Masonicare Home Health & Hospice, Inc.

“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 two of five patients (Patient’s #12 & #14) requiring blood glucose and/or weight monitoring for a diagnosis of type II diabetes mellitus and congestive heart failure, the agency nurses failed to follow physician’s orders. The findings include: Patient #12 had a start of care date of 3/07/24 and diagnoses that included congestive heart failure, type II diabetes mellitus and end stage renal disease. The physician’s orders dated 3/07/24 included nursing services two times a week for two weeks and once weekly for two weeks for assessments, weight monitoring with notification to the physician of a greater than two-pound weight gain in a day or a five-pound weight gain in five to seven days, assess blood glucose levels and review log and assess the right chest dialysis port for signs of infection. Additionally, the patient received physical therapy services and occupational therapy services. i. Interview and review of the nursing notes with the Quality Assurance Registered Nurse/RN on 4/11/24 at 10 AM failed to identify weight monitoring on 3/14/24 and 3/19/24, and monitoring of the right chest dialysis port for signs of infection on 3/19/24, 3/21/24, 3/28/24 and 4/04/24 and failed to follow physician’s orders. b. Patient #14 had a start of care date of 9/13/23 and diagnoses that included type II diabetes mellitus, left carotid artery occlusion, hypertensive chronic kidney disease and hypertension. The physician’s orders dated 9/13/23 included nursing services once weekly for assessments of functional status and to assess blood glucose levels and review log. Additionally, the patient received physical therapy services, speech language pathology services and occupational therapy services. ii. Interview and review of the nursing notes with the Quality Assurance Registered Nurse/RN on 4/11/24 at 11 AM failed to identify blood glucose monitoring on 9/21/23, 9/28/23, 10/02/23, 10/11/23 and 10/18/23 and failed to follow physician’s orders. Review of agency policies for Plan of Care directed the plan of care is sent to the Health Care Practitioner/HCP for signature and includes drugs services and treatments are administered only as ordered by the physician.”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on review of clinical records, interview with agency personnel and review of agency policies for one of seventeen patients in the survey sample (Patient #15) who required home health agency services, the agency failed to coordinate care delivery to meet the patient’s needs. The findings include: Patient #15 had a start of care date of 10/05/2023 with diagnoses that included breast cancer, osteoarthritis, and falls. The physician orders for the certification period of 10/05/2023 through 12/03/2023 included nursing services weekly for assessments, occupational therapy and physical therapy evaluations, home health aide services twice per week for assistance with activities of daily living and a medical social worker (MSW) evaluation for long term care planning. Interview and review of Patient #15’s clinical record with the Quality Assurance Registered Nurse (RN) on 04/11/2024 at 12:00 PM, identified the MSW did not visit the Patient until 11/30/2023 as the MSW did not receive a referral for an evaluation until the week of 11/19/2023. The Quality Assurance RN identified the agency failed to follow the agency’s Plan of Care policy by not coordinating care delivery to meet the patient’s needs. Review of the agency’s Plan of Care policy, identified the agency would assure communication with all health care providers involved in the plan of care, integrate orders from all health care providers involved in the plan of care to assure the coordination of all services and interventions provided to the patient, integrate services, whether services are provided directly or under arrangement, to assure the identification of the patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. Coordinated care delivery to meet the patient’s needs and would include the patient, representative, and caregiver, as appropriate, in the coordination of care activities.”

