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 observations, interviews, and record reviews, the agency failed to ensure that patients were informed of the services to be provided on admission and to participate in the development of the plan of care (POC) for 2 (#6 and #9) patients out of 17 records sampled. The findings included: Regulation Text: 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. A review of the admission consent for services for patient #6 revealed documentation for Services to be provided and anticipated frequency: “2wk4, 1wk4.” The consent did not document the services to be provided. The medical record revealed no additional evidence that the patient was consulted and consented to planned services and care both initially or to date. A review of the admission consent for services for patient #9 revealed documentation for Services to be provided and anticipated frequency: “1wk1.” The consent did not document the services to be provided. The medical record revealed no additional evidence that the patient was consulted and consented to planned services and care both initially or to date. During an interview with the administrator on 7/31/2024 at 3:00 PM, she confirmed that the consent for patients #6 and #9 and visit notes did not document the services to be provided. “They only put the frequencies.””

“Patient refuses services CFR(s): 484.50(d)(4) The patient refuses services, or elects to be transferred or discharged; This Element is not met as evidenced by: Based on observation, interviews, and record reviews, that agency failed to document the refusal of services and education provided to the patient with communication to the physician for 1 (#6) patient out of 7 home care visits conducted. The findings included: Interpretive Guidelines: In the case of patient refusals of skilled care, the HHA must document its communication with the physician or allowed practitioner who is responsible for the patient’s home health plan of care, as well as the measures the HHA took to investigate the patient’s refusal and the interventions the HHA attempted in order to obtain patient participation with the plan of care. The HHA may consider discharge if the patient’s decision to decline services compromises the agency’s ability to safely and effectively deliver care to the extent that the agency can no longer meet the patient’s needs. A medical record review revealed a referral dated 7/15/2024 requesting the following disciplines: “1. Skilled Nursing, Physical Therapy, and Occupational Therapy with orders for education/reinforcement. Home Health Nurse: Skilled Nurse to evaluate and treat. Incision checks and assists patient and family with dressing changes per discharge instructions, new medication compliance, and medication administration. 2. Home Health Therapy, PT (physical therapy)/OT (occupational therapy) to evaluate and treat. Please work on functional mobility, ADLs (activities of daily living), adaptive equipment training, gait training, strengthening exercises, home exercise program, joint mobilization, balance, proprioception, stretching, and Active and Passive Range of Motion. Therapy frequency and Duration: 2-4 Times/Week, for 4-6 weeks, Session Length: 0-60 minutes.” A review of the POC (Plan of care) with an admission date of 7/16/2024 and a current certification period of 7/16/2024 to 9/13/2024, with a primary diagnosis of fracture of right femur. For Frequency /Duration of Visits: PT 1wk1, 2wk 3, 1 wk 1. The POC does not have orders for Skilled Nursing or Occupational therapy. Patient #6 consented to a home care observation with Staff J, PT, on 7/31/2024 at 11:30 AM. Staff J, PT, said that the daughter of patient #6 had refused nursing and Occupational Therapy. “I had patient #6 before, and they requested me.” The administrator reviewed the medical record for patient #6 on 7/31/2024 at 3:00 PM. The administrator confirmed there was no documentation regarding the patient’s education for refusing services or that the patient’s physician was notified. “Yes, the physician should have been notified.” A review of a Client Coordination Note Report provided by the administrator dated 7/31/2024 at 3:33 PM documented that the daughter only requests physical therapy and does not want nursing or OT. The administrator said, “We just notified the physician.””

“Revisions communicated to patient and MDs CFR(s): 484.60(c)(3)(i) (i) Any revision to the plan of care due to a change in patient health status must be communicated to the patient, representative (if any), caregiver, and all physicians or allowed practitioner’s issuing orders for the HHA plan of care. This Element is not met as evidenced by: Based on observations, interviews, and record reviews, the agency failed to notify the physician of changes to the plan of care for 1 (#7) patient out of 7 home care visits conducted. The findings included: Regulation Text (i) Any revision to the care plan due to a change in patient health status must be communicated to the patient, representative (if any), caregiver, and all physicians or allowed practitioners issuing orders for the HHA plan of care. A review of the home care referral for patient #7 dated 7/18/2024 at 14:20 revealed orders for Skilled Nursing for wound checks and medication education, physical Therapy to Evaluate and Treat gait, range of motion, mobility, and a home exercise program, and Occupational Therapy if clinically indicated. During a review of the physician-ordered plan of care (POC) with an admission date of 7/19/2924 and a current certification period of 7/19/2024 to 9/16/2024 and a primary diagnosis of right knee replacement, the POC documents on page 2 of 5, “Occupational Therapy (OT) to Evaluate /Assess and develop occupational therapy plan of care that will be approved by the physician prior to implementation. Reviewing the Client Calendar Report revealed the agency had not provided OT visits. A home care observation was conducted on 7/31/2024 at 1:00 PM with patient #7. Patient #7 said he thought he was going to get OT. “I need all of the help I can get.” During an interview with the administrator on 7/31/2024 at 3:00 PM, she said that patient #7’s insurance company did not authorize OT. “ We should have let the physician and the patient know.””