Patient Care

“Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA’s policies and procedures. This Standard is not met as evidenced by: Based on clinical record review and interviews with agency personnel for one of eight patients (Patient #9), requiring medication management, the agency licensed personnel failed to follow agency expectations for medication documentation in the electronic clinical record. The findings include: Patient #9 had a start of care date of 11/16/23 and diagnoses that included chronic pain syndrome and post laminectomy syndrome. The physician’s orders for the certification periods of 1/15/24 through 5/13/24 included nursing services daily for pain assessment, medication administration of morning medications, and pre-pouring of the afternoon and evening medications. Patient #9’s medications included Belbuca Buccal film (an opioid analgesic controlled substance) 900 micrograms/mcg twice daily for pain, Gabapentin 800 milligrams/mg three times a day for pain and Tizanidine Hydrochloride 2 mg every eight hours for muscle spasms. Interview and review of LPN #1’s nursing notes dated 3/02/24, 3/04/24, 3/09/24, 3/10/24, 3/23/24 and 3/24/24 with the Administrator on 4/25/24 at 11 AM identified documentation of the Controlled Substance count of the Belbuca film administered and pre-poured daily, but failed to identify documentation of the medications administered and pre-poured during the nursing visit according to agency expectations.”

“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 clinical record review, review of agency policies and interview with agency personnel, for one of one patient (Patient #2) with a diagnosis of congestive heart failure requiring weight monitoring, the agency nurses failed to ensure the plan of care addressed the patient’s individual needs. Patient #2 had a start of care date of 2/04/23 and diagnoses that included heart failure, type II diabetes mellitus and hypertension. The physician’s orders for the certification periods of 1/30/24 through 5/28/24 included nursing services once weekly for medication pre-pour, diabetic and cardiac assessments. Interview and review of the physician’s certified plan of care with the Administrator on 4/25/24 at 10 AM failed to identify communication with the physician for the need to monitor weights and parameters for reporting abnormal findings to the physician. Review of the agency policy for Plan of Care directed that the plan of care includes patient specific interventions and education, measurable outcomes and goals identified by the agency and patient.”

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on clinical record reviews, review of an agency policies and interview with agency staff, for one of five patients (Patient #6) who required nursing assessments and blood glucose monitoring, the agency failed to perform the necessary assessments in accordance with the agency’s expectation and policy. The findings include: a. Patient #6 had a start of care date 04/08/2022 with diagnosis that included high blood pressure, type II diabetes and acid reflux. The physician’s orders for the certification periods of 01/28/2024 to 03/27/2024 included nursing services once per week for nursing assessments, weekly pre-pour of medications, assess the Patient’s diabetic status and review the Patient’s blood glucose log. i. Interview and review of Patient #6’s nursing notes with the Administrator on 04/25/2024 at 11:30 AM, failed to identify blood glucose levels were assessed and documented on 01/31/2024, 03/06/2024, 03/13/2024 and 03/27/2024. The Administrator indicated the agency’s expectation was to assess and document blood glucose levels at each nursing visit, to assess the Patient’s condition, and and the patient’s response to the medication and diabetic education. Review of the agency’s Patient Assessment, Initial and Reassessment policy, identified a patient’s status would be reviewed as an ongoing process. Patients are assessed for continued need and response to care and services.”