Tlc Home Health Services

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to ensure interventions and reassessment for pain were implemented in accordance with the plan of care for one of 7 sampled patients (Patient 5). This deficient practice has the potential to result in ineffective pain management. Findings: During a review of Patient 5 ‘s demographics indicated a start of care date of 8/20/2023, with diagnoses including bilateral primary osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), and hypertensive heart disease (refers to heart problems that occur because of high blood pressure that is present over a long time). During a review of Patient 5’s Home Health Certification and Plan of Care (POC) for the recertification period from 10/19/2023 to 12/17/2023, included an order for the skilled nurse (SN) frequency of visits of one visit on week 1, twice a week on the next 2 weeks, then once a week for 6 weeks, to assess all body systems, assess vital signs (measure the basic functions of your body that includes your body temperature, blood pressure, pulse and respiratory [breathing] rate), medication and diet compliance, and safety on every visit. The POC also indicated for the SN to assess pain level using pain scale of 0-10 (0 being no pain and 10 being the worst pain), intensity and severity, implement pain relief measures and evaluate their effectiveness. During a review of Patient 5’s SN Visit Clinical Notes, dated 10/19/2023, 10/23/2023, and 11/2/2023, indicated Patient 5 was experiencing pain 5/10 on BLE (bilateral lower extremities [legs]) and knees. There was no documented evidence of interventions and reassessment done for the pain. During a concurrent interview and record review, on 12/14/2023 at 11:28 a.m. with the Director of Patient Care Services (DPCS), of Patient 5’s pain assessment record, the DPCS stated pain assessment should include pain intervention that was implemented, the effectiveness of the intervention and pain reassessment using the pain level 0-10. DPCS stated, Patient 5’s pain assessment did not indicate effectiveness of intervention and pain reassessment was not done. During a review of the agency’s policy and procedure titled “Pain Assessment”, revised April 2020, indicated each patient will receive at least an initial pain assessment. When the patient or the clinician identifies pain, the following in-depth pain assessment information should be obtained whenever possible among others: pain intensity using a rating scale (on a scale of 0 - 10, 0 = no pain, 10 = unbearable pain), pain location, and present pain management regimen and effectiveness.”

“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 home health agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) staff failed to review all the medications and update the medication profile with currently used medications for one of 7 sampled patients (Patient 4). This deficient practice had the potential to put the patient at risk for medication errors and adverse drug reactions. Findings: During a review of Patient 4’s face sheet indicated a start of care (SOC) date of 11/29/2023 with a diagnosis that includes encounter for change or removal of dressing, hypertensive heart disease (refers to heart problems that occur because of high blood pressure that is present over a long time), and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]). During a review of Patient 4’s Home Health Certification and Plan of Care (POC) for certification period from 11/29/2023 to 1/27/2024, included an order for the skilled nurse (SN) to visit daily for wound care, to assess vital signs and pain level, and to evaluate therapeutic response to current/new medications and compliance to medication/diet regimen. On 12/13/2023, at 10:30 a.m., a joint home visit was conducted at Patient 4’s residence with the Registered Nurse (RN 1). Patient 4 was observed awake, alert, and oriented x 3 (to person, place, and time). During a review of Patient 4’s current medication with the RN 1, it included a bottle of Ibuprofen (medication to relieve minor aches and pain) 600 mg (milligram) 1 tablet every 8 hours as needed for pain. However, the medication profile provided by the HHA did not have this medication listed. There was also a bottle of Gabapentin (a medicine used to treat partial seizures and nerve pain) 300 mg 1 tablet by mouth three times a day, and Bumetanide (used to reduce extra fluid in the body [edema]) 1 mg 1 tablet every morning and 1 ½ tablet at bedtime. Patient 4 stated she was taking these medications for a couple of months. However, the current medication profile provided by the HHA indicated Patient 4 was taking Gabapentin 300 mg 1 tablet by mouth daily, and Bumetanide 0.5 mg 1 tablet by mouth two times a day. During a concurrent interview with RN 1, RN 1 stated Patient 4’s medication profile was not updated. During an interview on 12/14/2023 at 11:28 a.m. with the Director of Patient Care Services (DPCS), the DPCS stated patient’s medication profile should have been reconciled and updated on every SN visits. During a review of the agency’s policy and procedure titled “Medication Profile,” revised April 2020, indicated patient receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued 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 observation, interview and record review, Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to develop an individualized plan of care (documents the process of identifying a patient’s needs and facilitating complete care and ensures collaboration among nurses, patients, and other healthcare providers) for three of seven sampled patients (Patients 1, Patient 