St Joseph’s/ Candler Home Healthcare

“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 observation, record reviews, policy review, and staff and patient interview, it was determined that the agency failed to ensure that the plan of care included all required elements to address safety measures to protect against injury for one patient (P) (P#12) of 17 sampled patients. Findings include: Review of the policy document titled, “Assessment/Reassessment of Patients,” revised date 1/2/2022 reveals the following: The RN/Skilled Therapist shall gather information concerning the patient to determine the patient’s needs. The adult and geriatric assessment is documented in the software system. As appropriate, the assessment includes an evaluation of the: a. medical history b. diagnosis c. co-morbidities d. height and weight e. pertinent physical findings f. age-specific and gender specific findings: g. problems, needs and strengths of the patient. P#12 was admitted to home health on 8/3/23 with a diagnosis of end stage renal disease and dependence on renal dialysis (a condition where the kidney reaches advanced state of loss of function). During a home visit on 03/11/2024 for P#12, at approximately 10:00 a.m., observed an arteriovenous (AV) shunt (dialysis access) inserted in the left upper extremity. Review of the plan of care failed to reveal documentation of the presence of the AV shunt or interventions to protect the patient’s AV shunt from harm, such as to avoid blood pressures or venipunctures in this extremity. The agency failed to ensure that the plan of care included safety precautions to protect safety of the patient and preserve the AV shunt. During an in home interview with P#12 on 3/11/24 at approximately 10:00 a.m., P#12 confirmed the presence of an arteriovenous (AV) shunt (dialysis access) in the upper left arm and states this shunt is used for hemodialysis treatments three days a week. During an office interview on 3/13/24 at 10:00 a.m. with the Administrator it was confirmed the agency staff failed to include safety precautions on the plan of care to ensure the safety of the patient’s AV shunt.”

“Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This Element is not met as evidenced by: Based on staff interview, and review of group of professional personnel (GOPP) meeting minutes, it was determined that the Administrator failed to organize and direct the agency’s ongoing functions to include the participation of a community representative in the GOPP meetings and to ensure the GOPP met quarterly to advise the agency on professional issues as required. Findings include: On 3/11/2024 at 4:00 p.m., the agency’s Group of Professional Personnel (GOPP) meeting minutes and participants attendance sheet for the last three quarters was requested. The Administrator provided the GOPP meeting minutes dated 6/29/2022. Review of the GOPP meeting minutes, and the attendance sheet dated 6/29/2022, revealed that a member from the community who is neither an employee nor an owner participated in the meeting. The agency failed to ensure a member of the community actively participated in the GOPP meeting as required. The agency also failed to ensure the GOPP meetings were held quarterly in 2023 to advise the agency on professional issues as required. On 3/12/2024 at 10:00 a.m., an office interview was conducted with the Administrator. The Administrator verbalized that the agency did not have an appropriate representation to include at least one community representative at the GOPP meeting held on 6/29/2022 and did not conduct quarterly meetings in 2023 as required.”