization was wound infection, deteriorating wound status, new lesion/ulcer. 12. Interview with the DON on 4/17/06 at 12:22 PM revealed that the patient had to be admitted to the hospital due to deterioration of his/her wounds and that the skilled nurse did not document appropriately. The DON further revealed that he/she provides in-services about documentation to the skilled nurses but that the nurses do not follow instructions. 13. Further review of the clinical record revealed a resumption of care order dated 2/4/06. 14. Review of the skilled nurse's notes revealed that on 3 different occasions, the blood sugar levels were between 200 to 250 and the skilled nurse documented that he/she administered Regular insulin 6 units instead of the 4 units ordered: a. 2/14/06 - blood sugar level - 244. b. 2/16/06 - blood sugar level - 249. c. 2/19/06 - blood sugar level -244. 15. There was no documentation of wound care performed during the skilled nurse's visits on 2/19/06, 2/21/06, 2/22/06, 2/25/06, 2/26/06. 16. Review of the discharge assessment dated 3/28/06 revealed that the patient was transferred to an acute care hospital for deterioration of wound status. 17. Interview with the director of nurses on 4/17/06 at 12:42 PM revealed that the skilled nurse was not available to interview. The director of nurses further revealed that the clinical record had not yet been through quality assurance and that was the reason why the mistakes had not been caught yet. The director of nurses revealed that sample patient # 3 had not been discharged from the hospital yet as of 4/17/06. 18. The mandatory date of correction was designated as May 17, 2006. 19. A follow-up survey was conducted on May 19, 2006. Based on record review and interview, it was determined that the agency failed to provide care and services to reach appropriate goals as outlined in the plan of care for 3 of 3 sampled patients receiving wound care. The findings include the following. 20. Review of the clinical record of sample patient #1, start of care 4-21-06, revealed that the goals for the patient as stated on the plan of care were to demonstrate proper wound care and verbalize knowledge of disease management, medications, side effects, precautions, diet, fluids, and treatment program. The plan of care for the skilled nurse failed to include any teaching of the patient to facilitate the patient reaching the stated goals. The sampled patient was >80 years old and had wounds on both arms. The goal to demonstrate proper wound care was inappropriate for the patient. 2 hands were needed to do the wound care and the physician had not ordered the patient to be taught to do his/her own wound care. There was no evidence of documentation in the clinical record of the sampled patient during the home visits that included any education working toward the stated goals. 21. Review of the clinical record of sample patient #2, start of care 4-26-06, revealed that the goals for the patient as stated on the plan of care were to demonstrate proper wound care and understand that hypertension is a chronic disease requiring life long treatment, adhere to a low salt diet. The sampled patient was >90 years old and had a documented head wound and a wound somewhere on the right leg. The goal to demonstrate proper wound care was inappropriate for the patient. Neither the head wound or the leg wound areas were identified appropriately and the physician had not ordered the patient to be taught to do his/her own wound care. There was no evidence of documentation in the clinical record of the sampled patient during the home visits that included any education working toward the stated goals. 22. Review of the clinical record of sample patient #3, start of care 4-24-06, revealed that the goal for the patient as stated on the plan of care was to demonstrate proper wound care. The sampled patient was >80 years old and had a wound on the left ankle. The goal to demonstrate proper wound care was inappropriate for the patient. The physician had not ordered the patient to be taught to do his/her own wound care. This is an uncorrected deficiency from the survey of April 17, 2006. 23. Based on the foregoing facts, Nany Home Health Care Inc. violated Rule 59A-8.0095(3) (a), Florida Administrative Code, herein classified as an uncorrected Class III deficiency, which warrants an assessed fine of $500.00. COUNT II NANY HOME HEALTH CARE INC. FAILED TO DEVELOP A PLAN OF CARE THAT INCLUDED THE FREQUENCY OF NURSES’ VISITS AS ORDERED BY THE PHYSICIAN. SECTION 400.487 (6), FLORIDA STATUTES CLASS III . 24. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 25. A complaint investigation survey was conducted on April 17, 2006. Based on record review and interview, it was determined that the agency nurse failed to perform wound care as ordered for 5 of 5 sample patient (#1, #2, #3, #4, #5). The findings include the following. 26. Review of the clinical record for sample patient #1 revealed a Home Health Certification and Plan of Care dated 1/27/06. The principal diagnosis was decubitus ulcer. The specific orders for the skilled nurse were to clean the right heel ulcer with normal saline, apply accuzyme, cover with dressing, wrap with kerlix, secure with tape. 27. Review of the 32 skilled nurses’ notes from 1/27/06 to 3/1/06 revealed that the skilled nurse cleaned the right heel ulcer with normal saline, applied Bactroban and Panafil ointment to the wound. Complete review of the record failed to reveal a physician order to apply Bactroban and Panafil ointment to the right heel ulcer. 28. Interview with the director of nurses (DON) on 4/17/06 at 10:40 AM confirmed the findings. On 4/17/06 at 11:15 AM, the DON provided a modification order dated 4/17/06 and stated that he/she will fax it to the physician to try and change the order to Bactroban and Panafil. 29. Review of the clinical record for sample patient #2 revealed a Home Health Certification and Plan of Care dated 1/6/06. The principal diagnosis was decubitus ulcer to lower back. The plan of care specified the following treatment for the ulcer:' Cleanse the area with normal saline, pat ‘dry, apply Bactroban ointment, cover with 4 X 4 dressing and secure with tape. 30. Review of the 47 skilled nurse's notes form 1/7/06 to 3/6/06 revealed that the skilled nurse applied Bactroban cream to the wound, and not the specified Bactroban ointment. 31. Interview with the DON on 4/17/06 at 11:00 AM revealed that according to him/her Bactroban cream and ointment are the same. The DON revealed that he/she wasn't aware that a Bactroban cream existed. The DON further stated that sometimes the field nurses assume that ointment and cream are the same and document either/or. 32. Review of the clinical record for sample patient #3 revealed a Home Health Certification and Plan of Care dated 1/30/06. The diagnoses for the patient included diabetes Mellitus and decubitus ulcer to the right heel. The Plan of Care identified the need for daily skilled nursing visits to administer insulin and provide wound care. ‘The specific instructions for the skilled nurse included a sliding scale for regular insulin administration as follows: a. For blood sugar level 200 to 250 - 4 units. b. 251 to 300 - 6 units. Cc. 301 to 350 - 8 units. d. 351 to 400 - 10 units e. For blood sugar more than 401 - 12 units and call physician. 33. Additionally, the skilled nurse was to evaluate integumentary status, effectiveness of medication regimen and symptomatology related to disease complications. Document client's and caregivers response to learning. Skilled nurse to reinforce diabetic teachings. Skilled nurse o report abnormal findings to physician every visit. 34. Review of the skilled nurse's noted dated 1/31/06. revealed that the patient's wound measured 4.5 X 4.5 X 0.5. The skilled nurse documented cleaning the wound with normal saline, applied Granulex spray, covered with 4 X 4 gauze and applied 10 boot, no distress noted. There was no documentation in the note of the wound appearance, drainage, signs and symptoms of infection. 35. Review of the discharge assessment dated 1/31/06 revealed that the patient was admitted to an acute hospital for urgent care. The discharge assessment revealed that the reason for hospitalization was wound infection, deteriorating wound status, new lesion/ulcer. 36. Interview with the DON on 4/17/06 at 12:22 PM revealed that the patient had to be admitted to the hospital due to deterioration of his/her wounds and that the skilled nurse did not document appropriately. The DON further revealed that he/she provides in-services about documentation to the skilled nurses but that the nurses do not follow instructions. 37. Further review of the clinical record revealed a resumption of care order dated 2/4/06. 