Tahoe Forest Hhs

“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 interview, and record review, the registered nurse case manager failed to perform the initial assessment (the first home health visit) for one out of seven sampled patients (Patient 4), when the physical therapist (PT) performed the initial assessment instead. This failure had the potential for immediate care needs that would be provided by the registered nurse to be delayed, or missed and could negatively affect the patient’s health status. Findings: A review, of the agency’s policy and procedure titled, “Initial and Comprehensive Assessment, Start of Care (SOC)-DHH-2021,” revised 2/1/24, indicated, that an initial patient assessment will be performed and documented in the patient’s Electronic Medical Record (EMR) by a registered nurse, or physical therapist (if nursing services are not ordered) to determine immediate care and support needs of the patient (nursing services were provided by the registered nurse case manager). A review, of Patient 4’s, “Home Health Plan of Care,” (POC, a document that described the care that would be provided to the patient), dated 3/22/24, indicated, that Patient 4 was admitted to the agency on 3/22/24, with the diagnoses of diabetes, and end stage hypertensive chronic kidney disease (a condition where the kidneys were close to, or had stopped working). The POC indicated, that this was the initial assessment, and that is was performed by Physical Therapist (PT) 3. During a concurrent interview, and record review, on 4/10/24 at 12 pm, with PT 3, Patient 4’s POC, dated 3/22/24, was reviewed. PT 3 stated, that they had opened Patient 4 to home health services, and provided the initial assessment because nursing was not ordered. The section of the POC titled, “Face to Face Details,” (the physician must provide a face-to-face visit with a patient and document the reason home health services are needed, and indicate what services the patient would receive) was reviewed. PT 3 confirmed, the “Face to Face,” included an order for home health services, that included skilled nursing, and physical therapy. During a concurrent interview, and record review, on 4/11/24 at 10:42 am, with the Clinical Supervisor Manager (CSM), Patient 4’s POC, dated 3/22/24, was reviewed. CSM stated, that the section of the POC titled, “Face to Face,” indicated the physician ordered home health services, for skilled nursing and physical therapy. CSM confirmed, that PT 3 performed the initial assessment, and the registered nurse should have.”

“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 interview, and record review, the agency did not individualize the plan of care (POC, documentation that described what care a patient would receive) for four out of seven sampled patients (Patients 3, 4, 5, and 7), when the POC did not include pertinent diagnoses (conditions that were present and had the potential to affect patient response to care). This failure had the potential to negatively impact the quality and safety of patient care, which could lead to negative clinical outcomes. Findings: A review of the facility’s policy and procedure (P&P) titled, “Initial and Comprehensive Assessment, Start of Care (SOC),” revised 2/1/24, indicated, all pertinent diagnoses would be included in the POC. A review of Patient 4’s “Home Health Plan of Care” (POC), dated 3/22/24, indicated, admission to the agency on 3/22/24 with the diagnoses of diabetes, hypertensive (high blood pressure) chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease (your kidneys are close to or have already stopped working), and gout (a type of arthritis that caused pain and swelling in the toes, feet, and lower legs). A review of Patient 7’s “Home Health Plan of Care,” dated, 3/21,24, indicated Patient 7 was admitted to the agency on 5/26/24. The “POC,” included the diagnoses of a stage 4 pressure ulcer to the sacral region (a deep wound that could impact the muscle, tendons, ligaments, and bone. The sacral region was in the area between the lower back and tailbone), paraplegia (both legs were paralyzed and did not work), and major depressive disorder (a sad mood). During a concurrent interview and record review on 4/10/24 at 4:27 pm, with Registered Nurse Case Manager (RN CM) 1, Patient 4’s “POC,” dated 3/22/24, was reviewed. RN CM 1 stated, the “POC” indicated Patient 4 had the diagnoses of chronic kidney disease and gout. RN CM 1 confirmed, the POC did not include interventions (instruction for care or education) that included pertinent diagnoses of chronic kidney disease or gout and should have. During a concurrent interview and record review on 4/10/24 at 4:48 pm, with RN CM 1, Patient 7’s “POC,” dated 3/21/24 was reviewed. RN CM 1 stated the “POC” indicated, Patient 7 had the diagnoses of paraplegia and depression. RN CM 1 confirmed the POC did not include interventions that included pertinent diagnoses of paraplegia or depression and should have. During a concurrent interview and record review on 4/11/24 at 10:42 am with Clinical Supervisor Manager (CSM) and Administrator (Admin), Patient 4’s “POC,” dated 3/22/24 was reviewed. CSM confirmed Patient 4’s POC included the diagnoses of gout and chronic kidney disease. CSM reviewed Patient 7’s “POC,” dated 3/21/24 and confirmed Patient 7’s diagnoses of paraplegia and depression. CSM and Admin confirmed, Patient 4 and Patient 7’s “POC” did not include all pertinent diagnoses and should have. Findings: During a review of the agency’s policy revised 7/2021, titled, “Physician Participation in Plan of Care, DHH-2005,” indicated the purpose of this policy is to provide guidelines for the physician’s participation in home health care services. Physician orders will be individualized, based on patient’s needs and include the following: Diagnosis, Treatments and procedures needed, Medications, a description of equipment, and any medical or environmental precautions. This policy also indicated orders will be reviewed and revised by the patient’s physician based on changes in care or service, changes in patient’s physical or psychosocial condition, the patient’s response to care, the patient’s outcome to treatment care or services, and changes in diagnosis or treatment. During a review of the agency’s policy revised 2/2024, titled, “Initial and Comprehensive Assessment, Start of Care (SOC) DHH-2021,” indicated this policy manages the risk of not meeting regulatory requirements related to SOC assessments and plan of care (POC) by providing a consistent procedure. This policy also indicated a POC will be developed from the information