Human Touch Home Health Care Agency Inc. Pueblo

“Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to ensure care was provided according to each patient’s individualized written plan of care and in conformance with physician orders, for 1 of 6 active patient records reviewed ordered to receive skilled nursing (SN) services (Patient #5). Findings include: AGENCY POLICY According to the policy, “Physician Participation in Plan of Care,” revised November 2017 (in part): “A physician will direct the care of every home health care patient admitted for service. The attending physician will certify that medical, skilled, rehabilitative, and social services provided by the organization are medically necessary and meets the requirements to be covered by Medicare. The attending physician will participate in the care planning process by initiating, reviewing and revising the plan of care (therapeutic and diagnostic orders). The care will be provided in compliance with the therapeutic and diagnostic orders and accepted standards and practice.” 1. The clinical record for Patient #5 was reviewed on 3/26/24. The plan of care for the certification dated 3/1/24 to 4/29/24 revealed a start of care date of 3/1/24; diagnoses included acute cystitis without hematuria, chronic pain, weakness, chronic obstructive pulmonary disease (COPD), dependence on supplemental oxygen, hypertension (HTN) hypothyroidism, hyperlipidemia, long term use of drug therapy with drug level monitoring and depression and anxiety. Plan of care orders included skilled nursing (SN) visits once weekly for one week, three times weekly for eight weeks and once weekly for one week; and PT visits once daily for one day. a) The agency failed to ensure SN visits were completed as ordered. Review of the plan of care for the certification period beginning 3/1/24 revealed Registered Nurse (RN) #3 received verbal orders for SN services once weekly for one week, three times weekly for eight weeks, then once weekly for one week for assessment, education, medication administration as needed and to prefill medication planner for one week. However, clinical record review failed to show any visits until 3/13/24, 12 days after the initial start of care assessment. Further review failed to show any documentation of missed visits, coordination with the patient’s physicians or explanation of how the patient’s needs were met during that time. During an interview on 3/27/24 at 11:11 a.m., RN #3 confirmed she completed the start of care assessment for Patient #5 on 3/1/24 and that the patient did not receive any additional SN visits until 3/13/24. She stated the patient’s insurance had not authorized additional SN visits until late in the afternoon on 3/11/24 and she and the patient had previously decided visits would be completed on Mondays, Wednesday and Fridays and that was why, even though the insurance authorization was received on Monday, RN #3 did not see the patient until Wednesday, 3/13/24. During an interview on 3/28/24 at 9:06 a.m., the director of nursing (DON) stated typically the clinician completing the initial assessment and developing the plan of care would document the desired frequency on the plan of care and receive the orders from the physician for that frequency. She stated if a patient’s insurance company took an increased amount of time to authorize care and services, an order would be sent to the physician modifying the frequency and the clinician would notify the patient and document that communication in the record. During the same interview, the DON and Employee #7 confirmed there was no documentation in Patient #5’s record showing her physician had been notified of the missed visits due to a delay in insurance authorization and the SN frequency that had been authorized by the physician had not been followed.”

“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 the registered nurse (RN) conducted an initial assessment visit to determine the immediate care and support needs of the patient within 48 hours of referral, or on the physician ordered start of care date for 3 of 6 clinical records reviewed requiring start of care (SOC) assessment (Patients #3, #4 and #5). Findings include: AGENCY POLICY According to the agency’s policy, “Initial and Comprehensive Assessment,” revised November 2017 (in pertinent parts): “An initial patient assessment will be performed and documented in the patient’s clinical record by a registered nurse, a physical therapist, or speech therapist. The initial assessment visit must be performed either within 48 hours of the referral, within 48 hours of the patient’s return home, on the start of care date ordered by the physician (or other authorized licensed independent practitioner), or at the patient/family request with the approval of the physician (or other authorized licensed independent practitioner).” 1. The clinical record for Patient #3 was reviewed on 3/26/24. The plan of care (POC) for the certification period dated 2/28/24 to 4/27/24 revealed a SOC date of 2/28/24; diagnoses included non-pressure chronic ulcer to left lower leg with necrosis of bone, surgical amputation (of right great toe), osteomyelitis (bone infection), type 2 diabetes mellitus, diabetic neuropathic arthropathy, chronic pain, atrial fibrillation, hypokalemia, and gastro-esophageal reflux disease without esophagitis (acid reflux). Plan of care orders included skilled nurse (SN) visits two times weekly for assessment, education, management of wound care, and diabetic management. Wound care orders on the plan of care, dated 2/28/24, were to perform wound care to right great toe amputation, cleanse with saline and apply wound V.A.C. (vacuum assisted closure) dressing every visit using aseptic technique; and monitor/record wound size one time weekly. a) The agency failed to start services for Patient #3 within 48 hours of the referral. Record review showed Patient #3 was referred to the agency on 2/14/24 by a podiatry clinic to address wound care and wound V.A.C. changes two times a week by a health professional. The referral requested the agency to start services on 2/15/24 and later amended to 2/22/24. Review of the SOC assessment, dated 2/28/24, completed by RN #3 revealed Patient #3 started services on 2/28/24, six days after receipt of the referral. During an interview on 3/27/24 at 10:59 a.m. at the agency office, RN #3 provided a verbal order received and documented on 2/28/24. She stated the late SOC might be due to delay in insurance authorization or at the patient’s request, but confirmed there was no evidence the agency obtained the physician’s approval for the delayed initiation of services. During an interview on 3/27/24 at 12:25 p.m., the administrator assistant confirmed there was no documented communication in Patient #3’s chart regarding the timely physician notification of the delay of SOC nor the reason for the delay of initiation of services. She stated an order to delay the SOC was supposed to have been received by the agency, and confirmed there was no order from the physician authorizing a delayed SOC. During an interview on 3/28/24 at 10:53 a.m., the director of nursing (DON) explained the SOC policy and stated that care starts within 48 hours unless the doctor writes an order to wait per the patient’s request; and that authorizations take a long time to get from the insurance companies so the agency has to let the doctors know that it could take a little bit longer. The DON confirmed there was no evidence the agency timely obtained the physician’s approval for the delayed initiation of services for Patient #3. 2. Similar findings were found for Patients #4 and #5.”

