Mercy Home Care

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on interview, and record review, the agency failed to ensure that two out of 17 sampled patients (Patients 5, and 7) received additional ordered services within the 5-day window when: 1. Patient 5’s physician ordered Occupational Therapy (OT, assist patients with activities of daily living (ADL) such as: bathing, eating, and dressing self) services was one day late. 2. Patient 5’s physician ordered Medical Social Worker (MSW, a social worker that assisted patients with community services, such as assistance with care givers, food, and transportation) was missed, and not provided. 3. Patient 7’s physician ordered OT services was three days late. These failures had the potential for delayed services, and potentially needed community services to be missed which could lead to negative clinical outcomes. Findings: A review of the agency’s policy and procedure (P&P) titled, “33.43, Comprehensive Patient Assessment,” revised 4/15/22, indicated, that the comprehensive assessment would be completed within five days of the start of care (SOC, initial home visit). 1. During a review, of Patient 5’s, “Plan of Care” (POC), dated 2/3/24, it indicated, that Patient 5 was admitted to the agency on 2/3/24, with the diagnoses of lung and brain cancers, and “problems related to living alone.” The POC indicated, that Patient 5 would receive services from skilled nursing (SN), a physical therapist (PT), and OT. The POC indicated, that Patient 5 required the services of OT to assist, train, and educate on fall prevention, home safety, to increase independence, and to be able to perform ADLs on her own. A review of Patient 5’s “Calendar View,” dated 1/28/24 through 2/17/24, indicated, that OT performed the comprehensive assessment on 2/9/24, six days after Patient 5’s SOC visit on 2/3/24, and was one day late. During a concurrent interview, and record review, on 4/26/24 at 9:15 am, Patient 5’s POC, dated 2/3/24, and “Calendar View,” dated 1/28/24 through 2/17/24, was reviewed, with the Director of Clinical Services (DCS). DCS stated, the POC indicated, that Patient 5 had an order for OT, and confirmed, that Patient 5’s OT comprehensive assessment was completed one day late. 2. A review, of Patient 5’s, “Consult to Home Health” (a referral that included a physicians order and what services home health would provide the patient), dated 1/31/24, indicated, the physician had ordered home health services for Patient 5 that included: SN, PT, and MSW. The “Consult to Home Health,” indicated, Patient 5 needed a MSW for “advanced planning/goals of care/community resources.” A review, of Patient 5’s “Client Calendar Report,” dated 2/3/24 through 2/27/24, indicated, that Patient 5 was discharged from home health services on 2/17/24, and the MSW had not performed the physician ordered home visit. During a concurrent interview, and record review, with DCS, Patient 5’s “Consult to Home Health,” dated 1/31/24, and “Client Calendar Report,” dated 2/3/24 through 2/27/24, was reviewed. DCS stated the records indicated, that the physician had ordered MSW services to be provided to Patient 5, and confirmed, that MSW services had not been provided, and should have. 3. A review, of Patient 7’s POC, dated 1/31/24, indicated, that their admission to the agency on 1/31/24, with the diagnoses of atrial fibrillation (when the heart quivers, and had irregular heartbeats) and orthostatic hypotension (low blood pressure that occurred with position changes, such as standing up from a sitting position). The POC indicated, that Patient 5 required OT services for fall prevention, and training on ADLs. A review, of an untitled calendar, dated 1/28/24 through 3/2/24, indicated, that Patient 7 was admitted to the agency on 1/31/24, OT performed a comprehensive assessment on 2/8/24, and the OT evaluation was completed three days late. During a concurrent interview, and record review, on 4/24/24 at 4:20 pm, Patient 7’s untitled calendar, that included all home visits that were provided to Patient 7, dated 1/31/24, was reviewed with Clinical Supervisor (CS). CS confirmed, that OT performed the comprehensive assessment on 2/8/24, eight days after admission to the agency. The SC, and the Administrator confirmed, that the OT comprehensive assessment was three days late.”

