Adventist Health Home Care Services

“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 clinical record review, the agency failed to ensure one of 8 sampled patients (Patient 6) initial assessment visit was done within 48 hours of referral and as per physician’s request. This failure resulted in 6 days delay of care and services for Patient 6. According to the Plan of Care (POC) dated 4/15/24 through 6/13/24, the agency admitted Patient 6 with multiple diagnoses including paralysis, kidney failure and prostate (small gland in the male reproductive system) problems. A review of the home health referral form dated 4/3/24, indicated the physician requested the following clinical services for Patient 6,”Skilled nursing [SN], physical therapy [PT], occupational therapy [OT] and Medical Social Work [MSW].” A review of Patient 6’s clinical records contained documentation that the agency called the patient and his caregiver several times but was unable to contact the patient to schedule the initial visit from 4/5/24 until 4/9/24. A review of Patient 6’s clinical record contained a document titled, “Client Coordination Note Report,” dated 4/9/24 which indicated that Patient 6’s physician updated the referral date to 4/9/24. The coordination note indicated, “MD [medical Doctor] ordered SOC [start of care] ASAP [as soon as possible.] “ The note indicated that the agency’s staff informed Patient 6 on 4/9/24 that the SOC date was scheduled for 4/14/24. Patient 6’s clinical record indicated the patient was not assessed within 48 hours from the referral date of 4/9/24 until 4/15/24, a total of 6 days delay in services. There was no documented reason for the delay. During a review of Patient 6’s clinical record and the referral documents with the Director of Patient Care Services (DPCS) and Administrator (ADM) on 8/14/24 at 2:30 p.m., the DPCS stated Patient 6’s care should have been initiated within 48 hours as per the agency’s policy. The ADM stated that initially the agency had extremely difficult time contacting the patient to conduct the initial assessment. The DPCS acknowledged that Patient 6’s physician was contacted on 4/9/24 and a new referral date was to start the services on 4/9/24. The DPCS did not provide an explanation why the initial assessment and start of care was delayed from 4/9/24 to 4/15/24 as it was not documented. A review of the agency’s ‘Acceptance and Assignment of Referrals,’ policy with revision date of 11/2022, stipulated that the agency will schedule a visit within 48 hours of referral and/or agreed upon visit date with the patient and the physician. The policy indicated, “Patients will be evaluated within 48 hours, unless specified differently by the referral source, to determine needs and eligibility to admission to home care services …The initial assessment visit will determine the immediate care and support needs of the patient.””

“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 provide services ordered by the physician as indicated in the Plan of Care (POC) for three of 8 sampled patients (Patient 3, Patient 7, and Patient 5), when the patients did not receive Medical Social Work (MSW) and Occupational Therapy (OT) services. These failures resulted in the agency’s inability to ensure needed services were provided including information on how to obtain outside resources. Patient 5 had a start of care (SOC) date of 1/12/24 and diagnoses included stage four pressure ulcer of sacral region (an open wound that involves full tissue loss with exposed bones, tendon, or muscle, and occurs when a bony prominence is subjected to prolonged pressure), functional quadriplegia (complete immobility due to severe disability from another medical condition without injury to the brain or spinal cord [tube-like structure that carries signals that help in moving and feeling sensations]), and anxiety disorder (feelings of worry, anxiety, or fear that are strong enough to interfere with one’s daily activities). A review of Patient 5’s physician order dated 5/27/24 for the recertification period 5/11/24-7/9/24 indicated, “Order Description: MSW CONSULT...Calendar Frequency: MSW EFFECTIVE 5/26/24 1W1 [once a week for one week].” A review of Patient 5’s physician order dated 7/1/24 for the recertification period 5/11/24-7/9/24 indicated, “Order Description: OT TO EVALUATE PATIENT FOR UPPER BODY EXERCISES/STRENGTHENING…Calendar Frequency: OT EFFECTIVE 06/30/2024 1W1.” During a review of Patient 5’s “Client Calendar Report” for the recertification period 5/11/24-7/9/24, the report indicated, “MSW ADD-ON EVALUATION” was scheduled on 5/28/24 and “OT ADD-ON EVALUATION” was scheduled on 7/2/24. The report further indicated there were no begin time, end time, and worker name for both add-on evaluations, which indicated the visits were not done. In a concurrent interview and record review on 8/14/24 at 3:42 p.m. with the DPCS, the DPCS confirmed there was a physician order for the MSW evaluation and stated, “I don’t think there was any visit…I don’t think the social worker evaluation was done…It should have been messaged back to the provider, no documentation on physician notification.” The DPCS also confirmed there was an order for OT evaluation and stated the order for