Health Is Wealth Home Health Agency LLC

“Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure services identified in the plan of care were provided for one of three sampled patients (Patient 2) when three out of six planned and scheduled Skilled Nursing visits over a two-week period were not provided. This failure had the potential to result in the lack of follow-up care. Review of the clinical record indicated Patient 2 was admitted with diagnoses that included a pressure ulcer (otherwise known as bed sore, areas of damaged skin caused by staying in the same position for too long) of the sacral (tailbone) region, urinary tract infection, diabetes mellitus (abnormal levels of blood sugar) and anxiety disorder (constant feeling of fear, dread, and uneasiness). [Reference: https://medical-dictionary.com/results.php]. Review of Patient 2’s Plan of Care (POC, a patient’s treatment plan) for coverage period 3/1/2023 to 4/29/23 indicated Patient 2 would be provided three weekly Skilled Nursing visits for nine weeks. During an interview and concurrent record review with Administrator (ADM) on 4/6/23 at 11:57 a.m., ADM stated the clinical record indicated planned visits on 3/7/23, 3/8/23, 3/15/23 were missed. During a follow-up visit on 7/18/23 at 11:55 a.m., Receptionist (Rec) was not able to provide a copy of agency’s policy and procedure for missed visits.”

“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, for one of three sampled patients (Patient 1), the agency failed to ensure the individualized plan of care included foley catheter (a flexible tube that is inserted through the skin, passes through the urethra, into the bladder to drain urine) care. This failure had the potential to result in delayed management of an infection. Review of Patient 1’s Plan of Care (POC, a patient’s treatment plan) indicated Patient 1 was admitted to home health services for the period starting 2/18/23 to 4/18/23 with diagnoses that included chronic kidney disease, pressure ulcer (otherwise known as bed sore, areas of damaged skin caused by staying in the same position for too long) in the sacral (tailbone) region, and personal history of urinary tract infection. Patient 1’s POC also indicated; under Orders and Treatments, Patient 1 was described as bedbound with foley catheter and was also incontinent (inability to control the bowels or bladder). Under Goals and Outcomes, the POC indicated Patient 1 had diabetes (abnormally high blood sugar levels), pressure areas, and a foley catheter. Ongoing teachings were as follows; home safety, fall prevention, pain and diabetes management, skin management and protection and turning schedule. Patient 1’s POC did not address foley catheter care and management. [Reference: https://medical-dictionary.com/results.php]. During a telephone interview with Registered Nurse (RN) on 7/18/23 at 12 p.m., RN stated if there was indication that Patient 1 had a foley catheter, the visit notes should indicate documentation of assessment of the catheter. RN also stated at one time during the coverage period, Patient 1’s foley catheter was so plugged up that Patient 1 needed to be sent to the hospital. Review of Patient 1’s hospital Discharge Instructions from the Emergency Department (ED) dated 3/2/23 indicated Patient 1 was admitted to the ED and discharged the same day on 3/2/23 with diagnosis, malfunction of foley catheter. Discharge Instructions included to keep the foley catheter in place until seen by the urologist, drink lots of fluids and to take medication as prescribed. Patient 1 was prescribed ciprofloxacin (antibiotic to treat urine infection) 500 milligrams (mg) one tablet by mouth every 12 hours for 7 days. During an interview and concurrent review of the clinical record with Administrator (ADM) on 4/6/23 at 11:28 a.m., ADM stated Patient 1 had a foley catheter to aid in wound healing of the sacral region pressure ulcer but there was no care plan to address it. During a telephone interview and concurrent review of the clinical record with Licensed Vocational Nurse (LVN) 1 on 5/10/23 at 10:54 a.m., LVN 1 stated she provided home visits to Patient 1 on 3/3/23, 3/7/23 and 3/10/23. LVN 1 stated, foley catheter assessment and management, and foley catheter care education were not included in the clinical notes for the above dates. LVN 1 also stated, every home visit for a patient who had a foley catheter, urine output assessment should be done to make sure the catheter was not clogged, assess urine character and to check if there were signs of pain in the abdomen. LVN 1 also stated assessments should be documented in the patient’s clinical record. LVN 1 stated Patient 1’s last visit was on 3/10/23. Review of Patient 1’s hospital record dated 3/29/23 indicated Patient 1 was admitted to the hospital on 3/10/23 for altered mentation and urinary tract infection. Review of the agency’s policy and procedure titled “Patient Assessments/Plan of Care” with copyright date 2022, indicated, the care plan must specify the care and services to meet patient-specific needs as identified in the comprehensive assessment.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on interview and record review, for one of three sampled patients (Patient 2), the agency failed to ensure the clinical record included clinical notes for Skilled Nursing Visit on 3/17/23. This failure had the potential to result in the lack of coordination of care. Review of clinical record indicated Patient 2 was admitted with diagnoses that included pressure ulcer (otherwise known as bed sore, areas of damaged skin caused by staying in the same position for too long) of the sacral (tailbone) region, urinary tract infection, diabetes mellitus (abnormal levels of blood sugar) and anxiety disorder (constant feeling of fear, dread, and uneasiness). [Reference: https://medical-dictionary.com/results.php]. During an interview and concurrent record review with Administrator (ADM) on 4/6/23 at 11:57 a.m., ADM stated the clinical record indicated a visit on 3/17/23 had a “re-opened” status. ADM stated there were no clinical notes completed for this visit. ADM also stated the clinical notes for a Skilled Nursing Visit on 3/13/23 was not complete and should have been completed “sooner than now”. During a telephone interview with Licensed Vocational Nurse (LVN) 1 on 5/10/23 at 10:54 a.m., LVN stated clinical notes should be completed and in the patient’s chart within 24 hours after the visit. Review of the agency’s policy and procedure titled “Submission of Clinical Record Visits” with copyright 2017 indicated “All nursing visit notes must be submitted within 7 days of providing service and must be filed in the patient’s chart within 14 days of the visit.””