“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 review of clinical records and interview with agency personnel for five of seven patient’s (Patient’s #4, 10, 11, 12 & 14) who required intravenous (IV) therapy, blood glucose and/or weight monitoring, the agency nurses failed to provide necessary assessments. The findings include: a. Patient #12 had a start of care date of 3/07/24 and diagnoses that included congestive heart failure, type II diabetes mellitus and end stage renal disease. The physician’s orders dated 3/07/24 included nursing services two times a week for two weeks and once weekly for two weeks for assessments, weight monitoring with notification to the physician of a greater than two-pound weight gain in a day or a five-pound weight gain in five to seven days, assess blood glucose levels and review log and assess the right chest dialysis port for signs of infection. Additionally, the patient received physical therapy services and occupational therapy services. i. Interview and review of the nursing notes with the Quality Assurance Registered Nurse/RN on 4/11/24 at 10 AM failed to identify assessment of the patient’s weight on 3/14/24 and 3/19/24, and assessment of the right chest dialysis port for signs of infection on 3/19/24, 3/21/24, 3/28/24 and 4/04/24. b. Patient #14 had a start of care date of 9/13/23 and diagnoses that included type II diabetes mellitus, left carotid artery occlusion, hypertensive chronic kidney disease and hypertension. The physician’s orders dated 9/13/23 included nursing services once weekly for assessments of functional status and to assess blood glucose levels and review log. Additionally, the patient received physical therapy services, speech language pathology services and occupational therapy services. ii. Interview and review of the nursing notes with the Quality Assurance Registered Nurse/RN on 4/11/24 at 11 AM failed to assess the blood glucose levels on 9/21/23, 9/28/23, 10/02/23, 10/11/23 and 10/18/23. a. Patient #4 had a start of care dated 01/24/2024 with diagnoses that included sepsis, a stage four pressure ulcer to the sacrum, an unstageable pressure ulcer to the right buttock and infection to the left hip joint. The physician orders for the certification period of 01/24/2024 through 03/23/2024 included nursing services three times per week for eight weeks for nursing assessments, ostomy care, indwelling catheter care, IV site assessment and wound care. Review of Patient #4’s start of care nursing summary dated 01/24/2024, identified the Patient had a peripherally inserted central catheter (PICC) line to the right upper arm. The PICC line was to be removed on 01/25/2024 and the IV medication was discontinued. Review of the Memorandum of Understanding (MOU) developed between the Home Health Agency and the Infusion Company dated 01/24/2024, identified the shared responsibilities of both the home health agency and the infusion company in the patient assessment, education on IV matters, communicating changes in the patient’s condition and medical orders. Review of Patient #4’s nursing note dated 01/26/2024, failed to identify if the PICC line was removed on 01/25/2024 and failed to assess the PICC line site. b. Patient #10 had a start of care date of 06/17/2021 with diagnoses that included type II diabetes, congestive heart failure and high blood pressure. The physician orders for the certification period of 02/02/2024 through 04/01/2024 included nursing services once per week for eight weeks for nursing assessments, blood glucose monitoring, weight monitoring and to notify the physician of a weight gain of two pounds or greater in one day or five pounds or greater in one week. Additionally, the Patient received home health aide services three times per week for eight weeks for assistance with activities of daily living. Review of Patient #10’s nursing notes dated 02/07/2024, 02/15/2024, 02/20/2024, 02/29/2024, 03/05/2024, 03/15/2024, 03/19/2024 and 03/28/2024 failed to assess the Patient’s weight. c. Patient #11 had a start of care date of 01/19/2024 with diagnoses that included type II diabetes, a diabetic ulcer to the left foot, and cellulitis of the left lower leg. The physician orders for the certification periods of 01/19/2024 through 03/18/2024 included nursing services two to three times per week for nine weeks for nursing assessments, blood glucose monitoring and wound care to the left foot. Review of Patient #11’s nursing notes dated 02/02/2024, 02/05/2024, 02/08/2024, 02/10/2024, 02/14/2024, 02/19/2024, 02/21/2024, 02/23/2024, and 03/18/2024 failed to assess the Patient’s blood glucose levels. i. Interview with the Quality Assurance Registered Nurse (RN) on 04/11/2024 at 11:45 AM, identified the agency failed to perform the necessary assessments in accordance with the agency’s policy.”

“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 review of the clinical record, review of agency policies and interview with agency personnel, for one of seventeen patients (Patient #14) in the survey sample, the agency licensed nurses failed to communicate with the physician an alteration in the plan of care. The findings include: a. Patient #14 had a start of care date of 9/13/23 and diagnoses that included type II diabetes mellitus, left carotid artery occlusion, hypertensive chronic kidney disease and hypertension. The physician’s orders dated 9/13/23 included nursing services once weekly for assessments of functional status and to assess blood glucose levels and review log. Additionally, the patient received physical therapy services, speech language pathology services and occupational therapy services. Interview and review of the clinical record with the Quality Assurance Registered Nurse/RN on 4/11/24 at 1 PM identified the nursing discharge summary dated 10/26/23 although the last nursing visit was dated 10/18/23 and indicated that the patient cancelled the nursing visit on 10/26/23 but failed to communicate with the physician an alteration in the plan of care. Review of agency policies for Plan of Care directed in part that the agency must alert the relevant HCP to any changes in the patient’s condition that suggests the plan of care should be altered.”