38. Review of the skilled nurse's notes revealed that on 3 different occasions, the blood sugar levels were between 200 to 250 and the skilled nurse documented that he/she administered Regular insulin 6 units instead of the 4 units ordered: a. 2/14/06 - blood sugar level - 244. b. 2/16/06 - blood sugar level - 249. c. 2/19/06 - blood sugar level - 244. 39. There was no documentation of wound care performed during the skilled nurse's visits on 2/19/06, 2/21/06, 2/22/06, 2/25/06, 2/26/06. 40. Review of the discharge assessment dated 3/28/06 revealed that the patient was transferred to an acute care hospital for deterioration of wound status. 41. Interview with the director of nurses on 4/17/06 at 12:42 PM revealed that the skilled nurse was not available to interview. The director of nurses further revealed that the clinical record had not yet been through quality assurance and: that was the reason why the mistakes had not been caught yet. The director of nurses revealed that sample patient #3 had not been discharged from the hospital yet as of 4/17/06. 42. Review of the clinical record for sample patient #4 revealed a Home Health Certification and Plan of Care dated 2/16/05. The diagnoses for the patient included decubitus ulcer NOS. The medications: dose/frequency/Route (locator 10 on Plan of Care) listed Collagenase Santyl ointment to w/c. 43. The specific orders for the skilled nurse were to cleanse occipital area with normal saline, apply Bactroban, cover with vaseline gauze, secure with tape. Cleanse the sacral area with normal saline, apply vaseline gauze, cover with dressing and secure with tape. 44. Review of the 16 skilled nurse's notes Eom 2/17/06 to 3/2/06 revealed that the skilled nurse cleansed both ulcers with normal saline and applied Santyl collagenase to sacral area and Bactroban to back of the head. There was no documentation that the skilled nurse applied the vaseline gauze to the wounds as ordered. 45. Complete review of the record failed to reveal documentation that the physician had specified the use of collagenase Santyl ointment to the sacral ulcer. 46. Interview with the DON on 4/17/06 at 1:50 PM revealed that the skilled nursing services were provided by a subcontracted agency and that the agency had accepted the subcontracted agency's referral as a physician's order. 47. Review of the clinical record for sample patient #5 revealed a Home Health Certification and Plan of Care dated 3/30/06. The principal diagnosis was chronic ulcer, other part of the foot. The orders for the skilled nurse included to clean the ulcer with normal saline, pat dry, apply Bactroban, cover with dressing, wrap with Kerlix and secure with tape. 48. Review of the 7 skilled nursed notes from 4/2/06 to 4/8/06 revealed that the skilled nurse applied Santyl ointment to the wound. There was no evidence of documentation in the record that the physician had changed the wound care orders. 13 49, Interview with the director of nurses on 4/17/06 at 2:30 PM confirmed the findings. 50. The mandatory date of correction was designated as May 17, 2006. Sl. A follow-up survey was conducted on May 19, 2006. Based on record review and interview, it was determined that the agency failed to develop a plan of care that included the frequency of nurses visits as ordered by the physician for 4 of 4 sampled records reviewed. The findings include the following. 52. Review of the clinical record of sample patient #1, start of care 4-21-06, revealed that the verbal order from the physician was to provide wound care daily to the right arm and every other day to the left arm.. The plan of care identified. that the nurse would visit the patient daily for 15 days, then 5 times a week for 2 weeks and then 3 times a week for 2 weeks. This was not reflected in the order from the physician. 53. Review of the clinical record of sample patient #2, start of care 4-26-06, revealed that the initial assessment was completed on 4-26-06. The assessment identified a head wound. The order from the physician was for wound care to the right leg 3 times a week for 3 weeks on 5-1-06. The plan of care identified that the nurse would visit the patient 2 times a week for 1 week, then 3 times a week for 1 week and then I time the 14 following week. This was not reflected in the order from the physician. 