2, and Patient 3). This deficient practice resulted for Patients 1, Patient 2, and Patient 3 not to have a plan of care to identify the patient’s care and needs. a. During a review of Patient 1’s face sheet (admission record) indicated a start of care (SOC) date of 11/10/2023 with a diagnosis that includes idiopathic neuropathy (illness where sensory and motor nerves of the peripheral nervous system are affected). On 12/13/2023, at 12 p.m., a home visit was conducted at Patient 1’s residence with LVN 1. Patient 1 was observed walking using a walker. During a joint record review of Patient 1’s electronic health records, on 12/14/2023 at 11:30 a.m., with the Office manager (OM), a request was made from OM to provide a copy of the patient’s plan of care (POC). During the interview, the OM stated there was no documented evidence a POC was developed for Patient 1. b. During a review of Patient 2’s face sheet indicated a start of care (SOC) date of 11/9/2023 with a diagnosis that includes spondylosis (age related wear and tear of the spinal disks). On 12/13/2023, at 1:30 p.m., a home visit was conducted at Patient 2’s residence with LVN 1. Patient 2 was observed sitting on couch with a cane located next o the coffee table. During a joint record review of Patient 2’s electronic health records, on 12/14/2023 at 12 p.m. with the OM, a request was made from OM to provide a copy of the patient’s POC. During the interview, the OM stated there was no documented evidence a POC was developed for Patient 2. c. During a review of Patient 3’s face sheet indicated a start of care (SOC) date of 10/27/2023 with a diagnosis that includes diabetes mellitus (a group of disease that result in too much sugar in the blood). During a joint record review of Patient 3’s electronic health records, on 12/14/2023 at 12:30 p.m. with the OM, a request was made from OM to provide a copy of the patient’s POC. SN visit notes. During the interview, the OM stated there was no documented evidence a POC was developed for Patient 3. On 12/14/2023, at 1 p.m., during an interview with the DPCS (director of patient care services), she stated the plan of care supposed to be completed within a week after the initial comprehensive assessment was done by the registered nurse. A review of the agency’s undated policy and procedure titled, “Care Planning Process”, indicated a written plan of care will be initiated within five days of start of care and updated at least every 60 days or as patient’s condition warrants. The plan of care will be based upon the physician’s (or other authorized licensed independent practitioner’s) orders and will encompass the equipment, supplies, and services required to meet the patient’s needs.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on observation, interview and record review, the HHA failed to provide wound care treatment as per physician’s order for one of seven sampled patients (Patient 4). This deficient practice had the potential to cause delayed wound healing and worsening of the wound of Patient 4. Findings: During a review of Patient 4’s face sheet indicated a start of care (SOC) date of 11/29/2023 with a diagnosis that includes encounter for change or removal of dressing, hypertensive heart disease (refers to heart problems that occur because of high blood pressure that is present over a long time), and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]). During a review of Patient 4’s Home Health Certification and Plan of Care (POC) for certification period from 11/29/2023 to 1/27/2024, included an order for the skilled nurse (SN) to visit daily for wound care, to assess vital signs and pain level, and to evaluate therapeutic response to current/new medications and compliance to medication/diet regimen. During a review of Patient 4’s physician’s order dated 12/12/2023, indicated a daily dressing changes to patient’s right foot wound, as follows: cleanse with saline, pat dry with gauze, apply saline soaked gauze to graft site (the damaged or missing skin), apply mupirocin (a medication ointment that treats skin infections caused by bacteria) to other ulcerations (open sore in the skin), cover with adaptic (non-adherent dressing) and kerlix dressing. On 12/13/2023, at 10:30 a.m., a joint home visit was conducted at Patient 4’s residence with the Registered Nurse (RN 1). Patient 4 was observed awake, alert, and oriented x 3 (to person, place, and time). At 10:45 a.m., during an observation, RN 1 washed her hands, wore gloves, removed the old dressing from the wound on the right foot. RN 1 cleansed the right foot wound with normal saline, patted dry with dry gauze, applied saline soaked gauze to graft site, applied xeroform gauze (a yellow dressing that covers a wound) to two open wounds near the graft site, covered it with adaptic dressing, and then wrapped with kerlix dressing. During an interview, RN 1 stated pharmacy have not delivered the mupirocin ointment, so she just covered the two open wound with xeroform gauze. RN 1 stated she should have communicated with the physician if it was okay to use the xeroform gauze on the open wounds pending delivery of the mupirocin ointment. During an interview on 12/14/2023 at 11:28 a.m. with the Director of Patient Care Services (DPCS), the DPCS stated there was no current order to use xeroform gauze on Patient 4’s right foot wound, and the agency’s nursing staff should have clarified with the physician if it was okay to use the xeroform gauze while the mupirocin ointment is not available. The DPCS stated the agency nursing staff should always follow physician’s order and if the order was not clear, it should have been clarified.”

