Mederi Caretenders

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on staff interviews, records, and policy reviews, the agency failed to provide 2 patients (#7, #14) with written visit frequencies for the disciplines to be provided to the patient out of 17 records sampled. The findings included: A review of the agency policy titled Admission Process Policy Number 2.1.001 with an effective date of 4/15/1999 and revised on 10/012023. Documented under Procedure: 4. l. Informs patient/caregiver of anticipated services and frequency. M. Initiates the plan of care with input from the patient. A review of the medical record for patient # 7 revealed the Agreement for Services was dated 3/15/2024 and signed by the patient’s representative. The Agreement does not document the frequency of visits to be provided by skilled nursing or physical therapy. A review of the medical record for patient #14 revealed the Agreement for Services dated 12/06/2023 and signed by the patient’s representative. The Agreement does not document the frequency of visits to be provided by skilled nursing or physical therapy. An interview was conducted with the administrator on 5/302024 at 1:50 PM. She said the nurses on admission must fill out the Agreement to include the disciplines and frequencies for the services.”

“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 observations, interviews, and record reviews, the agency failed to ensure that patients received the home health services written in an individualized care plan ordered by a physician for 4 (#7, #8, #9, and #10) out of 7 home care observations. The findings included: A review of the agency policy titled Plan of Care (POC) policy number 2.1.007 with an effective date of 05/04/1999 with a revision date of 12/01/2021 revealed Purpose: To ensure an appropriate plan of care is developed and revised in a timely manner for each patient. To ensure that physician/authorized practitioner’s orders are followed. Policy: Each patient has an individualized Plan of Care (POC) developed in consultation with the patient, physician or authorized practitioner, and staff that integrates comprehensive assessment findings to address patient problems, needs, and goals, as well as to address specific services being provided. Procedure: The POC includes: The patient’s mental, psychosocial, and cognitive status Types, frequency, and duration of services required Prognosis and rehabilitation potential Functional limitations and activities permitted Nutritional requirements Medications and treatments Safety measures to promote against injury Pertinent diagnosis (es) Patient-specific interventions and education; measurable outcomes and goals identified by the agency and the patient Required equipment and supplies Patient’s risk for emergency department visits and re-hospitalization, including interventions that address underlying risk factors Patient/caregiver education and training for timely discharge Advance Directives All patient care orders 3. The qualified clinician develops and revises the POC under the direction of the physician or authorized practitioner. The POC is established prior to providing services. 6. Physician/authorized practitioner’s orders are obtained to update the POC, which may include problems and goals. 7. Medications, treatments, and interventions are provided by qualified agency staff as ordered by the physician or authorized practitioner. 8. Alterations to the POC are made only with the physician/authorized practitioner’s approval. A home visit with observation was conducted on 5/29/2024 at 9:00 AM with Staff C, Registered Nurse (RN), for patient #7. Staff C performed a glucose check using a glucometer and recorded a result of 148. Staff C then administered 8 units of insulin to the right upper arm. During an interview on 5/29/2024 at 9:27 AM, Staff C, RN, said we check patient #7’s glucose every morning. No, she is not on a sliding scale. It is Just every morning.” A review of the POC for patient #7 revealed an admission date of 12/23/2020 with a current certification period of 4/06/2024 to 6/04/2024 with a pertinent diagnosis of Type 2 Diabetes. Frequency and duration of visits: SN (skilled nurse) 1 WK 1, 7 WK 8, 3 WK1, Orders of discipline and treatments: SN (skilled nurse) for administration of SQ (subcutaneous) insulin 8 units daily. The POC does not have orders to obtain a capillary glucose sample. Documented for DME (durable medical equipment) and supplies; no orders were found for a glucometer or venipuncture supplies if needed. A review of the medication profile for patient #7 reflects an order for Insulin Glargine (U-100) 100 Unit/ML (3ML) subcutaneous pen. A home visit with observation was conducted on 5/29/2024 at 9:45 AM with Staff C, Registered Nurse (RN), for patient #9. Staff C, RN, used a glucometer to perform a glucose check and recorded a result of 117. Staff C then administered 32 units of insulin to the right upper arm. During an interview on 5/29/2024 at 9:27 AM, Staff C, RN, said we check patient 9 #’s glucose every morning. A review of the POC for patient #9 revealed an admission date of 3/5/2024 with a current certification period of 