Buena Vista County Public Health and Home Care

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on agency policy review, clinical record review and agency staff interview, the agency failed to follow a Plan of Care established and periodically reviewed by a physician or notify the physician of the need to vary frequency of visits in 2 of 2 sampled patients with missed visits. (Patient #4 and #5) Failure to follow a plan of care established by a physician placed patient at risk of not receiving safe, individualized and consistent care designed to meet each patient’s health care needs. 2.Patient #5 had a start of care date of 11/22/24. Clinical record review revealed: a. The POC, dated 11/22/24 to 1/20/25, included physician orders for home health aide to visit two times per week for 8 weeks. b. The clinical record lacked documentation of two home health aide visits for the week of 12/1/24, and lacked physician notification of missed visits during that week. The agency failed to implement clinical services in accordance with the POC. The above findings were reviewed with the Administrator and Staff C, RN. 1. Patient #6 had a start of care date of 3/1/24. Clinical record review revealed the following: a. The plans of care (POC), dated 8/28/24 to 10/26/24 and 10/27/24 to 12/25/24, included physicians orders for skilled nurse to visit one time per week. b Review of the weeks of 11/10/24 through 11/16/24,11/24/24 through 11/30/24 and 12/1/24 through 12/7/24, revealed the clinical record lacked documentation of a skilled nurse visit completed. c. The clinical record lacked a missed visit notification to the physician for the missed visits. The agency failed to include physician notification of missed visits. According the the agency policy titled Home Health Certification and Plan of Care Conformance with Physician orders, dated 3/30/22, The Plan of Care (POC) covers all pertinent diagnosis, including mental status, types of services and equipment required, frequency of visits, prognosis, rehabilitation potential, functional limitations, activities permitted, nutritional requirements, medications and treatments, any safety measures to protect against injury, instructions for timely discharge or referral, and any other appropriate items. The RN shall bring to the immediate attention of the physician, changes in the client’s condition which may indicate the need for altering the treatment plan or for terminating services. The Physician may be notified by telephone, conference, fax or in writing. During an interview on 12/16/24, at 10:55 AM, Staff B, Clinical Manager stated agency communication with the physician is documented in physician orders or in care coordination notes.”

“At discharge CFR(s): 484.55(d)(3) At discharge. This Element is not met as evidenced by: Based on agency policy review, clinical record review and agency staff interview, the agency failed to ensure a timely completion of the update to the comprehensive assessment by a Registered Nurse or in therapy only cases, a qualified therapist, who last visualized the patient or made a home visit at discharge for 1 of 2 sampled patients requiring a comprehensive assessment at discharge (Patients #7). Failure to complete a discharge comprehensive assessment in a timely manner increased the potential that patients might not receive services in a manner to meet individualized patient needs. Findings include: According to the undated agency policy titled Comprehensive Assessment Components, comprehensive assessments will be collected, encoded and transmitted according to State and Federal Coke. Comprehensive assessments are needed for all age groups receiving skilled nursing services and will be completed within the Electronic Health Record. Adult discharge charting components at last visit or with data from last visit if no in-home visit made. During an interview on12/23/24 at 1:25 PM the Administrator stated the discharge was not completed as agency staff had a lot of conversations with the Doctor, case worker and internally about the patient’s care. Patient #7 had a start of care date of 2/10/23 and discharged from the agency 3/25/24 a. The Plan of Care (POC), dated 2/5/24 to 4/4/24, included physician orders for skilled nursing and home health aide services. b. The agency identified the last skilled visit prior to discharge, dated 3/5/24. The skilled nurse visit note, dated 3/5/24, Staff F, Registered Nurse (RN), documented patient assessment, provided education regarding falls and pain. The visit note identified the next visit to be the next week. c. The Care Coordination note, dated 3/7/24, Staff B, Clinical Manager documented the patient refused further services by the home health agency. d. Staff F, Registered Nurse (RN), completed and documented Patient #7’s discharge comprehensive assessment on 3/25/24,18 days after the patient refused further services. The agency failed to completed the comprehensive assessment within 48 hours after discharge. The above findings reviewed with the Administrator and Staff C, RN.”

