Elite Home Health

“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 clinical record review and staff interview, it was determined the Agency failed to complete the initial assessment 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 for 2 (#8 and #10) of 17 (#1 - #17) clinical records reviewed. This failed practice had the potential to affect current and future patients in that a delay in completing the initial assessment would delay in the patient receiving care and services needed to prevent illness, incidences such as falls and/or a delay in promotion of improved health. Findings follow: 1. Review of clinical record #8 with a start of care date of 06/11/24 and certification period of 06/11/24 - 07/09/24 revealed a patient with a diagnosis of Hypertensive Emergency, Type 2 Diabetes Mellitus, Hemiplegia following Cerebral Infarction. a. The Agency received a referral on 06/03/24. The physician ordered the Start of Care as 06/07/24. b. The RN (Registered Nurse) Admission was dated 06/11/24. c. The PT (Physical Therapy) assessment was done on 06/12/24 and documented, “...He was DC [discharged] home last Tuesday [06/04/24] and had two fall[s], sliding out of bed right away...” d. The initial admission occurred 2 days after the required date 06/09/24 (48 hours after the physician ordered start of care). The two falls occurred while the patient and family waited for the initial admission to be done. 2. Review of clinical record #10 with a start of care date of 02/12/24 and certification period of 02/12/24 - 04/19/24 revealed a patient with a diagnosis of Malignant Neoplasm of Left main Bronchus, RA (Rheumatoid Arthritis), and Emphysema. a. A two-page letter from a local health clinic, dated 02/08/2024, and signed by the APRN (Advanced Practice Registered Nurse) documented, “...I would like to refer [patient name] to your service for evaluation and treatment of Malignant neoplasm of unspecified part of unspecified bronchus or lung...Plan: ...Referral initiated to home health services Elite Home Health...” b. A Visit Note Report dated 02/12/2024 documented, “...RN Admission...” c. The initial admission occurred 2 days after the required date 02/10/24 (48 hours from the date of the referral). 3. On 08/29/24, the Director was asked to provide any further information regarding the late initial assessments, and none was provided.”

“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 include all medications the patient was currently using during a review of the patients’ medication regimen in 4 (#1, #10, #12, and #13) of 17 (#1 - #17) clinical records reviewed. This failed practice posed a risk of potential harm for all patients on census by inhibiting the Physician’s ability to make informed decisions regarding the patients’ medication regimen related to potential adverse effects, drug reactions, significant side effects or significant drug interactions. Findings follow: Review of Clinical Record #1 with a start of care date of 05/11/24 revealed a patient with a diagnosis of Partial Traumatic Amputation of left foot/toes. The Client Medication Report for clinical record #1 included Total Beets 2 tablets daily. The medication review for adverse effects and interactions did not include the over the counter (OTC) medication Total Beets and there was no manual review of the medication Total Beets documented. Review of Clinical Record #10 with a start of care date of 02/12/24 revealed a patient with a diagnosis of Malignant Neoplasm of Left main Bronchus. The medication review for adverse effects and interactions did not include the on-going chemotherapy medication administered at the local Cancer and Blood Institute every 3 weeks. A document titled, “Oncology Follow Up” and dated 02/25/24 documented, “... Initiated C1 Carboplatin + Abraxane + Keytrua on 1/30/2024...” The chemotherapy treatment was changed on 01/30/24 due to toxicity levels after receiving previously ordered chemotherapy. The RN OASIS Admission dated 02/12/24 documented, “...Narrative...Patient has chemo with oncologist [Name] on every 3rd Tuesday for about 3 hours...” The admitting nurse documented their awareness that patient #10 had been receiving and would continue to receive chemotherapy every 3 weeks at the oncology clinic. Review of Clinical Record #13 with a start of care date of 03/10/24 revealed a patient with a diagnosis of Acute Cystitis without hematuria. The Client Medication Report for clinical record #13 included Oxygen @ 2L (Liters) nightly. The medication review for adverse effects and interactions did not include the use of oxygen as was being utilized by the patient and there was no manual review of the use of oxygen and its potential interaction with medications documented. On 08/29/24, the Director of the Agency was given an opportunity to provide any further documentation regarding a thorough medication review and none was provided by the end of the survey.