“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 observation, interview, and record review, the agency failed to review and document all medications in the home for three out of seven patients, (Patient 13, Patient 14, and Patient 17) during the initial assessment, and follow up visits to include in the clinical record and for the physician to review for interactions. This failure had the potential to cause unrecognized medication interactions to go undetected, and cause potential negative clinical outcome to occur. Findings: The agency’s policy titled, “Medication Administration and Management,” revised 9/29/23, was reviewed and indicated, that the purpose of this policy was to provide medication administration and management guidelines for patients receiving care in the home. This policy indicated, that the qualified clinician assesses the current medications as part of the initial assessment at start of care (SOC), resumption of care, recertification of services, and anytime a change, or updates is made in the medication profile. This policy indicated that clinical monitoring of medications included the information obtained from a medication history, and ongoing medication assessments that form a current medication profile assisted with the process. The agency’s policy titled, “Medication Administration and Management,” revised 9/29/23, was reviewed and indicated, that assessments of medication profiles and patient response to therapy are reviewed ongoing to facilitate appropriateness, safety and to prevent complications whenever possible. The Patient Medical Record reflects clinical monitoring of medications. Medication changes and/or updates during an episode of care are recorded on the patient’s medication profile through a physician or allowed practitioners’ order. The qualified therapist may update the medication profile. This agency’s policy also indicated, that the required elements of a medication profile are as follows but not limited to, needed (prn) orders, hold orders, automatic stop orders, taper orders, medication related devices, over the counter medications, Vitamins and Herbal products. The agency’s policy titled, “Comprehensive Patient Assessment,” revised 4/15/22, was reviewed and indicated, that the comprehensive assessment findings will be available to all associates providing care to the patient. This policy indicated the assessment is to include but not limited to diagnosis, identification of additional health problems or pertinent health history, data items collected from inpatient facility admission or discharge, and a review of current medications. 1. Patient 13’s clinical record was reviewed. Patient 13 was admitted to the home health agency on 4/19/24, with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD, a progressive disease of damaged lungs), dependent on supplemental oxygen, high blood pressure and hypothyroidism (disease when the thyroid gland does not make enough thyroid hormone). During an interview, on 4/24/24 at 10:50 am, Patient 13 stated, “I do get all my medications from here every day except my inhaler in the mornings. I miss my inhaler. The hospital also lost my CPAP machine (continuous positive airway pressure machine to keep breathing airways open while during sleep), they are supposed to be getting me a new one. I would appreciate it if you could check on that too, I have worn it at night for at least five years now.” During a concurrent interview, and record review, with Licensed Nurse (LN) D, they confirmed that Patient 13 had no inhaler, or CPAP machine listed on the medication list, and stated, “I will talk to the facility nurse, and doctor and clarify this medication, and make sure they have an appointment scheduled for a new CPAP machine at night. This is my first visit with Patient 13.” During a concurrent interview, and record review, with the Assisted Living staff, (LN) J and LN D, LN J confirmed, that the medication was not listed on the medication record, but the inhaler, Anor Ellipta 62.5 micrograms (mcg, a unit of measure)/25mcg was in the medication drawer for Patient 13. LN J stated, “I wondered why we had the inhaler but no order. I do confirm the hospital lost Patient 13’s CPAP machine, we have an appointment scheduled to get her a new one. I will call the doctor about the inhaler order, but the doctor already knows about the CPAP machine.” During a concurrent interview, and record review, on 4/25/24 at 11:25 am, with the Director of Clinical Services (DCS), it was confirmed that two inhalers had been added to the medication list after the doctor had clarified the medication orders for Patient 13. The medication Airsupra 90mcg/80mcg aerosol inhaler was ordered every 4 hours, 1 inhalation as needed for shortness of breath, and the inhaler Anor Ellipta 62.5 mcg/25mcg/actuation powder for inhalation was ordered 1 inhalation daily for Patient 13. 