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 interviews and record reviews, the agency failed to ensure two patients (#9, #13 ) were informed in advance of care and the frequency of the visits to be provided by the disciplines ordered out of 7 active patient records sampled. The findings included: A review of the agency policy titled Admission Process, Effective Date of 04/15/1999 and a Revised Date of 10/01/2023, revealed: During the admission/initial visit, the qualified clinician: a. identifies self and the agency. b. explains On-Call procedure and services available. c. obtains signed consent and visually inspects insurance cards. d. explains the Bill of Rights/Non-Discrimination Statement and the patient’s responsibilities. e. explains Advance Directives for adult patients. f. performs a safety assessment and explains safety precautions to patient/caregiver; g. explains that the patient admitted information found in the patient orientation booklet to the patient/caregiver. h. informs of the state hot-line phone number and the agency phone number. i. Perform an initial assessment j. conducts, as applicable, a patient-specific population home health comprehensive assessment using a patient-specific population assessment tool for (a) prenatal and postpartum patients, for (b) infants (0-1 years of age), and children and adolescents (1-18 years of age), and (c) for patients requiring behavioral health or psychiatric nursing services. k. explains the OASIS Privacy Act as appropriate to payor source. l. informs patient/caregiver of anticipated services and frequency. m. initiates the plan of care with input from the patient. Review of the agency Admission-Consent For Care signed by Patient #9 and the admitting nurse on 5/01/2024, Services to be Provided an “X” by skilled nursing and by Times A week for X weeks. Review of the agency Admission-Consent For Care signed by Patient #13 and the admitting nurse on 4/23/2024, Services to be Provided an “X” by skilled nursing and physical therapy. The Times A Week is blank. The administrator was interviewed on 4/16/2024 at 10:45 AM. The Administrator said the discipline visit frequencies should be discussed with the patient and documented in the consent form for services.”

“Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on interviews and record reviews, the agency failed to notify the physician of patient vital signs outside of the parameters on the physician-ordered plan of care for one patient (#5) out of an active patient sample of seven sampled. The findings include: A review of the agency policy titled Coordination of Care, From Admit through Discharge, with an effective date of 5/01/1999 and revised on 9/01/2023, revealed the following: 4. Coordination of care with physician/authorized practitioner: At admission, throughout care, and at discharge, coordination of services is promoted through routine communication with the patient’s physician: a. When changes occur in the patient’s condition or response to treatment b. When changes occur in caregiver support or the environment that affect the patient treatment c. When a missed visit occurs, altering the Plan of Care In Tennessee, for all Medicaid skilled patients, the agency will report a missed visit (that will not be made up in that week) within 3 calendar days to the Managed Care Organization utilizing the state-approved Home Health Missed Visit the form located in the online learning management system. d. When results of laboratory and other tests become available e. When there is a need to change the patient’s plan of care f. And at least every 60 days to review, revise, update, and/or continue the plan of care In the event that a physician cannot be reached to communicate the status of a patient the following will occur: The Medical Director and/or Supervisor will be contacted for assistance with contacting physician/authorized practitioner Patients with critical needs, as determined by the clinician, will be advised to seek emergency medical treatment. A review of the Plan Of Care (POC) for Patient #5 documented an admission date of 5/11/2024 and a certification period of 5/11/2024 to 7/9/2024. Documented under Orders of Discipline and Treatment (page 2 of 5), revealed, “When vital signs are obtained, licensed professional to report vital signs falling outside the following established parameters: Temp 101, pulse 110, Respirations 22. Systolic BP (blood pressure)160, Diastolic 100, Pain >6, and oxygen saturation <90. The POC lists essential hypertension as a pertinent diagnosis with an exacerbation date of 4/30/2024. On 5/15/2024 at 10:00 AM, Staff A, Licensed Practical Nurse (LPN), conducted a home visit for Patient #5. Staff A checked the patient’s vital signs, and the patient’s heart rate (HR) was 115. Staff A, LPN, did not instruct the patient on interventions to address the elevated heart rate and did not notify the patient’s physician of the elevated heart rate. A review of the Vital Sign report from the Agency’s electronic medical record system revealed the following: On 5/11/2024, the documented HR was 118, and on 5/12/2024, it was 112. The medical record reflected no documentation that the clinicians notified Patient #5’s physician of the elevated HR. A review of the visit note, dated 5/15/2024 at 4:20 PM, revealed documentation by the Administrator, “HR has stayed in this range since SOC (start of care). Smokes and uses vape, awake, alert, and in no distress—faxed to the physician on 5/15/2024 at 4:20 PM. An interview was conducted on 5/16/2024 at 11:44 AM with the Administrator, who confirmed Patient #5’s heart rate was documented outside of the parameters on the POC.”