Butte Home Health and Hospice

“State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This Element is not met as evidenced by: Based on interview and record review, the agency failed to inform one out of 17 sampled patients (Patient 12) of their patient rights when Licensed Nurse (LN) A did not provide information regarding the state toll free home health telephone hotline number (a number that a patient could call if they needed to file a complaint or had questions regarding a home health agency). This failure caused Patient 12 to not be aware of protected patient rights. Findings: During a review of the agency’s undated policy and procedure (P&P) titled, “Assessment, Initial,” indicated, “The primary staff member will complete and/or review with the patient and/or representative, if any, and family/caregiver the following on the initial visit:…Agency grievance procedure including the appropriate state hotline numbers.” During a review of Patient 12’s “Plan of Care (POC),” dated 1/3/24, indicated, Patient 12 was admitted to home health services on 12/28/23 with diagnosis that included uncontrolled hypertension (high blood pressure). During a review of Patient 12’s medical record titled: “OASIS [Outcome & Assessment Information Set-standardized assessment] NURSING SERVICES SOC/ROC,” dated 12/28/23, indicated, Patient 12’s cognition (ability to remember and recall information) was intact (not altered or impaired). During a concurrent interview and record review, located in Patient 12’s home, on 1/11/24 at 10:34 am, a patient booklet (that described patient rights and responsibilities) was reviewed. Page 5 of the patient booklet indicated, “You have the right to be advised of the state toll free home health telephone hotline to report complaints or ask questions about local home health agencies.” There were no patient initials located on page 5 of the patient booklet and the state hotline number was not circled. Patient 12 was asked if LN A reviewed the state hotline number during the Start of Care (SOC, the first in home visit made by the LN) visit. Patient 12 stated not knowing what the state hotline number was and did not recall LN A reviewing the patient booklet with Patient 12. During an interview on 1/12/24 at 12:02 pm, LN A stated the patient booklet was reviewed with patients during the SOC visit and the patient booklet included information on patient rights and patient responsibilities. LN A stated when reviewing the patient booklet, LNs were expected to circle the state hotline number located on page 5 of the patient booklet and initial that section. LN A was not able to recall if the state hotline number was reviewed with Patient 12. During an interview on 1/12/24 at 4:08 pm, Director of Patient Care Services (DPC) stated, when the LNs performed the SOC visit, the agency expectation was that LNs reviewed the state hotline number with the patient, circle the state hotline number, and have the patient initial the page as proof that LN provided the patient with the information.”

“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 agency failed to ensure two of 17 sampled patients (Patients 9 and 17) received a timely start of care (admission to the agency), within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physicians ordered start of care date. Both Patients 9 and 17 were opened to home health seven days late. These failed actions had the potential for delay of immediate care needs and support for services that were identified by the prescribing physician. Findings: During a review of the facility’s undated policy and procedure (P&P) titled, “Assessment, Initial,” the P&P indicated, “The initial visit will be completed by a registered nurse, unless it is a therapy only case (in which case a therapist may be assigned to do the admission), within 48 hours after referral/hospital discharge, unless otherwise ordered by the physician.” During a review of Patient 9’s “Plan of Care” (POC), dated 12/25/23, the “POC” indicated, Patient 9 was admitted to the home health agency on 12/20/23 with the diagnosis of postpolio syndrome (a group of potentially disabling symptoms that caused muscle weakness, pain in the muscle and joints, tiredness, and breathing problems) and history of falls. The “POC” indicated, Patient 9’s “Focus of Care” would