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on Clinical Record review, and staff interview, the Agency failed to follow Physician orders for administering medications and treatments for 1 (#14) of 17 (#1 - #17) Clinical Records reviewed. This failed practice had the potential to affect the quality of care received by all patients currently on census, in that patients may not receive treatments only as ordered by the Physician and this could result in adverse outcomes and risk of re-hospitalization. Findings follow: Review of Clinical Record #14 showed a patient admitted to home health for Hypertensive Heart Disease with Heart Failure (a long-term condition developed over many years in people who have high blood pressure). A document titled, “Plan of Care for 07/27/24 through 09/24/24” contained orders for Skilled Nursing (SN) to obtain ankle circumference every visit.” Review of a document titled, “Vital Sign Report” showed no ankle circumference measurements for SNV (Skilled Nurse Visit) on 07/28/24, 08/05/24, 08/12/24, 08/19/24, and 08/26/24. During an interview on 08/29/24 at 10:55 a.m., Personnel #3 confirmed the ankle circumferences were omitted from those SNV dates.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on Clinical Record review and staff interview, it was determined the Agency failed to alert the Physician of relevant assessment findings which may have necessitated an alteration in the Plan of Care (POC) in 1 (#15) of 17 (#1-#17) Clinical Records reviewed. This failed practice had the potential to affect all current patients on census in that Physicians may be unaware of new assessment findings resulting in missed opportunities for revision of patient goals/ interventions and prevention of hospitalizations. Findings follow: A document titled, “Home Health Certification and Plan of Care” dated 07/14/24 through 09/11/24 revealed an order for “Skilled Nurse [SN] to notify physician of 5 pound or more increase in weight.” A document titled, “Skilled Nurse Visit Report” dated 08/18/24, the SN documented a six-pound weight gain in one week. There was no documentation in the record to indicate the SN notified the physician of the change in calf circumference. On 08/29/24 agency staff were given an opportunity to provide additional documentation, and none was provided.”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on clinical record review and staff interview, it was determined the Agency failed to ensure medical equipment was ordered and delivered timely for 1 (#8) of 17 (#1 - #17) clinical records reviewed. This failed practice had the potential to affect all patients on census in that a delay in care and service delivery could have a direct effect on the health status and condition of the patient. Findings follow: Review of Clinical Record #8 with a start of care date 06/11/24 revealed a patient with Hypertensive Emergency, Type 2 Diabetes Mellitus, and Hemiplegia. a. The RN (Registered Nurse) Admission dated 06/11/24 documented the patient was dependent for mobility in sitting to standing, dependent for mobility in chair/bed-to-chair transfer, inability to transfer self and unable to bear weight or pivot when transferred by another person, and chairfast with inability to ambulate. b. The Home Health Certification and Plan of Care with a certification period of 06/11/24 - 08/09/24 documented, “... DME and supplies...wheelchair - bedside commode...” c. A Client Coordination Note Report dated 06/12/24 documented, “....PT [Physical Therapy] ... Patient lives with wife in single story home with board for ramp to enter, tight walkways and desperate need of equipment including hospital bed, WC [wheelchair] and hoyer [total assist] lift. He fell due to trying to get OOB [out of bed] from high bed in his bedroom...” A physician communication note dated 06/12/24 documented “...Patient will benefit from hospital bed, manual WC and Hoyer Lift due to significant issues with mobility and weakness and is currently bed bound...Practitioner: [check mark] Agree with Above Request...” and digitally signed by MD on 06/13/25. d. A Visit Note Report dated 06/25/24 noted there was a decline in the patient’s activity level and the patient revealed he wanted to look out the window but physically can’t get in and out of the bed. e. A Client Coordination Note Report dated 06/25/24 documented, “... Wife says hoyer lift and hospital bed has been ordered but have not heard [or] seen from them yet. Skilled nurse: DME [Durable Medical Equipment] company to check on it today. [They] need MD paperwork...called office gave [name] DME Fax NO [number] to fax DME orders to [Name].” f. The documents demonstrated the hoyer lift and hospital bed were needed, an order was obtained from the physician, but there was no evidence to demonstrate the order for the equipment was sent to the DME until 06/25/24. The required paperwork for the hoyer lift and hospital bed was sent to the DME 13 days after it was originally ordered. g. On 08/29/24, the Agency staff were asked to provide any further information that would support the Agency ensured equipment was ordered from the DME on 06/12/24 and delivered timely. There was no additional information provided.”