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 reviews, review of an agency policies and interview with agency personnel, for one of three patients (Patient #5) who required wound care and one of three patients (Patient #1) who required blood glucose monitoring in the survey sample, the agency’s licensed personnel failed to measure wounds and monitor blood glucose levels in accordance with agency policies. The findings include: 1. Patient #5 had a start of care date of 7/14/23 and diagnoses that included chronic kidney disease with failure, acute congestive heart failure and type II diabetes mellitus. The physician’s orders for the certification period of 11/11/23 through 1/09/24 included nursing services two times a week for assessments and wound care to the right upper back. i. Interview and review of LPN #1’s nursing note dated 11/20/23 with the Administrator on 1/10/24 at 11:50 AM identified the patients’ left heel was noted with a large necrotic area with intact skin but failed to identify measurements of the left heel necrotic area. ii. Interview and review of the clinical record with the Administrator on 1/10/24 at 11:40 AM identified twice weekly nursing visits but failed to identify documentation of wound measurements by LPN #1 for the weeks of 12/17/23, 12/24/23 and 12/31/23 (LPN #1 visited on 12/19/23, 12/22/23, 12/26/23, 12/29/23, 1/03/24 and 1/05/24) and failed to follow agency policies. Review of agency policy for Wound Assessment and Documentation directed the clinician will assess wounds at least weekly. Patient #1 had a start of care date of 08/19/2020 with diagnosis that included laceration to the right shoulder, retention of urine, type II diabetes mellitus with chronic kidney disease and falls. The physician’s orders for the home health recertification period of 12/02/2023 to 01/30/2024 included nursing services twice per week for eight weeks for assessments, wound care to the right shoulder, bladder irrigation twice weekly through the indwelling foley catheter and monthly changes of the indwelling foley catheter. Interview and review of Patient #1’s recertification nursing assessment summary and care plan dated 11/27/2023 with the Administrator on 01/11/2024 at 10:00 AM, identified the Patient and caregiver would understand and demonstrate compliance with the treatment regimen for diabetes by week nine but failed to identify who was responsible for checking the Patient’s blood glucose levels, the frequency of the blood glucose checks and obtained blood glucose parameters from a health care provider in order to report glucose levels falling outside of the established parameters. Interview and review of Patient #1’s clinical nurses’ notes dated 12/04/2023, 12/07/2023, 12/12/2023, 12/19/2023, 12/27/2023, 12/29/2023, 01/02/2024, 01/04/2024 and 01/08/2024 with the Administrator on 01/11/2024 at 10:15 AM, identified the Assisted Living Services Agency (ALSA) nurses’ checked the Patient’s blood glucose every other day, but failed to identify the home health agency nurses’ documented blood glucose levels in Patient #1’s clinical notes.”

“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 and interview with agency personnel, for two of ten patients (Patient #1 and #5) in the survey sample, the agency Registered Nurse/RN failed to ensure the plan of care addressed the patient’s individual needs. The findings include: P Patient #5 had a start of care date of 7/14/23 and diagnoses that included chronic kidney disease with failure, acute congestive heart failure and type II diabetes mellitus. The physician’s orders for the certification period of 11/11/23 through 1/09/24 included nursing services two times a week for assessments and wound care to the right upper back. Interview and review of the plan of care with the Administrator on 1/10/24 at 1:30 PM failed to identify the development of a comprehensive care plan that included frequency of weight monitoring and specific parameters for reporting weight fluctuations to the physician. a. Patient #1 had a start of care date of 08/19/2020 with diagnosis that included laceration to the right shoulder, retention of urine, type II diabetes mellitus with chronic kidney disease and falls. The physician’s orders for the home health recertification period of 12/02/2023 to 01/30/2024 included nursing services twice per week for eight weeks for assessments, wound care to the right shoulder, bladder irrigation twice weekly through the indwelling foley catheter and monthly changes of the indwelling foley catheter. i. Interview and review of Patient #1’s recertification nursing assessment summary and care plan dated 11/27/2023 with the Administrator on 01/11/2024 at 10:00 AM, identified the Patient and caregiver would understand and demonstrate compliance with the treatment regimen for diabetes by week nine but failed to identify the development of a comprehensive care plan that included who was responsible for checking the Patient’s blood glucose levels, the frequency of the blood glucose checks and obtained blood glucose parameters from a health care provider in order to report glucose levels falling outside of the established parameters.”

“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 clinical record reviews and interview with agency personnel, for one of three patients (Patient #5) who required wound care, the agency’s licensed personnel failed to coordinate wound care with the private caregiver. The findings include: Patient #5 had a start of care date of 7/14/23 and diagnoses that included chronic kidney disease with failure, acute congestive heart failure and type II diabetes mellitus. The physician’s orders for the certification period of 11/11/23 through 1/09/24 included nursing services two times a week for assessments and wound care to the right upper back. Interview and review of LPN #1’s nursing notes with the Administrator on 1/10/24 at 12:30 PM, identified the patient’s privately hired caregiver performed wound care prior to the nurses’ visits on 12/19/23, 12/22/23, 12/29/23 and 1/03/24 , and failed to identify nursing communication and understanding with the privately hired caregiver responsible for wound care, to allow the visiting nurse to visualize the wound status and directly perform wound care during nursing visits, in order to accurately document the wound progress and/or deterioration.”