“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, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to ensure pertinent clinical records were included to accurately reflect the care and assessment for five of 7 sampled patients (Patients 1, Patient 2, Patient 3, Patient 4, and Patient 5). This failure resulted in patient’s incomplete clinical record that had a potential for misinformation and lack of care and services provided to the patients. Findings: a. During a review of Patient 4’s face sheet indicated a start of care (SOC) date of 11/29/2023 with a diagnosis that includes encounter for change or removal of dressing, hypertensive heart disease (refers to heart problems that occur because of high blood pressure that is present over a long time), and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]). During a review of Patient 4’s Home Health Certification and Plan of Care (POC) for certification period from 11/29/2023 to 1/27/2024, included an order for the skilled nurse (SN) to visit daily for wound care, to assess vital signs and pain level, and to evaluate therapeutic response to current/new medications and compliance to medication/diet regimen. During a joint record review of Patient 4’s electronic health records, on 12/12/2023 at 1:45 p.m. with the Office manager (OM), a request was made from OM to provide a copy of the patient’s SN visit notes. OM was not able to provide copies and stated the visiting nurse has not submitted her clinical notes since the SOC. b. During a review of Patient 5 ‘s demographics indicated a start of care date of 8/20/2023, with diagnoses including bilateral primary osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time), type 2 diabetes mellitus, and hypertensive heart disease. During a review of Patient 5’s Home Health Certification and Plan of Care for the recertification period from 10/19/2023 to 12/17/2023, included an order for the skilled nurse (SN) frequency of visits of one visit on week 1, twice a week on the next 2 weeks, then once a week for 6 weeks, to assess all body systems, assess vital signs (measure the basic functions of your body that includes your body temperature, blood pressure, pulse and respiratory [breathing] rate), medication and diet compliance, and safety on every visit. On 12/12/2023 at 1:45 p.m., a request was made from the OM to provide a copy of Patient 5’s most current SN visit notes. OM provided the most current SN visit notes dated 11/2/2023 and none after that. OM stated the visiting nurse has been delayed submitting her notes. During an interview on 12/14/2023 at 11:28 a.m. with the Director of Patient Care Services (DPCS), the DPCS stated SN visit notes should have been submitted within 24 hours after the service was rendered per the agency’s policy. DPCS stated and acknowledged the findings. During a review of the agency’s policy and procedure titled, “Clinical/Service Data Collection”, revised April 2020, indicated home care personnel providing patient care and supervisory functions have authority to make entries into the clinical/service record. Documentation in the clinical/service record will be timely, detailed, accurate, and reflect the care or services provided. Entries into the clinical/service record will be made on the day care/service is provided to the patient. All documentation will be turned into the office at the end of the workday. a. During a review of Patient 1’s face sheet indicated a start of care (SOC) date of 11/10/2023 with a diagnosis that includes idiopathic neuropathy (illness where sensory and motor nerves of the peripheral nervous system are affected). During a joint record review of Patient 1’s electronic health records, on 12/12/2023 at 11:30 a.m., with the Office manager (OM), a request was made from OM to provide a copy of the patient’s SN visit notes. OM was not able to provide copies and stated the visiting nurse has not submitted her clinical notes since the SOC. b. During a review of Patient 2’s face sheet indicated a start of care (SOC) date of 11/9/2023 with a diagnosis that includes spondylosis (age related wear and tear of the spinal disks). During a joint record review of Patient 2’s electronic health records, on 12/12/2023 at 12 p.m. with the OM, a request was made from OM to provide a copy of the patient’s SN visit notes. OM was not able to provide copies and stated the visiting nurse has not submitted her clinical notes since the SOC. c. During a review of Patient 3’s face sheet indicated a start of care (SOC) date of 10/27/2023 with a diagnosis that includes diabetes mellitus (a group of disease that result in too much sugar in the blood). During a joint record review of Patient 3’s electronic health records, on 