2. Patient 14’s clinical record was reviewed. Patient 14 was admitted to the home health agency on 3/27/24, with diagnoses that included COPD, Urinary Tract Infection (UTI, a bladder infection), Adrenocortical Insufficiency (or sometimes called Addison’s disease when the adrenal glands do not function properly), Hypoglycemia (abnormal low blood sugar in the blood), and heart disease. During a concurrent interview, and record review, on 4/24/24 at 1:55 pm, with Registered Nurse (RN) A, and Patient 14, the medication list was not up to date and did not note a change in doses to one medication from 4/23/24. RN A confirmed, that the medication list was not accurate and up to date from Patient 14’s notes in the home, and she would call the doctor for clarification to update all changes for accuracy. During a concurrent interview, and record review, on 4/25/24 at 11:35 am, the DCS confirmed, that that the medication list was not accurate and up to date for Patient 14, and RN A had called the doctor and clarified the medication change, and updated the medication record. The medication Prednisone (a medication for adrenal insufficiency), 10 milligram, (mg, a unit of measure) tablet for Patient 14 had been decreased from 30 mg daily, to 20 mg daily for three days, then 10 mg daily for three days, and then discontinue. This change was effective to begin 4/23/24, and continue through 4/28/24. 3. Patient 17’s clinical record was reviewed. Patient 17 was admitted to the home health agency on 4/20/24, with diagnoses that included a spinal fusion (surgical repair of the lower back to cause the bones to grow together), hypothyroidism, pain, and depression (constant feeling of sadness and loss of interest). During a concurrent interview, and record review, on 4/25/24 at 10:30 am, in the home of Patient 17, with Physical Therapist (PT) 1, the medications in the home did not match the medication list in the clinical record. There were multiple medications not listed and the wrong strength on the medication profile for Patient 17, as follows: Equate sleep aide Ibuprofen pm 200 mg/doxylamine 25 mg. German supplement/herb Korodin, Synthroid 88 mcg 1 tablet daily in the morning, Cymbalta 50 mg daily for pain, and Tramadol 50 mg 1 tablet daily for pain every eight hours as needed. During an interview, on 4/25/24 at 10:45 am, Patient 17 stated, “I have been taking this same dose of Synthroid for years now, it has not been changed lately. I did not know this Ibuprofen was for nighttime, maybe this is why I get dizzy in the morning. I take this German supplement for dizziness; my sister gets it for me. I take Cymbalta for depression, not pain. I started taking it this past August, when my husband passed away. I don’t take the Tramadol for pain, but I am keeping it in case I need it.” During an interview, with PT 1 on 4/25/24 at 11:10 am, PT 1 stated, “These medications were not accurate on the medication list for Patient 17. I will update the clinical record. This is not safe, taking a nighttime medication in the morning could have caused a fall. I will fix it, and continue to educate on medications in the home.” During a interview, and record review, on 4/25/24 at 11:45 am, the DCS confirmed, that the medication list was not accurate and up to date for Patient 17. The DCS confirmed the wrong doses, wrong indications, omitted medications, and unsafe medication use for a nighttime medication used in the morning for Patient 17. DSC stated, “PT 1 called me after the visit, and told me the medications were not correct in the home. PT 1 said, that he would correct the list to make sure the clinical record is accurate for Patient 17, and continue education. The SOC nurses need to make sure these lists are correct on admission, and to educate for safety.” During an interview, on 4/25/24 at 1:50 pm, the Administrator (Admin) confirmed, that all medications should be clarified and current on the initial assessments of all current patients, and an ongoing review, at each visit in the home for safety. The Admin confirmed, that Patient 13, Patient 14, and Patient 17, did not have up to date and current medication lists in the clinical record, and all three patients needed a medication reconciliation due to the SOC medication list was not accurate at the admission visit. The Admin stated, “We will be educating our staff immediately on medication safety, and the importance of making sure the medication lists are accurate and include all supplements, herbs and OTC medications.””