OT was effective 6/30/24, and confirmed there were no visits done, no documentation why it was not done and cannot find documentation on physician notification. During a review of the facility’s policy and procedure (P&P) titled “STANDARD POLICY: CARE PLANNING AND COORDINATION OF SERVICES,” revised 4/4/23, the P&P indicated, “The agency establishes a written, individualized care plan for each patient which addresses needs that have been identified in the assessment process…Patients are accepted for treatment with the reasonable expectation that the agency can meet the patient’s nursing, rehabilitative and social needs in the patient’s residence…4. When the physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the practitioner is consulted to approve additions or modifications to the original plan…8. All patient care orders…are recorded in the Plan of Care…a. The agency communicates with and integrates orders from all physicians or allowed practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient…9. Patients’ care is coordinated using an interdisciplinary approach to support the implementation of the care plan…c. The agency integrates services…to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines.” During a review of the facility’s P&P titled “STANDARD POLICY: MEDICAL SOCIAL SERVICES,” revised 11/30/2022, the P&P indicated, “Medical Social Services, when required by the Plan of Care, must be available on a visiting, not consultative basis, in the patient’s residence. Medical social services will assess the needs of patients and families and will make appropriate referrals…A. Home evaluations of patients with a physician order for home social services will include, but not be limited to assessment of the following:…8. Development of a Plan of Care (POC) that is individualized to the patient’s needs and based on the data from the home evaluation…9. Communicate with the physician or allowed practitioner as necessary and complete physician’s Plan of Care (POC) including the frequency and duration of specific interventions and the goals of interventions.” During a review of the facility’s P&P titled “STANDARD POLICY: OCCUPATIONAL THERAPY,” revised 5/9/2024, the P&P indicated, “The Occupational Therapist (OT) is responsible for providing and supervising patient care as ordered by the physician on the Plan of Care…A. The occupational therapist will perform evaluations/assessments for patients with a physician order for occupational therapy services.” During a review of the facility’s P&P titled “STANDARD POLICY: EXPECTATIONS AND RESPONSIBILITIES FOR FIELD STAFF,” revised 1/19/2022, the P&P indicated, “Field Staff will:…B. Schedule their home visits in compliance with physician ordered frequency/duration…2. If the agency misses a visit, treatment or service which results in potential for clinical impact upon the patient, then the Agency must notify the responsible physician of such missed treatment or service…D. Provide care, treatment and services to each patient according to their established Plan of Care.” A review of the agency’s ‘Care Planning and Coordination of Services’ policy with the revision date of 4/2023, the policy stipulated that the agency admitted patients with the expectation that the agency can meet the patient’s needs, including social needs in the patient’s residence. The policy indicated, “The agency establishes a written, individualized plan of care for each patient which addresses needs that have been identified in the assessment process …The agency ensures that each patient receives the home health services that are written in the individualized plan of care.” According to Patient 3’s POC dated 6/29/24 through 8/27/24, the agency admitted the patient with multiple diagnoses which included chronic pain, brain bleed, and paralysis of left side of patient’s body. The POC included a physician’s order for MSW to evaluate Patient 3 for any needs with outside resources the week of 6/30/24. A review of Patient 3’s clinical record indicated there was no documented evidence MSW evaluation and/or MSW services were provided the week of 6/30/24 or any time after. There was no evidence the physician had been notified that the MSW services were not provided, 43 days from the start of care. During an interview and a concurrent record review with Director of Patient Care Services (DPCS) on 8/14/24, at 2:15 p.m., the DPCS stated that MSW visit was not on Patient 3’s calendar and was not able to find any supporting documentation indicating why the visit was not scheduled and not conducted. The DPCS validated that Patient 3 had not received MSW services since start of care and the physician was not made aware. The DPCS stated her expectations were that MSW services should have been rescheduled within the same week if possible and if unable to complete, the missed services should have been documented and the physician notified. According to Patient 7’s POC dated 6/18/24 through 8/16/24 indicated the agency admitted the patient with multiple diagnoses including aftercare for left leg fracture. Patient 7’s POC indicated that the patient had limitations with ambulation, transfer to bed and chair. The POC included an add on physician’s order dated 6/22/24 for