12/12/2023 at 12:30 p.m. with the OM, a request was made from OM to provide a copy of the patient’s SN visit notes. OM was not able to provide copies and stated the visiting nurse has not submitted her clinical notes since the SOC. a. During a review of Patient 1’s face sheet indicated a start of care (SOC) date of 11/10/2023 with a diagnosis that includes idiopathic neuropathy (illness where sensory and motor nerves of the peripheral nervous system are affected). During a joint record review of Patient 1’s electronic health records, on 12/12/2023 at 11:30 a.m., with the Office manager (OM), a request was made from OM to provide a copy of the patient’s SN visit notes. OM was not able to provide copies and stated the visiting nurse has not submitted her clinical notes since the SOC. b. During a review of Patient 2’s face sheet indicated a start of care (SOC) date of 11/9/2023 with a diagnosis that includes spondylosis (age related wear and tear of the spinal disks). During a joint record review of Patient 2’s electronic health records, on 12/12/2023 at 12 p.m. with the OM, a request was made from OM to provide a copy of the patient’s SN visit notes. OM was not able to provide copies and stated the visiting nurse has not submitted her clinical notes since the SOC. c. During a review of Patient 3’s face sheet indicated a start of care (SOC) date of 10/27/2023 with a diagnosis that includes diabetes mellitus (a group of disease that result in too much sugar in the blood). During a joint record review of Patient 3’s electronic health records, on 12/12/2023 at 12:30 p.m. with the OM, a request was made from OM to provide a copy of the patient’s SN visit notes. OM was not able to provide copies and stated the visiting nurse has not submitted her clinical notes since the SOC. d. During a review of Patient 4’s face sheet indicated a start of care (SOC) date of 11/29/2023 with a diagnosis that includes encounter for change or removal of dressing, hypertensive heart disease (refers to heart problems that occur because of high blood pressure that is present over a long time), and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]). During a review of Patient 4’s Home Health Certification and Plan of Care (POC) for certification period from 11/29/2023 to 1/27/2024, included an order for the skilled nurse (SN) to visit daily for wound care, to assess vital signs and pain level, and to evaluate therapeutic response to current/new medications and compliance to medication/diet regimen. During a joint record review of Patient 4’s electronic health records, on 12/12/2023 at 1:45 p.m. with the Office manager (OM), a request was made from OM to provide a copy of the patient’s SN visit notes. OM was not able to provide copies and stated the visiting nurse has not submitted her clinical notes since the SOC. e. During a review of Patient 5 ‘s demographics indicated a start of care date of 8/20/2023, with diagnoses including bilateral primary osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time), type 2 diabetes mellitus, and hypertensive heart disease. During a review of Patient 5’s Home Health Certification and Plan of Care for the recertification period from 10/19/2023 to 12/17/2023, included an order for the skilled nurse (SN) frequency of visits of one visit on week 1, twice a week on the next 2 weeks, then once a week for 6 weeks, to assess all body systems, assess vital signs (measure the basic functions of your body that includes your body temperature, blood pressure, pulse and respiratory [breathing] rate), medication and diet compliance, and safety on every visit. On 12/12/2023 at 1:45 p.m., a request was made from the OM to provide a copy of Patient 5’s most current SN visit notes. OM provided the most current SN visit notes dated 11/2/2023 and none after that. OM stated the visiting nurse has been delayed submitting her notes. During an interview on 12/14/2023 at 11:28 a.m. with the Director of Patient Care Services (DPCS), the DPCS stated SN visit notes should have been submitted within 24 hours after the service was rendered per the agency’s policy. DPCS stated and acknowledged the findings. During a review of the agency’s policy and procedure titled, “Clinical/Service Data Collection”, revised April 2020, indicated home care personnel providing patient care and supervisory functions have authority to make entries into the clinical/service record. Documentation in the clinical/service record will be timely, detailed, accurate, and reflect the care or services provided. Entries into the clinical/service record will be made on the day care/service is provided to the patient. All documentation will be turned into the office at the end of the workday.”