“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 include pertinent diagnoses, and interventions as relevant to the plan of care for four out of 17 sampled patients (Patient 1, Patient 3, Patient 6, and Patient 10). This failure had the potential for unidentified problems, risk for hospitalization, and negative clinical outcomes to occur. A review of Patient 1’s “POC,” dated 5/20/23, indicated admission to the agency on 5/20/23 with the diagnoses of COPD, atrial fibrillation (when the heart beats so fast it caused the heart to quiver and was not able to pump blood well), sciatica (pain, weakness, numbness, or tingling in the leg), and hypertensive heart disease with heart failure (the heart was not able to pump blood well and high blood pressure). During a concurrent interview and record review on 4/25/24 at 1:18 pm, Patient 1’s “POC,” dated 5/20/23, was reviewed with DCS. DCS confirmed the “POC” indicated, Patient 5 had the pertinent diagnoses of COPD, atrial fibrillation, sciatica, and hypertensive heart disease with heart failure. DCS confirmed, Patient 5’s POC was not individualized, did not include patient specific interventions as related to the pertinent diagnoses and should have. A review of Patient 3’s “Visit Note Report,” dated 10/18/23, indicated Patient 3 was admitted to the agency on 10/18/23 with the diagnoses of sepsis (a serious infection in the blood stream that could cause death), pneumonia (an infection in the lung), and atrial fibrillation. A review of Patient 3’s “Physician Note,” dated 11/15/23, indicated that Patient 3 went to the emergency room due to significant difficulty with breathing. The “Physician Note,” indicated, Patient 3 had an electrocardiogram (a test that recorded the electrical signals of the heart) that detected Patient 3 had a right bundle branch block (a delay or blockage in the heart that altered the heartbeat), a possible mucus plug (thick mucus) in the lung, and required to be admitted to the hospital. A review of the “Procedure Note,” dated 11/20/23, indicated, Patient 3 had a surgical procedure that included an implantation of an Abbott loop recorder (a medical device that continuously monitored heart beats) for unexplained fainting. A review of the untitled fax cover sheet, dated 11/21/23, indicated Patient 3 was being discharged from the hospital and required the agency to perform a ROC visit to keep Patient 3 on home health services. During a concurrent interview and record review on 4/24/24 at 1:18 pm, Patient 3’s “Physician Note,” dated 11/15/23, “Procedure Note,” dated 11/15/23, and “Resumption of Care” visit note, dated 11/22/23, was reviewed with DCS. DCS confirmed Patient 3 went to the emergency room on 11/15/22 and was admitted to the hospital. DCS confirmed, Patient 3’s “Physician Note” and “Procedure Note,” indicated, Patient 3 had a right bundle branch block and had an Abbott loop recorder implanted during his hospital stay. DCS reviewed Patient 3’s “Resumption of Care” (ROC) visit note, dated 11/22/24. DCS stated, the “ROC” visit note indicated Patient 3 had the diagnoses of right bundle branch block, atrial fibrillation, and depression (a sad mood). DCS stated, when Patient 3 was discharged from the hospital and the ROC visit was performed, the skilled nurse who performed the ROC visit would develop a new POC that included new health concerns needing to be addressed by the agency. DCS confirmed, the “ROC” visit note included a new POC that was not individualized with patient specific needs or interventions. DCS stated the “ROC” visit note did not include cardiac (heart) interventions that addressed the bundle branch block or the Abbott loop recorder. DCS stated Patient 3 had COPD and depression. DCS confirmed the POC did not include interventions that addressed COPD or depression and should have. Findings: The agency’s policy titled, “Comprehensive Patient Assessment,” revised 4/15/22 indicated the comprehensive assessment findings will be available to all associates providing care to the patient. This policy indicated this comprehensive assessment and plan of care (POC) development will include but is not limited by the following: Development of the POC, which will be appropriate for the type of care that is needed by the patient. Frequency and process for POC review. Care Planning directed toward driving positive patient outcomes. Skilled patients must have a comprehensive assessment, individualized, and appropriate to the care or services to be provided. This policy indicated the initial assessment is to include but not limited to diagnosis, identification of additional health problems or pertinent health history, data items collected from inpatient facility admission or discharge, and a review of current medications. During a review of Patient 6’s clinical record, Patient 6 was admitted to the home health agency on 4/10/24 with diagnoses that included congestive heart failure (a long-term condition in which your heart cannot pump blood well enough to meet the body’s needs), diabetes (disease when the blood sugar is too high), Chronic Obstructive Pulmonary Disease (COPD, a progressive disease of damaged lungs), and high blood pressure. During a review of Patient 6’s Plan of Care (POC, physician’s orders that help nurses and other team members organize aspects of patient care with a timeline) dated 4/10/24, a weight vital sign was not included with a parameter to notify the physician for a measurement of CHF to assess and monitor for weight gain, and exacerbations to prevent hospitalizations. During a concurrent record review and interview with the Director of Clinical Services (DCS) on 