John Muir Home Health Services

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information: (1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on interview and record review the agency failed to do accurate comprehensive assessment, create comprehensive care plan and provide appropriate medical supplies for one of three sampled patients (Patient 1), when the agency’s staff did not do a comprehensive assessment correctly to develop a care plan that included Patient 1’s Genitourinary disease. The agency staff also did not provide appropriate straight urinary catheter (a small, flexible, hollow tube that’s inserted into the bladder to empty urine) for Patient 1. This failure had the potential to result in inaccurate care plans that fail to address the patient’s needs, delayed or improper treatments, exacerbation of existing health conditions, increased risk of complications. Findings: During an interview on 11/13/24 at 9:00 a.m. with Patient 1, Patient 1 stated, the agency provided wrong type of self-catheter for him, and it took a while for them to order the right catheter. A review of Patient 1’s “Home Health Certification and Plan of Care” indicated Patient 1 was admitted to the agency with multiple disease including recurrent UTI (Urinary Tract Infection). During a concurrent interview and review on 10/30/24 at 11:36 a.m. with the Director of Patient Care and Services (DPCS), Patient 1’s “Home Health Certification and Plan of Care” record was reviewed. DPCS confirmed that the record indicated, the agency did not make a care plan for straight urinary catheterization for Patient 1 and did not add any supplies on the care plan to be ordered for Patient 1’s self-catheterization. A review of “ED (Emergency Room) Provider Notes by …” dated 9/7/24 indicated, Patient 1 had multiple diagnosis including “…self-catheterizes urinary bladder…” A review of Patient 1’s Start of Care (SOC) done by the Physical Therapist (PT) indicated “…Genitourinary, indicate genitourinary assessment findings, external catheter, retention…” A review of Patient 1’s “Visit Note Report, RN (Registered Nurse) evaluation” indicated “… Genitourinary… No abnormal genitourinary findings identified…” During an interview on 10/30/24 at 11:30 a.m. with the PT, PT stated she did the evaluation on Patient 1 and Patient 1 told PT that he was using straight urinary catheter, however PT did not do the further evaluation to see if Patient 1 had enough catheter and PT did not order any supplies for Patient 1. PT also stated she should have done more assessment and ordered supplies for Patient 1 at the time of the first visit. During an interview on 10/30/24 at 11:13 a.m. with the RN, RN stated she did the nursing evaluation on Patient 1, and she did not have any conversation about the self-catheterization with Patient 1 and RN did not know anything about that. During an interview on 10/30/24 at 11:36 a.m. with the DPCS, DPCS stated the clinicians should have documented, care planed and ordered supplies for Patient 1’s self-catheterization after the first visit (Start of Care). A review of the agency’s policy and procedure “CARE PLANNING PROCESS” 2024, indicated “…1. At the time of the initial assessment, the clinician, along with other involved disciplines, will develop the patient plan of care based upon the patient’s identified needs and will review it with the patient and family/caregiver. A Case Manager will be assigned to coordinate all activities involved in the patient’s care. 2. All clinicians will consider the conclusions of initial and ongoing assessments in their care planning process…” A review of the agency’s policy and procedure “INITIAL AND COMPREHENSIVE ASSESSMENT “2024 indicated “…During the initial and comprehensive patient assessment, all baseline data to be used in measuring the patient’s progress towards goals and other relevant information will be documented in the patient’s clinical record…” A review of the agency’s policy and procedure “SAFE/EFFECTIVE USE OF EQUIPMENT AND SUPPLIES” 2024, indicated “…Upon admission, the patient assessment will document the use of any medical equipment, or supplies being used in the home. The HME company providing the equipment and any patient instruction materials to be left in the home will be identified…””

“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 failed to develop a comprehensive care plan and provide appropriate care for one of three sampled patients (Patient 1), when the agency did not address Patient 1’s Genitourinary disease in Patient 1’s care plan, and did not provide medically necessary supply of straight urinary catheters (a small, flexible, hollow tube that’s inserted into the bladder to empty urine) for Patient 1. This failure placed Patient 1 at high risk to develop infection, cause discomfort, and delayed treatment. Findings: During an interview on 11/13/24 at 9:00 a.m. with Patient 1, Patient 1 stated, the agency provided wrong type of self-catheter for him, and it took a while for them to order the right catheter. A review of Patient 1’s “Home Health Certification and Plan of Care” indicated Patient 1 was admitted to the agency with multiple disease including recurrent UTI (Urinary Tract Infection). During a concurrent interview and record review of Patient 1’s “Home Health Certification and Plan of Care” record on 10/30/24 at 11:36 a.m. with the Director of Patient Care and Services (DPCS), the record review indicated the agency did not make a care plan for straight urinary catheterization for Patient 1 and did not add any supplies on the care plan to be ordered for Patient 1’s self-catheterization, and DPCS confirmed that. A review of “ED (Emergency Room) Provider Notes by …” dated 9/7/24 indicated Patient 1 had multiple diagnosis including “…self-catheterizes urinary bladder…” A review of Patient 1’s Start of Care (SOC) done by the Physical Therapist (PT) indicated “…Genitourinary, indicate genitourinary assessment findings, external catheter, retention…” A review of Patient 1’s “Visit Note Report, RN (Registered Nurse) evaluation” indicated “… Genitourinary… No abnormal genitourinary findings identified…” During an interview on 10/30/24 at 11:30 a.m. with the PT, PT stated she did the evaluation on Patient 1 and Patient 1 told PT, he was using Straight urinary catheter, however PT did not do further evaluation to see if Patient 1 had enough catheter and also PT did not order any supplies for Patient 1.PT also stated she should have done more assessment and ordered supplies for Patient 1 at the time of the first visit. During an interview on 10/30/24 at 11:13 a.m., with the RN, RN stated she did the nursing evaluation on Patient 1, and she did not have any conversation about the self-catheterization with Patient 1 and RN did not know anything about that. During an interview on 10/30/24 at 11:36, with the DPCS, DPCS stated the clinicians should have documented, care planed and ordered supplies for Patient 1’s self-catheterization after the first visit (Start of Care). A review of the agency’s policy and procedure “CARE PLANNING PROCESS” 2024, indicated “…1. At the time of the initial assessment, the clinician, along with other involved disciplines, will develop the patient plan of care based upon the patient’s identified needs and will review it with the patient and family/caregiver. A Case Manager will be assigned to coordinate all activities involved in the patient’s care. 2. All clinicians will consider the conclusions of initial and ongoing assessments in their care planning process…” A review of the agency’s policy and procedure “INITIAL AND COMPREHENSIVE ASSESSMENT “2024 indicated “…During the initial and comprehensive patient assessment, all baseline data to be used in measuring the patient’s progress towards goals and other relevant information will be documented in the patient’s clinical record…” A review of the agency’s policy and procedure “SAFE/EFFECTIVE USE OF EQUIPMENT AND SUPPLIES” 2024, indicated “…Upon admission, the patient assessment will document the use of any medical equipment, or supplies being used in the home. The HME company providing the equipment and any patient instruction materials to be left in the home will be identified…””