“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 interviews and record reviews, the agency failed to ensure physical therapy (PT) completed their assessments no later than five calendar days after the start of care for 1 of 1 active patient records reviewed who required therapy services (Patient #5). Findings include: 1. The clinical record for Patient #5 was reviewed on 3/26/24. The plan of care for the certification period dated 3/1/24 to 4/29/24 revealed a start of care date of 3/1/24; diagnoses included acute cystitis without hematuria, chronic pain, weakness, chronic obstructive pulmonary disease (COPD), dependence on supplemental oxygen, hypertension (HTN) hypothyroidism, hyperlipidemia, long term use of drug therapy with drug level monitoring and depression and anxiety. Plan of care orders included skilled nursing (SN) visits once weekly for one week, three times weekly for eight weeks and once weekly for one week; and PT visits once daily for one day. a) The agency failed to ensure PT completed an assessment of Patient #5 to determine the patient’s immediate therapy needs within five days of the start of care. Review of the hospital discharge order, dated 2/27/24, revealed Patient #5 presented to the emergency department (ED) twice on 2/15/24 and 2/26/24 following incorrect self-administration of medications used to treat depression and was diagnosed with a urinary tract infection (UTI). Referral comments included Patient #5 needed outpatient PT but was unable to independently access the services. The referral further stated Patient #5 needed home health nursing and PT. Review of the Admission Outcome and Assessment Information Set (OASIS), completed on 3/1/24 by Registered Nurse (RN) #3, showed Patient #5 was dependent on supplemental oxygen (O2), had multiple ED visits, demonstrated a recent decline in mental, emotional or behavioral status, had a history of difficulty complying with medical instructions to include medications, diet and exercise and lived alone. Further review of the OASIS showed Patient #5 was on three liters per minute (3 L/min) O2 continuously and the patient was noticeably short of breath after minimal activity. Additionally, Patient #5 was noted to be forgetful and constantly confused. The OASIS also revealed Patient #5 was considered a fall risk, had weakness in bilateral lower extremities and PT services were indicated. Review of a PT evaluation, dated 3/7/24, revealed Physical Therapist (PT) #8 performed an evaluation and documented Patient #5 needed PT for general weakness, abnormal gait and fall risk due to infection. PT #8 also documented Patient #5 was on 5 L/min continuous O2, demonstrated poor balance and demonstrated a high fall risk due to decreased bilateral hip flexion and foot clearance causing the patient to become entangled in her O2 tubing. Review of a verbal order, dated 3/7/24, revealed PT #8 received physician authorization for continued treatment of Patient #5 once weekly for one week then twice weekly for six weeks for general weakness, abnormal gait and fall risk. Review of documentation of internal communication between agency staff provided by Employee #7 showed PT #8 was not notified of the physical therapy referral for Patient #5 until 3/7/24, six days after the initial assessment was completed. However, the record failed to show any documentation as to why the PT evaluation was completed after the initial five days following the initial start of care assessment completed by RN #7 on 3/1/24. Further review failed to show the physician for Patient #5 was notified of the delay of PT services. During an interview on 3/28/24 at 9:09 a.m. the Director of Nursing (DON) stated the agency expectation was for services to be initiated within the time frames set forth in the regulations. She further stated it was problematic that PT did not initiate services with Patient #5 until six days after the initial start of care assessment, instead of within five days per regulation.”