“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 personnel, for one of three patients (Patient #5) who required wound care and one of three patients (Patient #1) who required blood glucose monitoring, the agency’s licensed personnel failed to assess wounds and monitor blood glucose in accordance with the agency’s policy. The findings include: 1. Patient #5 had a start of care date of 7/14/23 and diagnoses that included chronic kidney disease with failure, acute congestive heart failure and type II diabetes mellitus. The physician’s orders for the certification period of 11/11/23 through 1/09/24 included nursing services two times a week for assessments and wound care to the right upper back. On 11/21/23 through 12/15/23, the patient was transferred to a Skilled Nursing Facility/SNF for a three-week respite stay. RN #1’s resumption of care nursing note dated 12/16/23 identified a new stage II coccyx pressure ulcer, a stage II lower buttock pressure ulcer and an unstageable left heel pressure ulcer. Interview and review of LPN #1’s nursing notes with the Administrator on 1/10/24 at 12:30 PM identified the patient’s privately hired caregiver performed wound care prior to the nurses’ visits on 12/19/23, 12/22/23, 12/29/23 and 1/03/24 therefore, the wounds were not assessed or measured by a nurse since the resumption of care on 12/16/2023. Review of the agency’s Wound Assessment and Documentation policy identified the RN would perform the initial assessment for open wounds and surgical incisions upon admission. Wound assessments would be performed every visit, documented in the Wound Assessment Tool and include general observations, measurement of length, width and depth, undermining and tunneling drainage, wound bed appearance and surrounding skin condition. Patient #1 had a start of care date of 08/19/2020 with diagnosis that included laceration to the right shoulder, retention of urine, type II diabetes mellitus with chronic kidney disease and falls. The physician’s orders for the home health recertification period of 12/02/2023 to 01/30/2024 included nursing services twice per week for eight weeks for assessments, wound care to the right shoulder, bladder irrigation twice weekly through the indwelling foley catheter and monthly changes of the indwelling foley catheter. Interview and review of Patient #1’s recertification nursing assessment and care plan dated 11/27/2023 with the Administrator on 01/11/2024 at 10:00 AM, identified Patient #1’s care plan indicated the Patient and caregiver would understand and demonstrate compliance with the treatment regimen for diabetes by week nine but failed to identify who was responsible for checking the Patient’s blood glucose levels, the frequency of the blood glucose checks and obtained blood glucose parameters from a health care provider in order to report glucose levels falling outside of the established parameters. Interview and review of Patient #1’s clinical nurses’ notes dated 12/04/2023, 12/07/2023, 12/12/2023, 12/19/2023, 12/27/2023, 12/29/2023, 01/02/2024, 01/04/2024 and 01/08/2024 with the Administrator on 01/11/2024 at 10:15 AM, identified the Assisted Living Services Agency nurses’ checked the Patient’s blood glucose every other day, but the home health agency nurses failed to document blood glucose levels in Patient #1’s clinical notes. Review of the agency’s policy for Plan of Care, identified the qualified clinician would develop and revise the plan of care under the direction of the health care provider. The patient would be monitored for response to treatment and progress toward goals.”

“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, interview with agency personnel and review of agency policies, for two of ten patients (Patient #1 and Patient #5) in the survey sample, the agency nurses failed to communicate with the physician involved in the plan of care. The findings include: Patient #5 had a start of care date of 7/14/23 and diagnoses that included chronic kidney disease with failure, acute congestive heart failure and type II diabetes mellitus. The physician’s orders for the certification period of 11/11/23 through 1/09/24 included nursing services two times a week for assessments and wound care to the right upper back. Interview and review of LPN #1’s nursing note dated 11/20/23 with the Administrator on 1/10/24 at 11:50 AM identified the patients’ left heel was noted with a large necrotic area with intact skin but failed to identify communication with the physician for wound care orders. Patient #1 had a start of care date of 08/19/2020 with diagnosis that included laceration to the right shoulder, retention of urine, type II diabetes mellitus with chronic kidney disease and falls. The physician’s orders for the home health recertification period of 12/02/2023 to 01/30/2024 included nursing services twice per week for eight weeks for assessments, wound care to the right shoulder, bladder irrigation twice weekly through the indwelling foley catheter and monthly changes of the indwelling foley catheter. Interview and review of Patient #1’s recertification nursing assessment summary and care plan dated 11/27/2023 with the Administrator on 01/11/2024 at 10:00 AM, identified the Patient and caregiver would understand and demonstrate compliance with the treatment regimen for diabetes by week nine but failed to identify who was responsible for checking the Patient’s blood glucose levels, the frequency of the blood glucose checks and obtained blood glucose parameters from a health care provider in order to report glucose levels falling outside of the established parameters.”