Southeast Iowa Regional Home Health

“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 agency policy review, clinical record review, and agency staff interview, the agency failed to report changes in patient clinical findings or changes in patient needs to the physician for 3 of 13 sampled patients (Patients #2, #7 and #9). Failure to communicate the patient’s status with the physician placed agency patients at risk for unidentified worsening of conditions, inappropriate treatments, or unmet home health care needs. 2. Patient #2 with a start of care date of 12/15/2022. Clinical record review revealed the following: a. The Plan of Care, dated 12/10/23 to 2/7/24, included diagnoses of Malignant carcinoid tumor of the midgut, Chronic obstructive pulmonary disease, chronic pain syndrome, and Acute on chronic diastolic (congestive) heart failure; physician orders for weekly medication set up; but lacked physician orders to obtain weekly weights or notification to physician about weight variations. b. During a home observation visit on 1/8/24, Staff C, RN (Registered Nurse), was observed completing medication set up. Per patient request, Staff C did not set up Melatonin and Tizanidine. Staff C reported the patient keeps Melatonin and Tizanidine at bedside and self- administers. Alprazolam (Xanax) is ordered 3 times a day, as needed; however, nurse sets up Xanax at evening and bedtime per patient request. Staff C reported patient had asked RN to start setting up Xanax in the evening and at bedtime, RN did as requested but was unsure when this started. c. The Skilled Nurse visit note, dated 12/11/23, included documentation of a weight of 125.8 pounds. d. The Skilled Nurse visit note, dated 12/18/23, included documentation of a weight of 124.6 pounds. e. The Skilled Nurse visit note, dated 12/26/23, included documentation of a weight of 123.1 pounds. f. The Skilled Nurse visit note, dated 12/28/23, included documentation of a weight of 123.5 pounds. g. The Skilled Nurse visit note, dated 1/2/24, included documentation of a weight of 122 pounds. h. The Skilled Nurse visit note, dated 1/8/24, included documentation of a weight of 127.3 pounds. The agency failed to set up medications as ordered and failed to communicate weight changes to the physician. 3. Patient #7 with a start of care date of 12/8/2023. Clinical record review revealed the following: a. The Plan of Care, dated 12/8/23 to 2/5/24, included diagnoses of Encounter of orthopedic aftercare following surgical amp, Type II Diabetes mellitus with diabetic chronic kidney disease, and Hypertensive chronic kidney disease with stage 1-4; unspecified chronic kidney; Physician orders for skilled nurse to assess and evaluate but lacked physician orders to obtain weights or notification to physician about weight variations. b. Skilled Nurse visit note, dated 12/8/23, included a weight of 240 pounds. c. Skilled Nurse visit note, dated 12/18/23, included a weight of 245 pounds. d. Skilled Nurse visit note, dated 12/22/23, included a weight of 246.5 pounds. e. Skilled Nurse visit note, dated 12/29/23, included a weight of 247.6 pounds. f. Skilled Nurse visit note, dated 12/8/23, identified the normal blood pressure range for this patient 95/60-140/90 and documented current blood pressure of 160/78, which is outside the normal range. g. Skilled Nurse visit note, dated 12/15/23, identified the normal blood pressure range for this patient 95/60-140/90 and documented blood pressure of 200/84 before taking blood pressure medication and 162/74 after taking blood pressure medication, which fall outside the normal range. h. Skilled Nurse visit note, dated 12/22/23, identified the normal blood pressure range for this patient 95/60-140/90 and documented current blood pressure of 158/82, which is outside the normal range. i. Skilled Nurse visit note, dated 12/29/23, identified the normal blood pressure range for this patient 95/60-140/90 and documented current blood pressure of 145/66, which is outside the normal range. Agency failed to communicate to physician regarding blood pressures that fell outside the normal parameters set for patient, agency obtained weights routinely without an order and failed to communicate weight variations to physician. The above findings were reviewed with the agency Administrator and West Burlington Clinical Manager. Agency staff provided no further information prior to the end of the survey. Findings include: According to the agency policy titled, Home Health Care Planning Process, dated 7/2022, identified documentation includes physician’s notification/clarifications of problems with patient’s status. During an interview on 1/8/24 at 11:51 AM, West Burlington Clinical Manager reported communication with the physician should be documented in the communication notes. 1.Patient #9 with a Start of Care Date of 1/2/2024. Clinical record review revealed the following: a. The Plan of Care, dated 1/2/2024 to 3/1/24, included the diagnosis of Chronic Systolic Congestive Heart Failure, Pleural Effusion, and Pulmonary Embolism; Physician orders for the Skilled Nurse to monitor patient’s weight, weight changes and report any weight gain to provider. b. The Initial comprehensive assessment, dated 1/2/24, included a weight of 154.4. c. The skilled nurse visit note, dated 1/5/24, included a weight of 157.0. d. The skilled nurse visit note, dated 1/8/24, included a weight of 158 pounds 4 ounces. e. Total weight gain of 3.14 pounds in seven days. Agency failed to communicate the weight changes as ordered, to the physician.”