5/14/2024 to 7/12/2024 with a primary diagnosis of Type 2 Diabetes Mellitus with Diabetic Cataract. Frequency and duration of visits: SN (skilled nurse) 5 WK 1, 7 WK, 6 WK1, Orders of discipline and treatments: SN (skilled nurse) for administration of SQ (subcutaneous) insulin 27 units daily. The POC does not have orders to obtain a capillary glucose sample. Documented for DME (durable medical equipment) and supplies revealed no glucometer or venipuncture supplies orders. A review of the medication profile for patient #9 reflects an updated order for Insulin Glargine (U-100) 100 Unit/ML (3ML) 32 unit subcutaneous pen. Patient #8 had a home visit with observation on 5/29/2024 at 10:00 AM with Staff D, Physical Therapist (PT). Staff D provided treatment and exercises using the patient’s rolling walker. A review of the POC for patient #8 revealed an admission date of 4/30/2024 and a current certification period of 4/30/2024 to 6/28/2024 with a pertinent diagnosis of unsteady feet and a history of falls. Skilled PT will address LE (lower extremity) strength, balance, and endurance to facilitate return to PLOF (prior level of function) and decrease the risk of falls. For PT Frequency and duration of visits, we ordered PT 1 WK 9. It is documented for DME and Supplies lists “None.” The POC does not report using a walker for therapy interventions or goals. Staff C, RN, conducted a home visit with observation for patient #10 on 5/29/2024 at 11:15 AM. Staff C assisted the patient from outside to her room and observed her walking with her walker. The patient has severe kyphosis. A review of the POC for patient #10 revealed an admission date of 4/25/2024 and a current certification period of 4/25/2024 to 6/23/2024 with a pertinent diagnosis of unsteady feet and a history of falls. Summary: Skilled PT will address LE strength, gait endurance, posture stabilization, transfers, and pain management. The frequency and duration of physical therapy visits are as follows: PT 1 WK1, 2 WK 1, and 1 WK7. Documented for DME and supplies lists “None.” The POC does not order using a walker for therapy interventions or goals. The administrator was interviewed on 5/30/2024 at 1:40 PM. She said that the plan of care should include all treatment orders and supplies used to provide care to the patients.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on observation, interview, and record review, the agency failed to report the patient’s pain that was not controlled by medications for 1 (#11) out of 9 patients sampled during home care visits. The findings included: A review of the agency policy titled Physicians Orders Policy Number: 2.1.2008 with an effective date of 12/08/2003 and a revised date of 10/01/2023 revealed: Purpose: To outline the process of receiving and documenting physician or authorized practitioner orders. Procedure: 3. The agency accepts patient referrals from a physician/authorized practitioner or physician designee to collect information regarding the patient and services required. The referral intake serves as a verbal order to begin services. During the home visit conducted on 5/29/2024 at noon with Staff B, Registered Nurse (RN), the patient shared his experience of pain. He reported his pain today was between 6 and 7 and expressed, “It has been tough. My pain has been anywhere between 7 to 10.” A review of the plan of care (POC)for patient #11, with an admission date of 5/11/2024, reflected a current certification period of 5/11/2024 to 7/09/2024, with a primary diagnosis of aftercare following surgery on the circulatory system. The frequencies and durations were documented for SN (skilled Nursing) 1 WK 1, 2 WK 2, and 1 WK 3, and physical therapy was effective 5/12/2024 1 WK 1. Under Orders of Discipline and Treatments: SN is to monitor pain and instruct the patient regarding pharmacologic pain control measures at rest, relaxation, position changes, stretching, distraction, Heat or Ice, ETC. Documented for the SOC (start of care) Clinical Summary: “Patient was recently hospitalized for GI (Gastrointestinal) Bleed and referred to home care for JP (Jackson-Pratt (management/infection. Documented on the POC for Goals/Rehabilitation Potential/Discharge Plans: Patient/caregiver will verbalize understanding of pharmacologic pain control measures as evidenced by improvement in pain levels from 9 to 4 by week 4. The POC did not have vital sign parameters documented. A review of the medication record for patient #11 reflected an order for Hydromorphone 2 mg (3 tablets) every 4 hours for pain. A review of the nursing visit notes dated 5/13/2024, 5/16/2024, and 5/22/24 documents a pain level of 8. Under the Assessment for Pain on 5/22/2024, for the question Pain effect on sleep, ask the patient over the past five days, how much of the time has pain made it hard for you to sleep at night? The nurse documented: Frequently”. The visit notes revealed no documentation that the nurse notified the physician of the patient’s pain level. During an interview conducted on 5/30/2024 at 10:15 AM, the administrator said the patient’s pain should have been addressed and confirmed that vital sign parameters were not on the plan of care.”