“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 home visit observations, patient interviews, clinical record reviews and agency policy reviews, the agency failed to ensure accurate completion of all components comprising the Plan of Care, including all supplies/equipment, medications and orders that specify the frequency for each discipline for 2 of 7 sampled patients (Patients #3 and #5). Failure to maintain complete and accurate Plans of Care with current orders placed patients at risk to not receive services, medications, supplies and/or treatments according to assessed needs and physician orders. Findings include: According to the agency policy titled Plan of Care Conformance with Physician Orders, dated 3/30/22, the Plan of Care is physician orders for care of the client. The Plan of Care covers all pertinent diagnoses, types of services and equipment required, frequency of visits, prognosis, rehabilitation potential, functional limitations, activities permitted, nutritional requirements, medications and treatments, any safety measures to protect against injury, instructions for timely discharge or referral and any other appropriate items. 1.Patient #3 had a start of care date of 10/28/23. Clinical record review revealed the following: a. The Plan of Care (POC), dated 10/22/24 to 12/20/24, included orders for the following medications: Latanoprost 0.005% milliliters (ml) with instructions to instill one drop in both eyes every night at bedtime; Loratadine 10 milligram (mg) tablets with instructions to take one tablet daily as needed for allergies; and Famciclovir 500mg tablets with instructions to take 1 tablet three times a day as needed at first sight of sore/rash. The POC also included the following DME used by the patient: ace wraps, bath bench, bilevel positive airway pressure (BIPAP), brace, continuous positive airway pressure (CPAP), cane, compression stockings, incontinence supplies, electric stair lift, elevated toilet seat, glasses, grab bars in bathroom, grabber/reacher, hand held shower, hand rails, lifeline, magnifying glass, scale, thermometer and walker. b. During a home visit observation on 12/17/24 at 1:30 PM with Staff C, Registered Nurse (RN), the surveyor identified the bottle of Loratadine expired 3-19-24 and Famciclovir expired 2-28-24. In addition to the expired medications, the surveyor identified a bottle of Ferrous Sulfate (iron supplement) 325mg with instructions to take one tablet by mouth daily at breakfast. During an interview, the patient reported he/she has been taking this medication for several months. The bottle was last filled on 8-29-24. c. During the same home visit observation with Staff C, RN, the surveyor identified the following medical equipment in the home: pill cutter and toe sleeve. The patient stated he/she has utilized the pill cutter for several months and has worn the toe sleeve for several months. The POC failed to identify all current medication orders and all medical equipment the patient required for use. 2.Patient #5 had a start of care date of 11/22/24. Clinical record review revealed the following: a. The POC, dated 11/22/24 to 1/20/25 included orders for Physical Therapy to evaluate the patient. b. Staff H, Physical Therapist (PT), completed evaluation on 11/26/24. c. Staff H, PT, completed additional visits on 12/4, 12/6, 12/10, 12/12, 12/16 and 12/18/24. The POC lacked physician orders including frequency and duration of visits to be made by Physical Therapist. The above findings were reviewed with the Administrator and Staff C, RN.”

“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 agency staff interview, clinical record review and agency policy review, the agency failed to provide medications, treatments or services only as ordered by the physician for 3 of 7 sampled patients (Patients #1, #5 and #7). Failure to ensure staff obtain physician orders for administration of medications, treatments or services provided by agency staff placed agency patients at risk for inconsistent care/treatment and possible harm. Findings include: 3. Patient #1 had a start of care date of 3/1/23. Clinical record review revealed the following: a. The POC, dated 10/21/23 to 12/19/24, included physician orders for medications and treatments. b.The care coordination note, dated 12/4/24, Staff F, RN, indicated physician would be ordering an antibiotic to be delivered to the patients home, but does not specify the name or dosage. c.The skilled nurse visit note, dated 12/4/24, Staff F, RN, indicated an antibiotic had been initiated and placed in the patient’s’ medication planner for the treatment of skin infection, but lacked the name of the antibiotic and dosage of the medication added to the planner. The clinical record lacks a physician’s order for the antibiotic. The above findings review with the Administrator and Staff C, RN. 2. Patient #7 had a start of care date of 2/10/23 and discharged from the agency 3/25/24 a. The POC, dated 2/5/24 to 4/4/24, included physician orders for skilled nursing and home health aide services. b. The agency identified the last skilled visit prior to discharge, dated 3/5/24. The skilled nurse visit note, dated 3/5/24, Staff F, Registered Nurse (RN), documented patient assessment, provided education regarding falls and pain. The visit note identified the next visit to be the next week. c. The Care Coordination note, dated 3/7/24, Staff B, Clinical Manager documented the patient refused further services by the home health agency. d. The clinical record lacked documentation of an order to discharge the patient from home health services. The agency failed to include a physician’s order to discharge from home health services. According to the agency policy titled Plan of Care Conformance with Physician Orders, dated 3/30/22, the Plan of Care is physician orders for care of the client. The Plan of Care covers all pertinent diagnoses, types of services and equipment required, frequency of visits, prognosis, rehabilitation potential, functional limitations, activities permitted, nutritional requirements, medications and treatments, any safety measures to protect against injury, instructions for timely discharge or referral and any other appropriate items. During an interview on 12/16/24 at 10:55 AM, Staff B, Clinical Manager stated interim physician orders are incorporated into an updated Plan of Care. 1.Patient #5 had a start of care date of 11/22/24. Clinical record review revealed the following: a. The Plan of Care (POC), dated 11/22/24 to 1/20/25, included orders for skilled nursing services to assess/instruct patient on pain management measures; pain medication, rest, body alignment, range of motion, meditation and massage. b. The skilled nurse visit note, dated 12/19/24, completed by Staff C, Registered Nurse (RN) identified the patient utilizes medication, heat, ice, rest and relaxation. The POC failed to include orders for heat and ice to be used as pain relief treatments.”