4/26/24 at 9:45 am, the DCS confirmed the POC was not individualized for Patient 6 and should have included a weight parameter to notify the physician if indicated. DCS stated, “I confirm [Patient 6] should be monitored for weight gain for CHF, and we have a weight pathway that could have been easily added. I will continue to educate all the clinicians to add these parameters to the POC.” During a review of Patient 10’s clinical record, Patient 10 was admitted to the home health agency on 4/21/24 with diagnoses that included sepsis (the body’s extreme response to an infection), diabetes, heart disease, Urinary Tract Infection (UTI, a bladder infection), and chronic stage 3 kidney disease (mild to moderate loss of kidney function). During a review of Patient 10’s POC dated 4/21/24, the Foley (common type of tube), catheter (a device that drains urine from your bladder into a collection bag outside of the body) was not listed with the catheter size, bulb size or any specific care instructions for cleaning. No interventions or education for catheter care was listed on this POC. No orders were listed if the catheter became occluded (not draining). No labs were added to the POC to check the urine for an infection with a history of UTIs, sepsis and a UTI within the last 14 days. During a concurrent record review and interview with the DCS on 4/26/24 at 9:05 am, the DCS confirmed the POC was not individualized for Patient 10 and should have included the size of the Foley catheter as well as interventions to educate for specific catheter care to prevent infections. DCS confirmed each POC should be individualized to each patient with the pertinent history and diagnoses that are current problems. During an interview with the administrator on 4/26/24 at 10:02 am, the Administrator (Admin) confirmed Patient 6 should have had a weight parameter on the POC to monitor CHF. The Admin also confirmed Patient 10 should have more specific interventions with the size of the Foley catheter and bulb, specific instructions for catheter care, and labs (urinalysis to check for an infection) if needed to make the POC more individualized. Admin stated, “We will continue to educate the clinicians for more detailed POCs and add more patient specific interventions.””

“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 interview, and record review, the agency failed to promptly update the physician of a change in condition for one of 17 sampled patients (Patient 2), when they were refusing visits related to increased pain levels. This failure resulted in changes to care without physician knowledge or approval, and a lack of adequate physician oversight which could lead to negative clinical outcomes. Findings: The agency’s policy titled, “Medical Supervision,” revised 7/28/2022, was reviewed and indicated, that the purpose and policy of this agency is that all patients must be under the care of a licensed doctor of medicine (MD), doctor of podiatric medicine, (PDM) or doctor of osteopathic medicine (DO) when receiving home health care services. This policy indicated there are criteria established for notifying the patient’s physician or allowed practitioner that included the refusal of the patient to accept treatment, therapy, or services as ordered by the physicians, and changes in condition, as appropriate, and when the patient is discharged. Patient 2’s clinical record was reviewed. Patient 2 was admitted to the home health agency on 1/12/24, with diagnoses that included open wound to right lower leg (any break or damage to the skin’s surface), cellulitis of right lower leg (common bacterial skin infection), pyoderma gangrenosum (rare disorder that causes large painful sores, most often in the legs) and ulcerative colitis (inflammation and sores in the colon). During a concurrent interview, and record review, on 4/23/24 at 3:20 pm, with the Clinical Supervisor (CS) 1, and CS 2, CS 1 confirmed, that Patient 2 was non-compliant with visits for wound care and physical therapy ordered by the physician, and had refused home visits on 1/1/24, 1/17/24, 1/22/24, and 1/26/24, for increased pain. These missed visits were not faxed to the physician, or any update called or faxed related to the increased pain reported by Patient 2. CS 2 stated, “We had a system problem where missed visits were not faxed for a while.” CS 2 confirmed, that the physician was not called after the faxes were not sent. During a review, of Patient 2’s clinical record, Patient 2 was re-admitted to the agency for home health on 2/16/24, after a local hospital admission for increased pain, and was diagnosed with a new compression fracture in her back, and was using a back brace and walker to ambulate. During a concurrent interview, and record review, on 4/23/24 at 3:30 pm, the CS 1 confirmed, that the agency discharge was not completed in the home on 3/11/24, related to Patient 2 refused the discharge visit. An office discharge was completed on 3/11/24, without goals met. CS 1 stated, “Patient 2 was a challenging case, we should have updated the physician, and maybe added a social worker to help, Patient 2 did have depression, and some behaviors were documented.” During a concurrent interview, and record review, with Director of Clinical Services (DCS) on 4/23/24 at 3:50 pm, the DCS stated, “This was a missed opportunity. Patient 2 hurt for too long and we should have completed a significant change and given the physician a thorough update related to new pain. This was poor communication. If the physician did not respond we should have called back again. Patient 2 was non-compliant, but we could have done more.””