be fall prevention. During a concurrent interview and record review on 1/12/24 at 2:00 pm, with Director of Operations (DOO), Patient 9’s “Referral,” dated 12/12/23 was reviewed. DOO stated, the “Referral” indicated, Patient 9’s physician ordered home health services that included services from a Physical Therapist (PT) and Registered Nurse. DOO stated, during a review of the “Referral,” the agency identified Patient 9 did not need the services of a Registered Nurse and a new “Order” was required. DOO reviewed Patient 9’s “Referral,” dated 12/28/23, and stated the “Referral” indicated, Patient 9’s physician faxed the home health agency a new order for a PT to treat and provide services to Patient 9. DOO reviewed Patient 9’s Electronic Medical Record (EMR) and stated there was a note, dated 12/19/23, that indicated, the physician confirmed Patient 9 only needed a PT, and Patient 9 was admitted to home health services on 12/20/23. DOO confirmed there was no supporting documentation that indicated why there was a seven-day delay in contacting Patient 9’s physician for a new home heath order and confirmed Patient 9 was not opened to home health services in a timely manner. A review of Patient 17’s “POC,” dated 12/1/23, indicated Patient 17 was admitted to the agency on 11/26/23 with the diagnosis of type 2 diabetes mellitus with diabetic chronic kidney disease (diabetes, when the body is unable to regulate blood sugar levels. Chronic kidney disease, the kidneys were not able to filter waste from the body and is a common disease caused by diabetes). The “Focus of Care” indicated, Patient 17 required “Education/Assessment/Training on Diabetic Health Care.” During a concurrent interview and record review on 12/12/23 at 2:00 pm, with DOO, Patient 17’s “Referral,” dated 11/21/23 was reviewed. DOO stated, the “Referral” indicated, Patient 17’s physician ordered home health services for Patient 17. DOO reviewed Patient 17’s EMR and stated there was no supporting documentation that indicated why there was a seven-day delay in opening Patient 17 to home health services. DOO confirmed Patient 17 was not opened to home health services in a timely manner. Based on interview and record review the agency failed to ensure two of 17 patients received a timely start of care (admission to the agency within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physicians ordered start of care date. Both Patient 9 and 17 were opened to home health seven days late. These failed actions had the potential for delay of immediate care needs and support for services that were identified by the prescribing physician.”

“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 additional ordered therapies were provided timely to meet patient needs within 5 days unless otherwise ordered by the physician (Patient 3, 5, 6,14 and 16). 1. Patient 3’s prescribed Occupational Therapy (OT) services was two days late to provide services. 2. Patient 5’s prescribed Speech Therapy (ST) services was two days late to provide services. 3. Patient 14’s prescribed Physical Therapy (PT) services was one day late and OT was five days late to provide services. 4. Patient 16’s prescribed PT services was three days late and ST was 16 days late to provide services. 5. Patient 6’s prescribed ST services was 20 days late to provide service. These deficient practices had the potential for delayed services, needed equipment, falls, accidents and re-hospitalization to occur to patients. The record for Patient 6 was reviewed. His start of care with the agency was 12/22/23, He was admitted with diagnoses that included hemiplegia after a cerebral infarction (one sided paralysis after a stroke) effecting his left side, and dysphagia. The original referral, dated 12/19/23, included a request for a speech therapy evaluation. The Plan of Care, dated 12/23/23, also indicated that speech therapy should evaluate Patient 6. During a record review and concurrent interview, on 1/12/24 at 2:45 pm, with DOO she reviewed the record and confirmed that both the original referral and the Plan of Care indicated that a speech therapist should evaluate Patient 11. DOO stated that the speech therapy evaluation was being done today (1/12/24.) DOO confirmed that the agency did not act on the physician’s order in a timely manner. (20 days