Thrive 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: Based on clinical record review and personnel interview, it was determined the Agency failed to ensure the plan of care was followed as evidenced by missed skilled nursing visits for 2 (#3 and #5) of 7 (#1 - #7) clinical records reviewed. This failed practice had the potential to affect all patients under the care of the Agency as the patient was not assessed and/or received treatment as scheduled for the days missed. 1. A review of clinical record #3 revealed the following: A. Patient with a certification period of 04/04/24 – 06/02/24 and a diagnosis of Acute Kidney Failure (AKF). The physician’s orders included, “… Skilled Nurse visits twice weekly…” There were missed visits during the weeks of 04/07/24, 05/19/24, and 06/02/24. 2. Review of clinical record #5 revealed the following: A. Patient with a certification period of 05/06/24 – 07/04/24 and a diagnosis of Cellulitis right lower limb. The physician’s order dated 05/08/24 documented, “… Skilled Nurse visits 2 wk 1 wk [twice weekly first week] then 3 times weekly…” An updated order dated 05/22/24 documented, “3 wk 4 wk [3 times weekly for 4 weeks], 2 wk 1 wk [2 times weekly for 1 week].There were two missed visits the week of 05/19/24 and 1 missed visit the week of 05/26/24. 3. During an interview on 6/5/24 at 12:30 PM, agency personnel were asked to provide any additional information which would indicate there was an attempt to reschedule the visit, the physician or practitioner were notified of the missed visit, any potential impact, and educate the patient. With no additional information provided, it was verified by Agency Personnel #1 that the plan of care was not followed as all visits ordered were not completed for patients #3 and #5.”

“Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This Standard is not met as evidenced by: . Based on Clinical Record review, observation during home visits, and staff interviews, it was determined the Agency failed to provide written information to the patients and/or caregivers regarding medications schedule/instructions for 1 (#1) of 3 (#1, - #3) home visits completed. This deficient practice did not ensure the affected patients/caregivers had the opportunity to participate in the Plan of Care and had the potential risk of poor understanding of medications schedule/instructions.. . Review Patient #1 clinical record, observation during home visit, and interview with agency staff revealed the following: A. Plan of Care (POC) for certification period 3/11/24 to 5/9/24 which contained current medication orders. During a home visit on 6/4/24 at 9:00 AM, the Surveyor asked the Patient/caregiver if the Agency provided written information regarding the treatments specific to Patient #1 care along with medication instructions. The Patient’s Caregiver provided a folder which contained the documents the Agency had provided. The folder contained a document referring to medications which was blank. . B. During an interview the Surveyor asked the Skilled Nurse (SN) providing the care for Patient #1 how medication instructions were provided to Patient/caregiver. The SN stated “I enter the medicines in my computer”. When asked how the patient/caregiver would receive a copy by the surveyor, the SN stated: “It should be written in the booklet given to the patient/caregiver. I guess I must have forgotten to write the medicines in the booklet when I admitted [named patient]”. 2. During an interview on 6/5/24 at 12:30 PM Agency Personnel #1 stated, “The only information in the home regarding medications should be written in the Patient’s home folder in the medication section.” .”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on a review of personnel records, agency policies/procedures, and Agency administrative staff interview, it was determined the Agency failed to ensure the Centers for Disease Control and Prevention (CDC) standards of practice and the agency’s policies were followed to prevent the spread of Tuberculosis (TB). This was evidenced by failing to ensure 2 (#11 and #13) of 3 (#1-#3) employee files reviewed had the TB questionnaire completed on an annual basis. This failed practice had the potential to affect all patients under the care of the Agency as this exposes patients to potentially TB positive employees. C 1. A review of CDC (Centers for Disease Control) standards of practice revealed the following: A. CDC guidelines show a recommendation that “annual TB (Tuberculosis) education of health care personnel” without documented prior TB disease or latent TB infection. 2. A review of agency’s policy/procedure for “Tuberculosis Screening” states: “All employees should receive TB training during orientation, at least annually thereafter and whenever there are modifications to the TB control program”. 3. A review of employee #11 personnel record with hire date of 3/25/2020, showed last training for TB was completed on 3/29/2020 and employee #13 with hire date of 1/15/2020, showed education was last completed on 1/15/2020. 4. During an interview on 6/5/24 at 12:30 PM with agency staff, staff member #1 confirmed employee #11 and #13 had not received education for TB annually as recommended by the CDC and the agency’s policy. 2 1”

“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 personnel interview, it was determined the Agency failed to ensure the physician was notified regarding changes of condition for 2 (#2 and #4) of 7 (#1 -#7) clinical records reviewed. This failed practice had the potential to affect all patients under the care of the Agency as the physician was not given an opportunity to alter the plan of care for the patient as necessary. 1 1. Review of clinical record #2 revealed the following: A. Patient with a certification period of 02/04/24 – 04/03/24 and a diagnosis of Other Specified Health Status and an order dated 02/21/24. The order documented, “weekly weights and vital signs were sent to [Named facility] Notify MD [Medical Doctor] if O2 [Oxygen] sat [saturation] of less than 80%.” Patient #2 was hospitalized 02/02/24 – 02/20/24. Registered Nurse (RN) visit 01/22/24 documented O2 sat at 76%. RN visit note dated 02/21/24 documented O2 sat 78%. There was no evidence the MD was notified of either of these O2 saturation levels as ordered in the plan of care. 2. Clinical record #4 revealed the following: A. Patient with a certification period of 04/16/24 – 06/14/24 and a diagnosis of Hypoplastic Left Heart Syndrome. A review of the Home Health Care Certification and Plan of Care document which revealed, “…Orders/Treatments: …. Assess O2 saturation and notify MD [Medical Doctor] if pulse ox [oximetry] is A Skilled Nurse Visit Note dated 05/06/24 documented, “…Baby was discharged on ¼ lpm [1-4 liters per minute] NC [nasal cannula], however parents increased to 3-4 Lpm on 05/05/24 due to Oxygen (O2) desaturation to 67-68%. Pulse ox was on 3-4 Lpm this visit 74-80% and heart rate 130’s via monitor….” There was no evidence the MD was notified of these O2 desaturation levels as ordered in the plan of care nor that the MD was notified regarding the parents reports of the O2 desaturations and the increase in O2 by the parents. 3. On 06/05/24 at 10:45 a.m., the Agency personnel #1was asked to provide any additional documentation of MD notification. Agency personnel #1 stated: “Those are orders from [named hospital] and we just need to update our order to say, ‘If the O2 sat isn’t recovered, then to notify the Doctor.’ Something like that would be more accurate.” With no further information, Agency Personnel #1 verification that the MD was not notified of changes in condition for patients #2 and #4.”