Floyd Valley Hospital Community Health Services

“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 the accurate completion of all components comprising the Plan of Care, including all supplies/equipment and medications used by the patient for 3 of 7 sampled patients (Patients #1, #2, and #3). Failure to maintain complete and accurate Plans of Care with current orders placed the 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 Documentation, dated 9/2023, documented assessments will include, but are not limited to a complete physical assessment by professional rendering care, home environment/safety, equipment, functional status, medical history, and psychosocial assessment. All medications, including over the counter medications the patient is self administering should be identified in the patient record. 1.Patient #1 had a start of care date of 4/18/24. Clinical record review revealed the following: a. The Plan of Care (POC), dated 6/17/24 to 8/15/24 included the following medications: Astepro Allergy 205.5 micrograms(mcg) (0.15%) 1 spray each nostril once a day, Calcium 600 milligrams (mg) 1 tablet twice a day, One A Day Men’s Complete 1 tablet daily in the morning, Super B Vitamin 1 capsule daily in the evening, Velphoro 500 mg 2 tablets before meals or snacks, Acetaminophen 500 mg 2 tablets every 6 hours as needed, Albuterol sulfate 90 mcg/actuation 2 puffs 4 times a day as needed, Aspirin 81 mg 1 tablet in the morning, Atorvastatin 20 mg 1 tablet at bedtime, Calcitriol 0.5 mcg 1 capsule 3 days a week Monday, Wednesday, Friday, Calcium Acetate 667 mg 2 tablets twice a day, Clopidogrel 75 mg 1 tablet in the morning, Gabapentin 300 mg 1 capsule twice a day, Guaifenesin 600 mg 1 tablet every 12 hours as needed, Lactulose 10 gram/15 ml 30 ml daily in the morning, levothyroxine 50 mcg 1 tablet daily in the morning, metoprolol succinate 25 mg 1 tablet daily at bedtime, midodrine 5 mg 2 tablets twice daily morning and evening, 2 tablets at noon as needed for systolic blood pressure less than 100, pantoprazole 40 mg 1 tablet daily in the morning. b. During a home visit observation on 7/2/24 at 9:30 AM with Staff D, Registered Nurse (RN), an interview with the patient revealed the patient is taking Claritin 24 hour as needed and fiber gummies as needed. The patient also reported he/she does not take Guaifenesin or Albuterol Sulfate as needed. c. The POC included the following durable medical equipment (DME) used by the patient: Scale, pill box, lifeline, toilet riser, grab bars, hand held shower head, cane, pill splitter, handrails on stairs, walker, and dentures. d. During a home visit observation on 7/2/24 at 9:30 AM, with Staff D, RN, the surveyor identified the following additional DME in the home: lift chair. During this same visit, an interview with the patient revealed the lift chair has been utilized since the start of care. The POC failed to include correct medications and all DME the patient required for use. 2.Patient #2 had a start of care date of 5/23/24. Clinical record review revealed the following: a. The revised POC dated 6/26/24, included orders for Vitamin D3 25 mcg 1 capsule every evening, Amiloride-hydrochlorothiazide 5-50mg .05 tablet every morning, Bupropion HCL 75 mg 1 tablet every morning, Clopidogrel 75 mg 1 tablet every morning, Vitamin B-12 1000 mcg 1 tablet every morning, Furosemide 20 mg 1 tablet every morning, Gabapentin 300 mg 1 capsule twice a day, Isosorbide mononitrate 30 mg 0.5 tablet every morning, Metoprolol succinate 25 mg 0.5 tablet extended release, Naproxen sodium 220 mg 2 capsules twice a day as needed; Nitroglycerin 0.4 mg 1 sublingual tablet at onset of chest pain as needed, Polyethylene glycol 400, 0.25% 1 drop both eyes as needed twice a day, and Rosuvastatin 5mg 1 tablet daily in the evening. b. During a home visit observation on 7/2/24 at 1:00 PM with Staff F, Physical Therapist (PT), an interview with the patient revealed the patient has been taking Vitamin B12 2500 mcg one time a day since April of 2024. c. The POC included the