Bartlett Home Health and Hospice

“Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient’s plan of care, for each patient’s medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This Condition is not met as evidenced by: Based on record review and interview, the agency failed to have an organizational chart which evidenced the home health agency’s functions were organized separately from another agency. This failed practice had the potential to not define or organize the facility clearly under its delegated authority. Review of the Organizational Chart “Bartlett Home Health and Hospice Org Chart,” undated, revealed a flow chart. At the top of this chart was the Bartlett Board of Directors, then this flowed to the Chief Nursing and Operating Officer, and to the Executive Director of Post-Acute Care Services. This flow chart then divided into two sections with the Clinical Manager of Hospice on one side and the Clinical Manager of Home Health on the other side. Under the Clinical Manager of Hospice, the chart flowed to LN #5; LN #2; and LN #4; CNA #1; the office manager, Volunteer Coordinator; Chaplain #1; and Chaplain #2. The other side of this flow chart showed staff under the Clinical Manager of Home Health including LN #1, LN #3, PT #1, and OT, which was currently a vacant position. During an interview on 3/8/24 at 10:30 AM, the Clinical Manager and Administrator stated the hospice and home health program were separate. Review of the facility’s policy “Organization and Services Administration,” dated 3/20/23, revealed: “Organization, services furnished, administrative control and the lines of authority for the delegation of responsibility for patient care are clearly defined via Organizational Chart and is readily identifiable. Procedure: 1. Staff will be able to identify the chain of command within Home Health and Hospice as well as Bartlett Regional Hospital.” .”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on record review and interview, the facility failed to complete the initial assessment within 48 hours for 2 patients (#1 and #10), out of 10 patients reviewed. This failed practice had the potential to cause a delay in needed treatment and care. Findings: Patient #1 Record review on 3/4-8/24 revealed Patient #1 was admitted with a start of care date of 11/8/23 and referral date of 11/5/23 with diagnoses that included acute cystitis (infection of the bladder) and neuromuscular dysfunction of the bladder (the bladder lacks muscular control due to a brain, spinal cord, or nerve disorder). Review of a RN [Registered Nurse] SOC OASIS – E [Outcome Assessment and information set], or a start of care assessment visit, revealed it was dated 11/8/23 and signed by Licensed Nurse #1. The referral date on this document was 11/5/23. During an interview on 3/7/23 at 3:10 PM, the Clinical Manager agreed that the start of care was delayed and did not occur within 48 hours. Patient #10 Record review on 3/4-8/24 revealed Patient #10 was admitted with a SOC date of 1/4/24 and a referral date of 12/29/23 with diagnoses that included acute and chronic respiratory failure with hypercapnia (too much carbon dioxide in blood) and chronic obstructive pulmonary disease with acute exacerbation (a lung disease that blocks airflow into the lungs). Further review included administrative communication documents. A note created by the Clinical Manager, dated 1/2/24, revealed: “TC [telephone communication] to patient to discuss referral and schedule admission visit. No answer, identified self on VM [voicemail] greeting and writer left message at this time.” Further review included another administrative communication document dated 1/3/24, “…Finally spoke with patient … patient is open to receiving all services and admission visit is scheduled for tomorrow.” During an interview on 3/5/24 at 10:23 AM, the Clinical Manager agreed that the start of care was delayed and did not occur within 48 hours. Review of the facility’s policy “Home Health/Initial Assessment/Comprehensive Assessment,” dated 12/14/22, revealed: “A RN [Registered Nurse], PT [Physical Therapist] or SLP[Speech Language Pathologist must conduct the initial assessment visit within 48 hours of referral, within 48 hours of the patient’s return home or on the physician/practitioner ordered start of care.””