late) Findings: During a review of the facility’s undated policy and procedure (P&P) titled, “Assessment, Initial,” the P&P indicated “Additional discipline(s) will provide service(s) according to the patient’s need, physician’s orders and acuity but within 5 days, unless otherwise ordered by the physician.” (Additional disciplines were physical therapist (PT, help improve with movement and pain), occupational therapist (OT, helps improve ability to do daily tasks such as sitting, standing, dressing), and speech therapist (ST, assist with speaking and swallowing) when the Licensed Nurse (LN) performed the initial home visit assessment.) During a review of Patient 3’s “Plan of Care” (POC), dated 7/9/23, the “POC” indicated, Patient 3 was admitted to home health services on 7/4/23 with the diagnosis of “Displ intertroch fx l femur” (left hip fracture). During a review of Patient 3’s “Referral,” dated 7/3/23, the “Referral” indicated, the physician faxed an order to the home health agency requesting home health services. The “Referral” indicated Patient 3 would receive services from LN, PT, and OT. During a review of Patient 3’s “Calendar” (a calendar that included dates the patient was or will be seen and who will provide the visit), dated 7/4/23 through 7/24/23, indicated, Patient 3 was opened to home health services on 7/4/23, and the LN performed the initial assessment. The “Calendar” indicated, OT provided services on 7/11/23, two days late. During an interview on 1/12/24, at 2:00 pm, with Director of Operations (DOO), the DOO stated there were some “issues” with the electronic medical record, and DOO was not able to access all of Patient 3’s medical records. DOO was not able to confirm the OT evaluation was two days late. A request for Patient 3’s “Referral” and order for home health services was made and not provided. During a review of Patient 5’s “POC,” dated 9/19/23, the “POC” indicated Patient 5 was admitted to home health services on 9/14/23 with the diagnoses of dysphagia (difficulty in swallowing) and aphasia (difficulty in speaking). A review of Patient 5’s “Ambulatory referral to Home Health,” dated 9/13/23, indicated Patient 5’s physician ordered home health services that included LN, PT, OT, and ST. A review of Patient 5’s “Calendar” indicated, ST provided services on 9/21/23, two days late. During an interview on 1/12/24, DOO stated performing an independent record review of Patient 5’s referral to the home health agency and “Calendar.” DOO confirmed the ST provided services on 9/21/23 and was two days late. During a review of Patient 14’s “POC,” dated 1/7/24, the “POC” indicated, Patient 14 was admitted to home health services on 1/2/24 with the diagnoses of saddle embolus of pulmonary artery with acute cor pulmonale (a rare type of blood clot that extended into both lungs and could cause sudden death) and a history of falling. During a concurrent interview and record review on 1/12/24 at 2:00 pm, with DOO, “Referral,” dated 12/31/23 was reviewed. DOO confirmed the “Referral” indicated, Patient 14 was ordered home health services that included LN, PT, and OT. DOO performed an independent record review and stated PT provided services on 1/8/24, one day late, and OT provided services on 1/12/24, five days late. DOO stated there was no supporting documentation found in Patient 14’s medical records that indicated the patient or doctor requested PT and OT services to be started at a later date. During a review of Patient 16’s “POC,” dated 12/25/23, the “POC” indicated Patient 16 was admitted to home health services on 12/20/23 with the diagnoses of muscle weakness, history of falls, and unqualified visual loss, left eye, normal vision right eye (low vision or blindness in the left eye). During a review of Patient 16’s “Calendar,” dated 12/20/23 through 1/26/24, the “Calendar” indicated PT provided services on 12/28/23, three days late, and ST provided services on 1/10/24, 16 days late. During an interview on 1/12/24 at 2:00 pm, DOO stated performing an independent record review of Patient 16’s medical records. DOO confirmed PT and ST services were provided late and stated there was no supporting documentation in Patient 16’s medical record that that indicated the patient or doctor requested PT and OT services to be started at a later date.”