following DME used by the patient: Scale, compression stockings, incontinent supplies, glasses, dentures, cane, walker, walk in shower, shower chair, hand held shower head, grab bars, wheelchair, pill planner, pill splitter, gait belt, treadmill, exercise bike, heating pad, nonskid shower mat, weights, blood pressure cuff, and thermometer. d. During a home visit observation on 7/2/24 at 1:00 PM, with Staff F, the surveyor identified the following additional DME in the home: shoe horn. e. During an interview, the patient identified he/she had been using the shoe horn for several months to assist with putting on shoes. The POC failed to identify correct medications and all DME the patient required for use. 3.Patient #3 had a start of care date of 6/14/24. Clinical record review revealed the following: a. The POC, dated 6/14/24 to 8/12/24 included the following medications: D3-5000, 125 mcg 1 capsule daily in the morning, Acetaminophen 500 mg 2 tablets every 6 hours as needed, Amlodipine 10mg 1 tablet daily in the morning, Aspirin 81 mg 1 tablet daily in the morning, Calcitriol 0.25 mcg 1 capsule every Monday, Wednesday, Friday, Carvedilol 12.5 mg 1 tablet two times a day, Clopidogrel 75 mg 1 tablet daily in the morning, Folic acid 1 mg 1 tablet daily as needed during chemo treatments, Hydralazine 100 mg 1 tablet four times a day, Hydrochlorothiazide 25 mg 1 tablet two times a day, Insulin aspart 100 unit/ml (3ml) subcutaneous 2-15 units three times a day with meals, Insulin glargine 100 unit/ml (3ml) subcutaneous 25 units every morning, 10-12 units at bedtime, Losartan 100 mg 1 tablet daily, Minoxidil 2.5 mg 1 tablet two times a day, Ondansetron 8mg disintegrating 1 tablet three times a day as needed, Phenylephrine HCl 1% 1 drop into nostril as needed, Prochlorperazine maleate 10mg 1 tablet four times a day as needed, and Spironolactone 25 mg 0.5 tablet daily in the morning. b. During a home visit observation on 7/3/24 at 9:30 AM with Staff E, RN, an interview with the patient revealed the patient is taking Minoxidil 2.5 mg oral tablet 1 time a day per the instructions on the bottle. Patient reported he/she has always taken this medication at this dose and frequency. The POC failed to include a medication list that accurately reflected what medication the patient is taking. The above information was reviewed with the Clinical Manager and Chief Nursing Officer.”

“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 agency policy review, clinical record review and agency staff interview, the agency failed to complete and send a transfer summary to the physician caring for the patient at the inpatient facility after transfer within 2 business days to the physician and other health care professionals who would be providing care to the patient for 1 of 1 sampled patients with transfers (Patients #6). 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 agency policy titled Transfer and Discharge Criteria, dated 3/2024, upon transfer to another organization, the receiving organization, primary care practitioner and/or other healthcare professional responsible for providing care and services will be provided with a transfer summary withing 2 business days of a planned transfer or 2 business days after becoming aware of an unplanned transfer if the patient still remains in the facility at the time of notification. During an interview on 7/8/24 at 1:20 PM, the Administrator stated she had been unable to locate a transfer summary in the patient’s clinical record. Patient #6 had a start of care date of 3/15/24 and discharged from the agency on 5/13/24. Clinical record review revealed: a. The skilled nurse note, dated 4/14/24, documented the patient transferred to the emergency room for evaluation. b. The outcome and assessment information set (OASIS) transfer summary, dated 4/16/24, documented the patient admitted to the hospital for treatment. The agency failed to complete a transfer summary and send to the physician and receiving hospital. The above findings were reviewed with the Administrator.”