Crawford County Home Health, Hospice & Public Heal

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on clinical record review and agency staff interview, the agency failed to ensure documentation included electronic staff signature and credentials for 1 of 3 sampled patients with orders for Physical Therapy. (Patient #5) Failure to maintain appropriately authenticated electronic signatures risked patients receiving services from inappropriate staff. Findings include: 1. Patient #5 had a start of care date of 2/17/2020. Clinical record review revealed the following: The initial Physical Therapy Evaluation dated 3/28/24, lacked both an electronic signature and credentials. Agency staff failed to appropriately authenticate the clinical record documents The above findings were reviewed with the Staff A, Administrator, Staff B, Clinical Manager, Staff C RN and Staff D RN. The agency provided no further information prior to the end of the survey.”

“Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This Element is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to ensure agency staff advised the patient of the extent to which payment for agency services may be expected and the charges for services that may not be covered from Medicare, Medicaid, or any other federally-funded or federal aide program known to the agency and the charges the individual may have to pay before the agency initiated care for 2 of 4 sampled patients, who had an admission between 11/8/23 through 4/1/24. (Patients #1 and # 4). The agency reported a current census of 26 patients. Failure to ensure agency staff advised the patient the extent to which payment for agency services may be expected and the charges for services that may not be covered from Medicare, Medicaid, or any other federally-funded or federal aide program known to the agency and the charges the individual may have to pay before the agency initiated care placed agency patients at risk for the patient’s rights being violated and the patient being unexpectedly charged for services. Findings include: 1. Patient #1 had a start of care of date of 11/8/2023. The Plan of Care, dated 11/8/23 to 1/6/24, included physician orders for skilled nursing and home health aide services. The Financial data form, dated 11/8/23 included a financial responsibility section which identified the agency planned to bill services through medicaid, but failed to identify the amount the patient would be responsible to pay. During an interview on 4/1/24 at 3:15 PM, Staff B, Clinical Manager verified Patient #1 should have “Zero for the amount the patient would owe”. The above findings were reviewed with the Staff A, Administrator, Staff B, Clinical Manager, Staff C RN and Staff D RN. The agency provided no further information prior to the end of the survey. Findings include: 2. Patient #4 had a start of care of date of 1/15/24. The Plan of Care, dated 1/16/24 through 3/16/24, included physician orders for skilled nursing and physical therapy services. The Financial data form, dated 11/8/23 included a financial responsibility section which identified the agency planned to bill services through Medicare, but failed to identify the amount the patient would be responsible to pay. During an interview on 4/1/24 at 3:15 PM, Staff B, Clinical Manager verified Patient #4 should have “Zero for the amount the patient would owe”.”

“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 clinical record review, agency staff interview, and home visit observation, the agency failed to report changes in patient clinical findings or changes in patient needs to the physician for 2 of 2 sampled patients with home visit observations completed that included medication set up. (Patient #2 and #3) Failure to communicate the patients status with the physician placed the agency at risk for unidentified worsening of conditions, inappropriate treatments, or unmet home health care needs. Findings include: 1. Patient #2 had a start of care date of 5-22-19. a. The Plan of Care (POC) dated 2/25/24 through 4/24/24, included orders for all medications the patient was to be taking, and included orders for the nurse to set up the medications each week in the medication planner. b. During a home observation visit on 4-1-24 at 1pm, the surveyor observed Staff C, Registered Nurse, (RN) set up medications in a medication planner for the following week. The RN observed and commented that the patient missed one night of taking all of his bedtime medications. c. Review of the clinical record revealed the following: the RN documented the missed medications, however failed to notify the physician that the patient had missed taking his medications and the details of the medications missed. 2. Patient # 3 had a start of care dated 10/9/23, The Plan of Care (POC) dated 2/6/24 through 4/5/24, included orders for all medications the patient was to be taking, and included orders for the nurse to set up the medications each week in the medication planner. Review of the clinical record revealed the following: On 3/4/24, the RN documented Patient # 3 missed Wednesday medications, however failed to notify the physician that the patient had missed taking his medications and the details of the medications missed. During staff interview on 4-3-24 at 8:15 am, the RN and the Clinical Manager both stated they were not aware they needed to alert the physician when a patient failed to take medications as set up by the RN. The above findings were reviewed with the Staff A, Administrator, Staff B, Clinical Manager, Staff C RN and Staff D RN. The agency provided no further information prior to the end of the survey.”

“Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient’s discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner’s issuing orders for the HHA plan of care, and the patient’s primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any). This Element is not met as evidenced by: Based on clinical record review and agency staff interview, the agency failed to communicate, and involve the physician and the patient, in plans for discharge from the agency prior to the patients discharge in 1 of 3 sampled patients discharged. (Patient #7) Failure to communicate and involve the patient and the physician in the discharge planning process prior to the patients discharge, placed the patient at risk for not receiving needed care and services after discharge from the agency. Findings Include: 1. Patient #7 had a start of care date of 9/18/2023 and a discharge date of 9/28/2023. The Plan of Care (POC) dated 9/18/23 through 11/16/23, included orders for skilled nursing, physical therapy, and home health aide services. Review of the clinical record revealed the following: a. POC included orders for patient to wear a back brace except when lying down, with restrictions including no bending or twisting, and no sitting for excess of 30 minutes at a time. b. Skilled nurse visit note dated 9/21/23, Patient declined the physical therapy initial evaluation. Skilled nurse documented the physical therapy initial visit was cancelled per the patients request. The clinical record lacked physician notification of the patients refusal of physical therapy services. Clinical record lacked documentation the patient or physician was included in any discharge planning discussion before the nursing visit dated 9/28/23, where the discharge assessment was completed and the physician order for discharge was received on 9/29/23. During an interview with the Administrator and the Clinical Manager on 4/3/24 at 9:15 am, the clinical manager stated the patient basically kicked the agency out of the home stating the patient didn’t need services. The clinical record lacked documentation of this discussion between the patient and the agency staff. The agency failed to notify and involve the patient and the physician in discharge planning prior to the discharge date of 9/28/23. The above findings were reviewed with the Staff A, Administrator, Staff B, Clinical Manager, Staff C RN and Staff D RN. The agency provided no further information prior to the end of the survey.”

“Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This Element is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to coordinate care provided by all disciplines, and integrate services, to assure patient needs are being met for 1 of 1 patients sampled with contracted therapy services. (Patient #4) Failure to coordinate care provided by all disciplines and to integrate services, puts the patients at risk for inappropriate treatments or unmet home health care needs. Findings include: 1. Patient #4 had a start of care date of 1/16/24. Review of the clinical record revealed the following: a. Physical Therapy Assistant (PTA) documented on 2/1/24, patient’s spouse was concerned about a pink area on the top of the patient’s left foot. PTA documents the spouse to continue to monitor the pressure area on the top of the patient’s left foot and discussion with the spouse to find alternate footwear that would not cause any pressure to that area, and indicated to spouse, may have to try laced up tennis shoes. The documentation lacked notification the PTA had communicated with the RN or supervisor of possible pressure area on the foot. b. The PTA documentation on 2/5/24, indicated that the pressure area on the top of patients left foot was improved and that the patient was wearing different shoes that were of a looser fit. The documentation lacked notification or coordination with the RN or a supervisor. c. The RN documentation from the visit on 2/7/24, lacked any assessment of the left foot or pressure area and indicated no skin issues noted, or discussed with the patient or spouse. d. During an interview on 4-3-24 at 9:20 am, the RN indicated she was not aware of a possible pressure area on patients foot and that she had not been notified by therapy of any skin issues. RN indicated that the coordination of care is expected to happen in weekly phone conversations for patients care needs, but that most of the conversations are centered around to increase, decrease or discontinue services and not the specific of the care itself. The above findings were reviewed with the Staff A, Administrator, Staff B, Clinical Manager, Staff C RN and Staff D RN. The agency provided no further information prior to the end of the survey.”

“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 review, agency policy review, home visit observation and agency staff interview, the agency failed to ensure skilled professional staff involved in the patient’s plan of care completed an ongoing interdisciplinary wound assessment as required by agency policy and expectation for 1 of 1 sampled patients with wounds (Patient #3). Failure to complete an ongoing interdisciplinary assessment of wounds placed patients at risk unidentified worsening of the wounds. Findings include: According to the agency policy, titled Wound Assessment and Photography, dated 6/2020, wounds will be measured weekly and more often if wound deterioration is noticed. Do depth measurement first. Complete measurement with length and width. During interview on 4/1/24 at 2:00 PM, Staff B, Clinical Manager, reported wound measurements should be completed weekly. The measurements include depth, length and width of the wound. The wound measurements would be documented in the clinical record under assessment. Patient #1 had a start of care date of 11/8/23. Clinical record review revealed: Plan of Care, dated 3/7/24-5/5/24 included physician orders for skilled nursing 3 times a week that included wound care to left great toe. Interview during home visit with Staff C, Clinical Manager, reported wounds are usually measured at the first visit of the week Skilled nursing visit notes, dated 3/11/24 and 3/13/24, documentation did not include a length, width and depth of the wound. No wound measurements were completed for the week of 3/10/24. The agency nurse failed to follow their agency policy and measure wounds weekly. The above findings were reviewed with the Staff A, Administrator, Staff B, Clinical Manager, Staff C RN and Staff D RN. The agency provided no further information prior to the end of the survey.”