Chi St Vincent Hot Springs Health at Home

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: This STANDARD is NOT MET as evidenced by: Based on Clinical Record Review, observation and staff interview, it was determined the Agency Staff failed to ensure 16 of 18 records reviewed had an individualized plan of care that identified the patient-specific measurable outcomes and goals which were established, periodically reviewed, and signed by the patients physician or practitioner, Specifically, the Clinical Records lacked parameters for measuring the patients pain. This had the potential to affect all patients on census in that a clinician should have the ability to measure and document any pain the patient may have had prior to treatment, during the delivery of care and treatment, after treatment or as an unusual symptom. Without the ability to measure and reassess or remeasure the patients pain, there is no way a physician or practitioner can make an informed decision to intervene with changes to Plan of Care. It was determined during review, all but two Clinical Records record to have a pain parameter. (#6 and #13 were the exception). All Home Health Plan of Care And Certifications for each patient had the following: “Skilled Nurse for observation/Assessment of pain, effectiveness of pain management including medication review and pharmacological and nonpharmacological treatments and skilled teaching related to pain management. Skilled nurse to intervene with increased pain level to minimize complications.” On observation during home visits, Surveyor noticed the lack of Skilled Nurse (SN) asking about patient’s discomfort or pain. The Surveyor observed a patient exhibit physical indications of pain AEB: grimace, wince, grunting and holding breath during wound care. On 11/21/2024 at 10:00 AM, Agency Representative #1 agreed that there was a lack of pain parameters on the Agency’s Clinical Records.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on Clinical Record review and staff interview, it was determined the Agency failed to assure all medications were included in a comprehensive medication review to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy in seven (#2, #4, #5, #8, #9, #10, #12) of Eighteen (#1-#18) records reviewed Findings follow: 1. Review of Record #2 revealed the following: a) A document titled “Home Health Certification And Plan of Care” with dates of 08/30/2024-10/28/2024 diagnosis of “dependence on supplimental oxygen” b) A document titled “Client Medication Report “ lists Oxygen 3 liters continuous. When viewed on the computer screen, it is colored in blue to indicate it was not checked against all other medications. 2. Review of Record #4 revealed: a) Document titled “Home Health Certification And Plan of Care” with dates of 10/18/2024-12/16/2024 showed a diagnosis of “Dependence on Supplimental Oxygen” b) A document titled “Client Medication Report” with Oxygen 2 liters, continuous. When viewed on the computer screen, this medication is blued out, indicating it was not checked against all other medications. 3. Review of Record #5 showed: a) Document titled “Home Health Certification And Plan of Care dated 10/20/2024-12/18/2024, listed a diagnosis of “Dependence on Supplimental Oxygen” b) A document titled “Client Medication Record” with Oxygen 2 liters, continuous. When viewed on the computer screen, this medication is highlighted by the color blue to indicate the EMR system did not check it against all other medications. 4. Review of Record #8 revealed: a) Document titled “Home Health Certification And Plan of Care” with dates of 10/24/2024-12/22/2024 and listing a diagnosis of “Acute Respiratory Failure with Hypercapnia”. b) Document titled “Client Medication Report” with Oxygen-use via Trilogy at bedtime. May increase to 4lpm (liters per minute) for shortness of breath. When this is viewed on the computer screen, the Oxygen is highlighted in the color blue to indicate it is not checked against all other medications by the computer program used. 5. Review of Record #9 showed: a) Document titled “Home Health Certification And Plan of Care” with dates of 10/19/2024-12/17/2024 showed a diagnosis of “Malignant Neoplasm of Esophagus (growing cancer of the throat) b) A document titled “Client Medication Report” with a listing of “Marijuana (cannabis) oral edible every three hours for pain. When this medication is viewed on the computer screen, it shows up highlighted in blue indicating it isn’t checked against all other medications in the patients record. 6. Review of Record # 10 revealed the following: a) Document titled “Home Health Certification And Plan of Care” dated 11/14/2024-01/12/2025 with diagnosis of “Acute and Chronic Respiratory failure.” b) A physicians order from above named document stating, “Instruct patient/caregiver in oxygen therapy including administration, care of equipment and safety. c) A document titled “Client Medication Record” without oxygen listed as a medication. 7. Review of record #12 showed: a) A document titled, “Home Health Certification and Plan of Care” with dates of 10/12/24 to 12/10/24 listed a diagnosis of Encounter for attention to colostomy and Hypertension. b) A document titled, “Client Medication Report” listed Magnesium Glycinate 800 mg (milligrams) with Zinc and Vitamin D3 by mouth at bedtime. When this medication is viewed in the computer system, it is highlighted in blue indicating it was not checked against all other medications. On 11/21/2024 at 10:15 AM, Agency Representative #1 was asked to present evidence that the medications above were reconciled against all other client medications. Agency Representative #1 stated, “There isn’t any. We need to work on that.””

“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 Clinical Record Review and Agency staff interview, the Agency staff failed to ensure the patients Plan of Care (POC) included the required elements of all patient specific interventions, education, measurable outcomes, goals and supplies and equipment specific to the individual patient in 1 (#13) 0f 18 records reviewed. Review of Record #13 revealed the following: a. A document titled, “Home Health Certification and Plan of Care” with dates of 09/28/24 to 11/26/24 listed a diagnosis of Encounter for Fitting and Adjustment of Urinary Device, Paraplegia. b. The Plan of Care documented, “…Skilled nurse for insertion of catheter using 20G [gauge], 30 ml [milliliters] balloon. Change every 3 weeks and prn [as needed] dislodgement or stoppage…” c. The Skilled Nurse Coordination notes dated 10/24/24, 10/03/24, and 09/12/24 documented the patient has a coude’ catheter. ( A coude’ catheter is a type of urinary catheter that has a curved tip, allowing it to navigate around obstructions in the urethra). d. On 11/20/24 at 10:30 a.m., during a home visit, it was noted the patient has a coude’ catheter. e. On 11/20/24 at 3:50 p.m., Agency Representative #1 was asked about the patient having a coude’ catheter vs. an indwelling foley catheter and the physician’s order is not specific to which type of catheter. She stated, “I’ll look at that. I believe it should be in there.””

“Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This Element is not met as evidenced by: Based on Clinical Record review and staff interview, it was determined the Agency failed to ensure documentation of wound measurements and assessment, including late entry documentation, of all assessments and wound measurement in 1 (#13) of 18 (#1-#18) medical records reviewed. Wound measurements are important as they monitor the healing process and determine if a wound is getting better or worse by tracking the changes in its size over time. This failed practice had the potential to affect all patients on census in that direct caregivers and practitioners would not have a full and accurate patient file to reference and use for care planning.. Review of Record #13 revealed the following: a. A document titled, “Home Health Certification and Plan of Care” with dates of 11/13/24 to 01/11/25 listed a diagnosis of Pulmonary Embolism. b. The Plan of Care documented an order for a dressing change to an open wound to Left Lower Extremity two times weekly. c. There were no measurements of the wound by the agency personnel in the clinical record since admission on 11/13/24. d. On 11/20/24, Agency Representative #1 was asked for additional measurements completed by the agency personnel and there was none. The Skilled Nurse visit dated 11/18/24 had an assessment but not a measurement of the wound. e. On 11/21/24, Agency Representative #1 provided a Skin and Wound Care Protocol which documented, “… Wound Measurements Time Period: Weekly (or with each visit if frequency is less than weekly).”