54. Review of the clinical record of sample patient #3, start of care 4-24-06, revealed that the physician ordered wound care to the left ankle, with no additional information. The plan of care identified that the nurse would visit the patient daily for 21 days, then 3 times a week for 2 weeks and then 2 times a week for 1 week. This was not reflected in the order from the physician. 55. Review of the clinical record of sample patient #4, start of care 5-1-06, revealed that the physician ordered home services for the patient, with no additional information. The plan of care identified that the nurse would visit the patient daily for 5 days, then 3 times a week for 4 weeks. This was not reflected in the order from the physician. 56. Interview with the Director of Nurses on 5-19-06 at 12:30 pm revealed that the field nurse was providing the number of visits to the data entry personnel to complete the plan of care. Interview with the data entry personnel on 5-19-06 at 12:30 pm confirmed the findings. This is an uncorrected deficiency from the survey of April 17, 2006. 57. Based on the foregoing facts, Nany Home Health Care Inc. violated Section 400.487(6), Florida Statutes, herein 15 Classified as an uncorrected Class III deficiency, which warrants an assessed fine of $500.00. CLAIM FOR RELIEF WHEREFORE, the Agency requests the Court to order the following relief: 1. Enter a judgment in favor of the Agency for Health Care Administration against Nany Home Health Care Inc. on Counts I and II. 2. Assess against Nany Home Health Care Inc. an administrative fine of $1,000.00 on Counts I and II for violations cited above. 3. Assess costs related to the investigation and prosecution of this matter, if applicable. 4. Grant such other relief as the court deems is just and proper on Counts I and II. Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes. Specific options for administrative action are set out in the attached Election of Rights. All requests for hearing shall be made to the Agency for Health Care Administration and delivered to the Agency Clerk, Agency for 16 Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECEIVE A bs) = EQUEST FOR A HEARING WITHIN TWENTY-ONE (21) DAYS OF REC BIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. Alba M. steed tp Bed Fla. Bar No.: 0880175 Assistant General Counsel Agency for Health Care Administration 8350 N.W. 52 Terrace - #103 Miami, Florida 33166 Copies furnished to: Diane Reiland Field Office Manager Agency for Health Care Administration 5150 Linton Blvd. - Suite 500 Delray Beach, Florida 33484 (U.S. Mail) Jean Lombardi Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) Home Health Agency Unit Program Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) 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 Roberto Gonzalez, Administrator, Nany Home Health Care Inc., 9010 S. W. 137 Avenue - # 111, Miami, Florida 33186; Roberto Gonzalez, Registered Agent, 11990 8. W. 94 Court, Miami, Florida 33176 on this a Y day of C yur , 2006. Qibes 7). Alba M. Rodriguez, Esq. -U.S.-Postal Service - CERTIFIED -MAILa-RECEIPT-. COMPLETE THIS SECTION ON (Domestic Mail Only; No insurance Coverage Provided) DELIVERY Return Reclapt Fea (Endorsement Required) Rastricted Delivery Fae (Endorsement Required) 13. Service Type 0 Gertitied Mai Cl Express Malt CO Registered Ki Retu Cl insured Mai o com Receipt for Merchandise . 7O0e 24340 8001 4234 b430 CLA Gn PS Form 3800, June 2002 ' PS Form 3811, August 2001 = f te [beats of se “U.S. Postal Servicer | CERTIFIED MAIL». RE (Domestic Mail Only; No Insurance @ Complete items BO 2, and 3, Also complete ‘ _ item 4 if Restricted Delivery is desired, @ Print your name and address on the reverse 0 e f= | c i A i so that we can retum the card to you. 7 ® Attach this card to the back of the mailplece, or on the front if space permits. 1. Article Addressed to: : Postage D, Is ddtivenyaddress different from itam 1 Certified Fee it YES, enter delivery address below: OO1 42354 94? Retum Raciept Fee (EnSarsement Required) Alstricted Delivery Fea (Endorsement Requirad) Wato Sw 4G Gear Neame. Flotdes 234, ‘Total Postage & Fees 3. Service Type O Certified Mat CI Express Ma O Registered O Retum Recdipt for Merchandise ie C0 Insured Mail O'c.0.p. ou)_ff iP 7002 2410 0001 4234 Es47 fede 7002 241o D Yes PS Form 3800, June 2002

Docket for Case No: 06-003233