“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 observation, interview and record review, the agency failed to have an individualized plan of care (POC, Physicians orders) for pertinent diagnoses along with medications and treatments for three of 17 sampled patients (Patient 2, 11 and 16). 1. Patient 2 had a diagnoses of diabetes (increased sugar in the blood stream) with no POC to include the frequency of blood sugar testing, the sliding scale amount to be administered or the parameters of when to notify the physician. 2. Patient 11 had a diagnosis of diabetes and his POC failed to contain parameters for hypo or hyperglycemia (abnormally low or high blood sugars) for when the physician would be notified. There was no indication of how frequently Patient 11 should test his blood sugars. 3. Patient 16 had a diagnoses of vision loss in the left eye. The POC failed to include interventions related to his vision loss. These failures had the potential for diabetic medication management to be ineffective, delay in services, falls and injury and the potential for negative outcomes to occur to patients. A review of Patient 11’s record indicated he was admitted with a primary diagnosis of Type 2 diabetes with foot ulcer (wound). Patient 11’s physician’s orders, dated 11/29/23, indicated “Insulin Glargine (a long-lasting insulin 100unit/ml, 28 units subcutaneous every night at bedtime.” A second physician’s order, dated 11/29/23, indicated “Empaglifozin (medication used to treat diabetes) 10 mg orally each day.” Patient 11’s Plan of Care, dated 11/29/23 was reviewed. Under the section titled “interventions” the plan of care indicated skilled nursing staff were to “Assess for an S/S (signs and symptoms) of hypo or hyperglycemia (abnormally low or high blood sugar) document and report and S/S observed” but no parameters were given. There was no frequency indicating how often or when Patient 11 should use his glucometer. During an observation of a home visit on 1/11/24 at 12:30 pm with LN (Licensed Nurse) C she asked Patient 11 how often he checks his blood sugars, and what have his readings been. Patient 11 responded that he checks several times a day when he “feels like it” and confirmed he performs this procedure himself. Patient 11 stated he needed a new glucometer, as his current one was not working consistently and was often giving errors. Patient 11 was uncertain what his last reading was, but stated he felt his current blood sugar was “in the 130’s”. LN C checked the glucometer, but stated that no history of prior readings was recorded. LN C asked Patient 11 to demonstrate using his glucometer. Patient 11 was able to complete this task only with a great deal of coaching from the nurse. Patient 11 made multiple errors including inserting the glucometer strips upside down, inserting the strips backwards, and he poked several different fingers for a blood draw, prior to preparing the glucometer to read the sample. During an interview and concurrent record review on, 1/12/24 at 3:40 pm, with DOO, she confirmed that Patient 11’s medications included a long-lasting insulin and an oral medication, both used to treat diabetes. DOO stated that Patient 11’s physician orders should include how frequently Patient 11 should be checking his glucose, and parameters of high and low to guide when the physician should be called. DOO confirmed that the agency expectation is for both a frequency and parameters to be included in the Plan of Care for a patient with a diagnosis of diabetes, and this was not included for Patient 11. Findings: During a review of Patient 16’s “POC”, dated 12/25/23, the “POC” indicated, Patient 16 was admitted to the agency on 12/20/23 with the diagnosis of unqualified visual loss, left eye, normal vision right eye (there was low vision or complete blindness in the left eye). The “POC” indicated, Patient 16 required the use of an “assistive device such as a four-pronged cane or walker to ambulate safely related to” being “blind in the left eye.” The focus of care included fall prevention and Patient 16 had a functional limitation (difficulty or cannot do) due to vision. The “POC” did not include “Interventions” (the action taken to improve something) related to Patient 16’s vision loss. During a concurrent interview and record review, on 1/12/24 at 3:45 pm, with Executive Director (ED), Patient 16’s “POC,” dated 12/25/23, was reviewed. ED confirmed the “POC” indicated, Patient 16 had a pertinent (important or meaningful) diagnosis of vision loss in the left eye. ED stated all pertinent diagnoses should be included in the patient’s “POC.” ED stated Patient 16’s “POC” did not include “Interventions” related to Patient 16’s vision loss and should have. Findings: During a review of the facility’s undated policy and procedure (P&P) titled “Plan of Care,” the