MSW to evaluate Patient 7 for any needs with outside resources. A review of Patient 7’s clinical record indicated there was no documented evidence the MSW services were provided since 6/22/24. There was no evidence the physician was notified that Patient 7 did not receive MSW services, 52 days from the date the MSW services were ordered. During an interview and concurrent record review with DPCS on 8/14/24, at 2:45 p.m., the DPCS acknowledged the MSW was scheduled to visit Patient 7 on 6/22/24 as ordered by the physician. The DPCS was not able to find any supporting documentation indicating why the visit was not conducted as scheduled. The DPCS validated Patient 7 had not received MSW services since start of care and the physician was not notified of missed services. The DPCS stated her expectations were that MSW services should have been rescheduled within the same week depending on patient’s and clinician’s availability. The DPCS stated if the MSW was unable to complete the visit, the missed services should have been documented and the physician notified. A review of the agency’s MSW job description (JD) indicated the MSW role was to provide social work support to patients in their place of residence and the responsibilities included providing community resources, placement options and counselling to patient and families as needed. The JD indicated the agency’s expectations for MSW were that the practitioner “makes the initial assessment as ordered …makes visits as needed, serving as a resource liaison …Provides patients/families with community resources.” A review of the agency’s policy titled, “Medical Social Services,” revised 11/2022, stipulated, “Medical Social Services, when required by the Plan of Care, must be available on a visiting …in the patient’s place of residence. Medical social services will assess the needs of patients and families and will make appropriate referrals.””

“Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the physician was notified of missed visits for three of 8 sampled patients (Patient 3, Patient 7, and Patient 5), when the physician was not informed that the three patients did not receive Medical Social Work (MSW) and Occupational Therapy (OT) services. This failure had the potential for Patient 3, Patient 7, and Patient 5 needs to be unmet. Patient 5 had a start of care (SOC) date of 1/12/24 and diagnoses included stage four pressure ulcer of sacral region (an open wound that involves full tissue loss with exposed bones, tendon, or muscle, and occurs when a bony prominence is subjected to prolonged pressure), functional quadriplegia (complete immobility due to severe disability from another medical condition without injury to the brain or spinal cord [tube-like structure that carries signals that help in moving and feeling sensations]), and anxiety disorder (feelings of worry, anxiety, or fear that are strong enough to interfere with one’s daily activities). A review of Patient 5’s physician order dated 5/27/24 for the recertification period 5/11/24-7/9/24 indicated, “Order Description: MSW CONSULT...Calendar Frequency: MSW EFFECTIVE 5/26/24 1W1 [once a week for one week].” A review of Patient 5’s physician order dated 7/1/24 for the recertification period 5/11/24-7/9/24 indicated, “Order Description: OT TO EVALUATE PATIENT FOR UPPER BODY EXERCISES/STRENGTHENING…Calendar Frequency: OT EFFECTIVE 06/30/2024 1W1.” During a review of Patient 5’s “Client Calendar Report” for the recertification period 5/11/24-7/9/24, the report indicated, “MSW ADD-ON EVALUATION” was scheduled on 5/28/24 and “OT ADD-ON EVALUATION” was scheduled on 7/2/24. The report further indicated there were no begin time, end time, and worker name for both add-on evaluations, which indicated the visits were not done. In a concurrent interview and record review on 8/14/24 at 3:42 p.m. with the DPCS, the DPCS confirmed there was a physician order for the MSW evaluation and stated, “I don’t think there was any visit…I don’t think the social worker evaluation was done…It should have been messaged back to the provider, no documentation on physician notification.” The DPCS also confirmed there was an order for OT evaluation and stated the order for OT was effective 6/30/24, and confirmed there were no visits done, no documentation why it was not done and cannot find documentation on physician notification. During a review of the facility’s policy and procedure (P&P) titled “STANDARD POLICY: CARE PLANNING AND COORDINATION OF SERVICES,” revised 4/4/23, the P&P indicated, “The agency establishes a written, individualized care plan for each patient which addresses needs that have been identified in the assessment process…Patients are accepted for treatment with the reasonable expectation that the agency can meet the patient’s nursing, rehabilitative and social needs in the patient’s residence…4. When the physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the practitioner is consulted to approve additions or modifications to the original plan…8. All patient care orders…are recorded in the Plan of Care…a. The agency communicates with and integrates orders from all physicians or allowed practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient…9. Patients’ care