“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 home observation visits, staff and patient interviews, clinical record review and agency policy review, the agency failed to ensure accurate and thorough completion of all pertinent components of each comprehensive assessment for 1 of 7 sampled patients (Patient #1). Failure to assure all staff who provide patient care communicated and assured coordination of care provided by all disciplines placed patients at an increased risk for unidentified condition changes. Patient #1 had a start of care date of 3/1/23. Clinical record review revealed the following: a. The Plan of Care (POC), dated 10/21/24 to 12/19/24, included physician orders for the skilled nurse to visit one time per week and for the home health aide (HHA) to visit two times per week. b. The comprehensive assessment at the time of recertification, dated 12/16/24, completed by Staff F, Registered Nurse (RN), identified Impetigo (a common skin infection caused by bacteria that causes sores and blisters), on the forehead, but identified no additional abnormal skin areas or concerns. c. During a home observation visit on 12/16/24, at 9:30 AM, with Staff F, RN, assessed the visible blisters and scabs to the face caused by impetigo during the comprehensive assessment, but failed to assess any other areas of the skin during the visit. d. An inter-office communication note dated 10/25/24, Staff E, (HHA), reported redness to the right abdominal fold with bleeding noted. e.The skilled nurse note, Staff F, RN, dated 10/25/24, documented scattered brown spots, moles and old scars, but failed to address the right abdominal fold. f. An inter-office communication note dated 10/29/24, Staff E, HHA reported an open area to the coccyx. g. The skilled nurse visit note dated 11/1/24, Staff C, RN, failed to address the open skin area to the coccyx the HHA had reported. h. The skilled nurse visit note dated 11/7/24, Staff F, RN failed to address the open skin area to the coccyx the HHA reported. i. An inter-office communication note dated 11/12/24, Staff G, HHA reported 2 open areas to the right abdominal fold with bleeding. j. An inter-office communication note dated 11/22/24, Staff G, HHA reported 1 open area to the right abdominal fold with bleeding. k. An inter-office communication note dated 12/3/24 and 12/6/24, Staff G, HHA, reported blisters and scabs on the patients chest and back. l. The skilled nurse note, dated 12/4/24, Staff F, RN noted left side of face swollen and red with impetigo, but failed to address blisters and sores on the patients chest and back as reported by the HHA. m. An inter-office communication note dated 12/10/24, Staff E, HHA, reported blisters and scabs to patients chest and back. The agency failed to address the blisters and open wounds. The above findings were reviewed with the Administrator and Staff C, RN.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the 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) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on observations, agency staff interviews, record review and policy review, the agency failed to send a discharge summary to the physician and other health care professionals who would be providing care to the patient after discharge within 5 business days for 1 of 2 sampled patients discharged from the agency. ( Patient #7) Failure to send the physician and other health care professionals a summary of the patient’s care while receiving services from the agency in a timely manner may result in inadequate or inappropriate follow-up during inpatient care or after discharge. Findings include: According to the undated policy, titled Description of Clinical Record, When home health services (Skilled Nursing and/or HCA) are terminated, the record will show the date and reason for termination (for example, patient not in need of service, goals met, patient deceased, transferred to the hospital or nursing home, etc.) and summary indicating if goals are met. Discharge summaries will be sent to the physician but do not need signed or returned. Discharge Summary completed within 2 calendar days and discharge notes in clinical record will be completed within seventy-two (72) hours of discharge. During an interview on12/23/24 at 1:25 PM the Administrator stated the patient’s discharge paperwork not completed timely as agency staff had a lot of conversations with the Doctor, case worker and internally about the patient’s care. Patient #7 had a start of care date of 2/10/23 and a discharge date of 3/25/24. Clinical record review revealed the following: a. The Plan of Care, dated 2/5/24 to 4/4/24 included orders for skilled nursing services and home health aide services. b. The Care Coordination note, dated 3/7/24, Staff B, Clinical Manager documented the patient refused further services by the home health agency. c. Staff F, RN, completed and documented Patient #7’s discharge summary on 4/1/24,17 business days after the patient refused further services. The agency failed to completed the discharge summary and send to the physician within 5 days of discharge. The above findings reviewed with the Administrator and Staff C, RN.”