P&P indicated, “The initial Plan of Care must include, at a minimum, these patient specific items:…All pertinent diagnoses.” The P&P indicated “All Pertinent Diagnoses means all known diagnoses.” A review of an undated “Plan of Care” policy indicated that all pertinent diagnoses, treatments and medication doses and frequencies would be included in patients POCs. A review of Patient 2’s record indicated he had a start of care (admission) to the agency on 1/12/23 with a primary diagnosis that included diabetes (a condition where the body cannot produce enough insulin resulting in high glucose levels in the blood stream). A review of Patient 2’s Outcome and Assessment Information Set (a patient specific standardized assessment upon admission) dated 1/12/23 indicated Patient 2 /Care Giver were checking his blood sugars six times a day without a schedule. The POC directed the Registered Nurse (RN) / Licensed Vocational Nurse (LVN) to visit for one time a week for one week (1 week 1) from 1/12 to 1/13/23, and then two times a week for four weeks (2 week 4) from 1/14 to 2/10/23 to assess and instruct Patient 2 and his Care Giver on insulin, diabetic medication compliance, the use of the glucometer (device used to test glucose levels) and recording the results. Under medications, the POC indicated Patient 2 was prescribed the following diabetic medications: Glimepiride 1 milligram (mg) oral tablet daily starting 1/12/23. Insulin Glargine 100 units / milliliter (ml) subcutaneous (injected under the skin) 5 units daily effective 1/12/23. Insulin Lispro (1 unit dial) Humalog Kwik Pen) 100 units/ml subcutaneous per sliding scale (a set amount of insulin injected dependent on the glucose level reading using from the glucometer) starting 1/12/23. There were no sliding scale instructions included in the POC. There was also no direction for when Patients 2’s blood sugars were to be tested with the glucometer to know the amount of this insulin to be administered depending on the glucometer results in this POC. There were also no prescribed parameters for when the physician would be notified when Patient 2’s blood sugars were low (hypoglycemic) or high (hyperglycemic) and when Patient 2 or the Care Giver should administer the diabetic medication. During an interview and concurrent record review on 1/12/24 at 12 pm with the RN Case Manager (RNCM) she acknowledged Patient 2’s POC for 1/12/23 start of care failed to have sliding scale orders for the Lispro Humalog Kwik insulin pen. The RNCM additionally acknowledged Patient 2’s POC failed to contain orders for when Patients 2’s blood sugars were to be tested with the glucometer, and parameters when to not administer the diabetic medications and when the physician would be notified when Patient 2’s blood sugars were high or low.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on interview and record review the agency failed to follow a physician order for one out of 17 sampled patients (Patient 17) when ordered laboratory testing and services (collection of blood samples, used to manage a patient’s health) were not completed. This failure placed Patient 17 at risk for a decline in health status. Findings: During a review of the facility’s undated policies and procedures (P&P) titled, “Plan of Care,” indicated, “All patient care orders, including verbal orders are a part of the plan of care. The plan should be revised to reflect any verbal order received during the 60-day certification so that all agency staff are working from a current plan.” During a review of Patient 17’s “Plan of Care,” dated 12/1/23, indicated Patient 17 was admitted to the agency on 11/26/23 with diagnosis that included type 2 diabetes mellitus with diabetic chronic kidney disease (diabetes, the body was unable to regulate blood sugar levels). Chronic kidney disease, (the kidneys were not able to filter waste from the body and was a common disease caused by diabetes). The “Plan of Care” did not indicate the physician faxed an order to the agency, on 11/28/23, that indicated Patient 17 required laboratory testing and services. During a concurrent interview and record review on 1/12/24 at 2:00 pm, with Director of Operations (DOO), Patient 17’s faxed “Lab Request,” dated 11/28/23, was reviewed. DOO confirmed the faxed “Lab Request” was an order from Patient 17’s physician for the agency to provide Patient 17 with laboratory testing and services. During a record review, DOO was not able to locate lab results in Patient 17’s medical records. After DOO performed an independent record review, DOO stated, the agency performed laboratory testing and services to Patient 17 on 12/12/23 (14 days after Patient 17’s physician first faxed the “Lab Request”). DOO stated having no knowledge of why laboratory services ordered on 11/28/23 were not provided to Patient 17.”