is coordinated using an interdisciplinary approach to support the implementation of the care plan…c. The agency integrates services…to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines.” During a review of the facility’s P&P titled “STANDARD POLICY: MEDICAL SOCIAL SERVICES,” revised 11/30/2022, the P&P indicated, “Medical Social Services, when required by the Plan of Care, must be available on a visiting, not consultative basis, in the patient’s residence. Medical social services will assess the needs of patients and families and will make appropriate referrals…A. Home evaluations of patients with a physician order for home social services will include, but not be limited to assessment of the following:…8. Development of a Plan of Care (POC) that is individualized to the patient’s needs and based on the data from the home evaluation…9. Communicate with the physician or allowed practitioner as necessary and complete physician’s Plan of Care (POC) including the frequency and duration of specific interventions and the goals of interventions.” During a review of the facility’s P&P titled “STANDARD POLICY: OCCUPATIONAL THERAPY,” revised 5/9/2024, the P&P indicated, “The Occupational Therapist (OT) is responsible for providing and supervising patient care as ordered by the physician on the Plan of Care…A. The occupational therapist will perform evaluations/assessments for patients with a physician order for occupational therapy services…10. Communicate findings to the physician or allowed practitioner and complete the Plan of Care (POC)…11. Coordinate care with additional disciplines caring for the patient.” During a review of the facility’s P&P titled “STANDARD POLICY: EXPECTATIONS AND RESPONSIBILITIES FOR FIELD STAFF,” revised 1/19/2022, the P&P indicated, “Field Staff will:…B. Schedule their home visits in compliance with physician ordered frequency/duration…2. If the agency misses a visit, treatment or service which results in potential for clinical impact upon the patient, then the Agency must notify the responsible physician of such missed treatment or service…D. Provide care, treatment and services to each patient according to their established Plan of Care.” According to Patient 3’s POC dated 6/29/24 through 8/27/24, the agency admitted the patient with multiple diagnoses which included chronic pain, brain bleed, and paralysis of left side of patient’s body. The POC included a physician’s order for MSW to evaluate Patient 3 for any needs with outside resources the week of 6/30/24. A review of Patient 3’s clinical record indicated there was no documented evidence MSW evaluation and/or MSW services were provided the week of 6/30/24 or any time after. There was no evidence the physician had been notified of the missed MSW visit, 43 days from the start of care. During an interview and a concurrent record review with Director of Patient Care Services (DPCS) on 8/14/24, at 2:15 p.m., the DPCS validated that Patient 3 had not received MSW services the week of 6/30/24 or after. The DPCS did not have an explanation for the missed visit and stated that the physician should have been notified. The DPCS stated her expectations were that MSW services should have been rescheduled within the same week if possible and if unable to complete, the missed services should have been documented and the physician notified. According to Patient 7’s POC dated 6/18/24 through 8/16/24 indicated the agency admitted the patient with multiple diagnoses including aftercare for left leg fracture. Patient 7’s POC indicated the patient had limitations with ambulation, transfer to bed and chair. The POC included an add on physician’s order dated 6/22/24 for MSW to evaluate Patient 7 for needs with outside resources. A review of Patient 7’s clinical record indicated there was no documented evidence the MSW visit was conducted on 6/22/24 or at a later date. There was no evidence the physician had been notified that Patient 7 did not receive MSW services, 52 days from the date the MSW services were ordered. During an interview and a concurrent record review with DPCS on 8/14/24, at 2:45 p.m., the DPCS reviewed Patient 7’s visit calendar and stated that MSW was scheduled to visit patient on 6/22/24. The DPCS validated that there was no documented evidence that MSW visit was conducted as scheduled and as ordered by the physician. The DPCS validated that Patient 7 had not received MSW services since start of care and the physician was not notified of missed visit and services. The DPCS stated her expectations were that MSW services should have been rescheduled within the same week depending on patient’s and clinician’s availability. The DPCS stated that if MSW was unable to complete the visit, the missed services should have been documented and the physician notified. A review of the agency’s policy titled, “Expectations and Responsibilities of Field Staff,” dated 1/2022, indicated that the staff was responsible to schedule home visits in compliance with physician ordered frequency and duration, reschedule patients to meet the weekly frequency for refused/missed visits, and if the agency missed the visit or service, the agency were to notify the responsible physician of missed treatment or service.”

“Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to provide RN (Registered Nurse) supervision to LVN (Licensed Vocational Nurse) for one of eight sampled patients (Patient 8), when Patient 8 did not have an RN supervisory visit from 4/6/24 to 8/15/24. This failure had the risk potential for Patient 8’s care needs to not be evaluated by an RN to determine if desired outcomes were met. A review of Patient 8’s “Home Health Certification and Plan of Care [POC],” for certification period 4/30/24 to 6/28/24, indicated Patient 8 had a Start of Care (SOC) date with HHA on 11/2/23 for diagnoses including dressing change for chronic left leg ulcer, diabetes (too much sugar in the blood), and heart failure (heart does not pump blood as well as it should). The POC indicated “...Frequency/ Duration of Visits: SN [Skilled Nurse] 1WK9 [once a week for 9 weeks] ...” A review of Patient 8’s POC, for certification period 6/29/24 to 8/27/24, indicated “...Frequency/Duration of Visits: SN effective 06/30/24 1WK1 [once a week for 1 week], 1EVERY2WKS6 [once every 2 weeks for 6 weeks], 1WK1 [once a week for 1 week], plus 2 PRN [as needed visits] ...” A review of Patient 8’s “Client Calendar Report,” for 5/2/24 to 8/14/24, indicated Patient 8 had visits from LVN on 5/2/24, 5/9/24, 5/16/24, 5/23/24, 5/30/24, 6/13/24, 6/20/24, 7/3/24, 7/17/24, 7/31/24, and 8/14/24. A review of Patient 8’s “Client Calendar Report,” for 5/2/24 to 8/14/24, indicated Patient 8 had visits from RN on 6/6/24 and 6/27/24. A review of Patient 8’s “Visit Note Report,” completed by RN, dated 4/5/24, indicated “...Supervisory Functions Were Supervisory Functions Performed? Yes Indicate Discipline of Employee Being Evaluated: LVN/LPN [Licensed Practical Nurse] ...” A review of Patient 8’s “Visit Note Report,” completed by RN, dated 6/6/24, indicated “...Supervisory Functions Were Supervisory Functions Performed? No...” A review of Patient 8’s “Visit Note Report,” completed by RN, dated 6/27/24, indicated “...Supervisory Functions Were Supervisory Functions Performed? No...” During a concurrent interview and record review on 8/14/24 at 3:27 p.m. and subsequent concurrent interview and record review on 8/14/24 at 4:20 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated the HHA practice is for the RN to conduct supervisory visits of the LVN every 30 days. The DPCS stated that Patient 8 was seen by RN on 6/6/24 and 6/27/24. The DPCS acknowledged that Patient 8 was not seen in July 2024 by an RN. The DPCS stated, “Should have been seen in July by RN for supervisory visit. Don’t know why wasn’t seen.” The DPCS acknowledged that Patient 8 had RN supervisory visit on 4/5/24, but not on 6/6/24 or 6/27/24. The DPCS acknowledged that Patient 8 had not received an RN supervisory visit since 4/5/24. The DPCS stated, “Practice is for supervisory visits to be done on a 30-day basis. No idea why not done.” A review of the HHA Policy and Procedure (P&P) titled “Standard Policy: Skilled Nursing-Licensed Vocational or Practical Nurses,” revised 6/18/20, indicated “...The skilled licensed vocational/practical nurse (LVN/LPN) is considered a skilled nurse and provides guidance and/or continuous nursing care to patients under the guidance and supervision of a Registered Nurse...” A review of the HHA P&P titled “Standard Policy: Expectations and Responsibilities for Field Staff,” revised 1/19/22, indicated “...Communicate pertinent information from initial assessment/reassessments to other appropriate members of the healthcare team through documentation using electronic medical record, team conferences, status change notices, secure messaging, voice mail or person-to-person communication...” A review of the HHA “Job Description Report.” for RN, not dated, indicated “...Supervises and directs the activities of various levels of assigned nursing staff, and coordinates care with other disciplines while utilizing critical thinking, professional and supervisory discretion, and independent judgment...coordinates care delivery...evaluates progress toward attaining outcomes...Provides learning opportunities for...team members...Directly provides health information to patient’s, families, and treatment team...Delegates appropriately and coordinates duties of healthcare team members...””