gathered during the initial and comprehensive assessment. The patient’s physician is consulted via the electronic medical record for approval if additions or modifications to the POC are required after the assessment is completed. The POC will include all pertinent diagnoses an patient specific interventions and education, measurable outcomes, and goals identified. During a review of Patient 3’s clinical record, Patient 3 was admitted to the home health agency on 3/5/24 with diagnoses that included colostomy (an opening called a stoma is formed between the large intestine and abdominal wall that drains stool wastes from the body), new surgical abdominal incision, sepsis (body’s response to an extreme infection), diverticulitis with perforation and abscess (inflammation of pouches in the large intestine that can become serious by rupturing or causing an infection), hypokalemia (low potassium), hypothyroidism (a thyroid gland disorder which does not produce enough hormones which can affect the whole body), and an acute embolism (a blood clot that travels to the lungs, suddenly forms a blockage). During a review of Patient 3’s clinical record, hypothyroidism was documented in the History and Physical titled “Discharge Summary,” dated 3/3/24 as an active problem. During an interview on 4/10/24 at 10:50 am, Patient 3 confirmed she takes her thyroid medication every morning on an empty stomach for a thyroid disease. During an interview on 4/10/24 at 10:55 am, Registered Nurse (RN) 1 confirmed the diagnosis of hypothyroidism should have been included on the POC to provide education for Patient 3, and monitor for any signs and symptoms to report to the physician. During an interview on 4/10/24 at 3:50 pm, the Clinical Supervisor Manager (CSM) confirmed the ICD codes (International Statistical Classification of Diseases, a combination of diagnoses of diseases and symptoms) and documentation from all hospital records including the History and Physical dated 3/3/24 documented an active diagnosis of hypothyroidism and should be included in the current POC and interventions added for nursing to monitor. During a review of Patient 5’s clinical record, Patient 5 was admitted to the home health agency on 3/26/24 for diagnoses that included spinal fusion (surgery that joins two or more vertebrae that causes the bones to grow together), spinal stenosis (narrowing of the spinal canal in the lower part of your back), high blood pressure, prediabetes (serious condition when the blood glucose is high but not high enough to be diagnosed with diabetes), liver disease, and a history of falling. During a concurrent record review and interview on 4/10/24 at 4:05 pm, the CSM confirmed the diagnoses of liver disease, high blood pressure and prediabetes should be included in the POC and interventions added for nursing to monitor and update physician if indicated.”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on interview, and record review, the agency failed to ensure two of seven sampled patients (Patient 2, and Patient 6) received all disciplines ordered by the physician, this included home health orders that included a Medical Social Worker (MSW) for Patient 2, and a Home Health Aide (HHA) for Patient 6, when admitted to the agency. This failure could result in changes to care without physician knowledge or approval, and a lack of adequate physician oversight leading to negative clinical outcomes. A review of Patient 2’s “OASIS Start of Care” (Outcome and Assessment Information, data collected during the initial assessment) visit note, dated 6/14/23, indicated, Patient 2 was admitted to the agency for hypokalemia (a low potassium level that could affect muscles, specifically the heart) and muscle weakness. During a concurrent interview and record review on 4/10/24 with Registered Nurse Case Manager (RN CM) 1, Patient 2’s “OASIS Start of Care” visit note, written on 6/14/23, by RN CM 7, was reviewed. RN CM 1 confirmed the “OASIS Start of Care” visit note indicated Patient 2 required a Medical Social Worker (MSW) to assist with potential plans to move to another state. RN CM 1 reviewed visit notes dated 6/14/23 through 6/22/23 and confirmed, the MSW had not been out to see Patient 2 and should have. During a concurrent interview and record review with CSM and Administrator (Admin), on 4/11/24 at 10:42 am, CSM reviewed Patient 2’s “OASIS Start of Care” visit note, written on 6/14/23 by RN CM 7. CSM confirmed the “OASIS Start of Care” visit note indicated Patient 2 required services from the Medical Social Worker (MSW) and one was not provided. Admin confirmed the MSW visit should of occurred as ordered. Findings: During a review of the agency’s policy revised 2/2024, titled “Intake Process, DHH-2002,” indicated this policy manages the risk of not meeting regulatory requirements related to the referral and admission process by providing a consistent procedure. This policy also indicated the purpose of this agency’s policy is to establish the process for acceptance and entry of patients into the organization. The organization accepts only those patients who needs can be met by the services it provides. During a review of the agency’s policy revised 2/2024, titled, “Admission Criteria & Process, DHH-2003,” indicated a patient will be accepted for care based on consideration to the adequacy and and suitability of organizational personnel, resources to provide the required services, and the reasonable expectation that the patient’s medical, nursing, rehabilitate, and social needs can be adequately met in the patient’s place of residence. This policy also indicated a patient will be referred to other resources if the organization cannot meet their needs. During a review of Patient 6’s clinical record, a home heath referral dated 3/18/24, titled “Intake Form,” indicated Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), and (HHA) was ordered for Patient 6. During a review of Patient 6’s clinical record, the Plan of Care (POC) or Physician’s Orders dated 3/19/24 did not include HHA services to be provided as ordered for Patient 6. During a review of Patient 6’s clinical record, documentation was not completed for communication to the physician that the HHA was not added in the POC. During a concurrent record review and interview on 4/11/24 at 8:25 am, the Clinical Supervisor Manager (CSM) confirmed the HHA was not added to the POC, and the physician was not updated. The CSM confirmed the referral orders were not followed as ordered for Patient 6, and stated, “The order for the HHA was missed, and should have been added to the POC.””