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on record review, observation, and interview, the facility failed to ensure the individualized plans of care were accurate and complete for 2 Patients (#2 and #7), out of 10 patients reviewed. This failed practice had the potential to affect all patients (based on a census of 23) with the potential to have patients, patient representatives, staff, suppliers, and providers unaware of the equipment and supplies necessary for patient care. Patient #2 Record review on 3/4-8/24 revealed Patient #2 was admitted on 1/26/24 with diagnoses that included peritoneal abscess (an infected area in the abdominal cavity) and congestive heart failure. The initial plan of care, for the certification period of 1/26/24 – 3/25/24, included a hospital bed under the supplies section of the plan of care. However, there was no hospital bed present in the patient’s home for the patient’s use. Further review showed a RN [Registered Nurse] SOC OASIS – E [Outcome Assessment and information set] or a SOC assessment visit dated 1/26/24 and signed by Licensed Nurse (LN) #1 with a section titled “DME [durable medical equipment] Assistive Device Assessment – Bed/Transfer equipment: Hospital bed recommended.” Review of a Skilled Nursing Visit note, dated 1/30/24 and signed by LN #1, revealed: “[Representative for Patient #2] again stated concerns that a hospital bed is needed for feedings, dressing changes, and colostomy care. Advised hospital bed takes some time, the request for PCP [Primary Care Provider] to sign off on need and then it goes through insurance.” Review of a Communication note, dated 1/26/24 and signed by the Social Worker (SW), revealed: “Received message from patient’s RN [Registered Nurse] who reported pt [patient] is interested in acquiring a hospital bed. Spoke with patient’s [representative] regarding the process and faxed necessary paperwork to [Clinic #1] to be completed upon patient’s next appointment. Requested [Clinic #1]to forward completed order/progress note to [Medical Equipment Supplier #1] when complete. Texted [Medical Equipment Supplier #1 representative] information to confirm, noting beds may also be purchased out of pocket.” During an interview and concurrent observation on 3/5/24 at 1:00 PM, the Patient Representative of Patient #2 stated that Medicare was not effective getting the patient a hospital bed. This had been discussed at the first visit with the nurse and had not occurred yet. Now a hospital bed was no longer needed. There was no hospital bed observed for the patient’s use at this visit. Review of a DME [durable medical equipment] Communication, dated 3/5/24 and signed by the Clinical Manager, revealed: “No update yet regarding status of ordering hospital bed. Note SW Communication note from 1/26/24 TC [telephone communication] to SW … to see if there are further updates about ordering the hospital bed, and she says she is not aware of any. TC communication to [Medical Clinic #1], spoke to receptionist and inquired if a hospital bed had been pursued from the Clinic. After a few minutes of checking the patient chart states she did not find any documentation indicating order of a hospital bed. TC to [Medical Equipment Supplier #1 and spoke with [Office Representative #1]. Inquired if there was anything in their system for [Patient #2] and ordering a hospital bed. After looking in their system, [Office Representative #1] had not found anything. SW will be notified of these communications and request she follow-up.” During an interview on 3/6/24 at 9:20 AM, LN #1 stated the patient’s representative did not have a hospital bed at this time. The patient representative had requested one at the onset of care but now was refusing. LN #1 stated he/she recommended a recliner at this time when the patient had a need to have the body position in an upright position due to daily tube feedings (feedings through a tube into the stomach). The patient was currently using wedge pillows to stay upright during tube feedings. During an interview on 3/6/24 at 4:12 PM, the Clinical Manager stated the plan of care was inaccurate since a hospital bed was not part of the patient’s equipment in the home and it stated a hospital bed was present in the home. Patient #7 Record review on 4/4-8/24 revealed Patient #7 was admitted on 11/30/23 with diagnoses that included lymphedema (swelling, mostly in an arm or leg, caused by lymphatic system blockage) and venous insufficiency (improper functioning of the vein valves in the leg, causing swelling and skin changes. A plan of care for the certification period of 1/29/24 – 3/28/24 failed to include a Lymphedema Pump (A lymphedema pump is a mechanical device that helps move fluid out of an area of the body that has excess fluid. The pump applies light pressure starting at the furthest point of the body and gently squeezes toward the center of the body. This can be applied to any swollen area that is being treated) and interventions and goals for its use. This pump was used by the patient regularly to reduce swelling in the legs and not listed under the supplies section of the care plan. Review of a Communication note, dated 12/5/23 at 11:22 AM and signed by LN #2, revealed,: “[Patient #7] stated that [he/she] was doing well and that [he/she] had been using … lymphedema pumps regularly since our last visit.” Review of a Communication note, dated 1/15/24 at 1:29 PM and completed by the Clinical Manager, revealed: “TC [telephone communication] received from [family of Patient #7] states … would like home health team to come up with solutions for 3 things: the bed height for patient to lift leg to get into bed and then still be able to get OOB [out of bed], suggestions for better ways [for patient]to pump [his/her] legs specifying the process of sitting down and getting [his/her] legs into the pump sleeve, and standing for shower support.” Review of a SN (Skilled Nurse) Summary, dated 2/12/24 and signed by LN #2, revealed: “[Patient #7] also demonstrates compliance with … the daily use of lymphedema pumps.” Review of a Physical Therapy Visit note, dated 2/26/24 and signed by Physical Therapist (PT) #1, revealed care plan documentation that included bed mobility training. There was documentation concerning the lymphedema pump training: “The futon will likely be used a pumping station so can pump [his/her] legs in a better position.” During an interview on 3/7/24 at 2:55 PM , the Clinical Manager stated the lymphedema pump was not included on the plan of care for patient #7. During an interview on 3/8/24 at 9:30 AM, the family of Patient #7 stated the patient had a lymphedema pump to use to eliminate edema in the patient’s lower legs. During an interview on 3/8/24 at 10:00 AM, PT #1 stated Patient #7 had a lymphedema pump that was used for edema on the patient’s legs twice a week. A goal for Patient #7’s care was to have a place for the patient’s legs to be elevated that was accessible to the patient. Review of the facility’s policy “Home Health Plan of Care,” dated 12/14/22, revealed: “Each patient must receive an individualized written plan of care … the individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline and the measurable outcomes that the HH [home health] anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice…Each patient must receive the home health services that identifies patient – specific measurable outcomes and goals … Patient – specific goals must be individualized to the patient based on the patient’s medical diagnosis, physician’s/practitioner’s orders, comprehensive assessment and patient input … the Individualized plan of care must include the following … types of services, supplies and equipment required … Patient – specific interventions and education, measurable outcomes and goals identified by the HH and the patient.””