Idaho Home Health & Hospice

“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 record review and staff interview, it was determined the agency failed to ensure death records were complete for 2 of 3 patients (Patients #3 & #6) who died and whose records were reviewed. Failure to document the cause of death for patients resulted in incomplete findings in the clinical record. Findings include: 1. Patient #3 was a 72 year old male admitted to the agency on 10/25/22 with a primary diagnosis of dysfunction of bladder. Additional diagnoses included urinary retention and urinary tract infection. He received SN services. His record for the certification period 10/20/23 to 12/18/23 was reviewed. Patient #3 died at home on 10/25/23. Patient #3’s medical record included a note dated 10/25/23 titled “Death at Home” signed by the RN. The note stated, “wife called to notify HH [home health] that patient had passed away in the night period MD notified.” There was no additional documentation about the death. There was no documentation how Patient #3 died or if the death was expected. Incident reports regarding Patient #3’s death were requested but not provided. The DCS was interviewed on 2/07/24 at 12:23 PM and Patient #3’s medical record was reviewed. The DCS confirmed there was no documentation about Patient #3’s cause of death. She stated he died of a suspected heart attack. She confirmed this should have been documented. Additionally, she stated there should have been an incident regarding Patient #3’s death, and there was not. 2. Patient #6 was a 68 year old male admitted to the agency on 1/18/23 with a primary diagnosis of alcohol use withdrawal. Additional diagnoses included hypertension, anxiety disorder, and schizoaffective disorder bipolar type. He received SN and PT services. His record for the certification period 1/24/23 to 3/24/23 was reviewed. Patient #6 died at home on 3/10/23. Patient #6’s medical record included a note dated 3/10/23 titled “Death at Home” signed by the RN. There was no documentation how Patient #6 died or if the death was expected. Patient #6’s medical record included a coordination note dated 3/10/23 which stated, “received report by coroners office on 3/10/ 23 that patient had died at home either last night or early this morning.” Patient #6’s medical record did not include any other documentation regarding his death. Incident reports regarding Patient #6’s death were requested but not provided. The DCS was interviewed on 2/07/24 at 12:23 PM and Patient #6’s medical record was reviewed. She confirmed there was no documentation regarding what happened around Patient #6’s death. She stated agency staff called the coroner on 2/07/24 who stated Patient #6’s cause of death was due to pneumonia, alcohol use, and chronic pain. She confirmed Patient #6’s record did not have documentation regarding his cause of death and should have. Additionally, she confirmed there should have been an incident report regarding Patient #6’s death and there was not. The agency failed to ensure clinical documentation was complete in patients who died.”

“Patient’s needs CFR(s): 484.55(c)(4) The patient’s medical, nursing, rehabilitative, social, and discharge planning needs; This Element is not met as evidenced by: Based on medical record review and staff interview, it was determined the agency failed to identify need for social work intervention during the initial comprehensive assessment for 1 of 5 discharged patients (Patient #6) whose records were reviewed. This failure caused lack of social work interventions on a patient with identified problems with depression and alcohol use. Findings include: Patient #6 was a 68 year old male admitted to the agency on 1/18/23 with a primary diagnosis of alcohol use withdrawal. Additional diagnoses included hypertension, anxiety disorder, and schizoaffective disorder bipolar type. He received SN and PT services. His record for the certification period 1/24/23 to 3/24/23 was reviewed. Patient #6 died at home on 3/10/23. Patient #6’s record included an RN SOC admission dated 1/24/23. The admission visit note contained the following answers for Patient #6’s depression screening: “over the last two weeks have you been bothered by any of the following problems? … - little interest or pleasure in doing things … yes … 7 - 11 days (half or more of the days) - feeling down, depressed, or hopeless … yes … 7 – 11 days (half or more of the days) - feeling tired or having little energy … yes … 12 - 14 days (nearly every day) - feeling bad about yourself - or that you are a failure or have let yourself or your family down … yes … 12 - 14 days (nearly every day) - How often do you feel lonely or isolated from those around you? ... often - Cognitive, behavioral, and psychiatric symptoms that are demonstrated at least once a week... Impaired decision-making: failure to perform usual ADLS or IADLS, inability to appropriately stop activities, jeopardizes safety through actions - Frequency of disruptive behavior symptoms (reported or observed) any physical, verbal, or other disruptive/ dangerous symptoms that are injurious to self or others or jeopardize personal safety ... at least daily” There was no documentation a Social Worker was contacted based off Patient #6’s depression screening on 1/24/23. Patient #6’s record included a PT evaluation dated 2/07/23. The visit note contained the following documentation: - “Patient was observed as drunk based on gait pattern, slowed visual scanning, strong smell of beer, multiple cans near patient, forgetfulness ... Therapist educated patient to use the walker always and that physical therapy will not be helpful until his drinking is controlled.” There was no documentation a Social Worker was contacted regarding the Physical Therapist’s observations on 2/07/23. Patient #6’s medical record included an RN visit note dated 3/07/23. The note stated the following: - “patient still drinking 3-4 + beers daily, drinking during visit. Encouraged patient to not drink but he now states hes [sic] never gonna [sic] stop drinking … patient verbalizes understanding but shows no signs of compliance. No other questions or concerns at this time.” There was no documentation a Social Worker was contacted regarding Patient #6’s identified alcohol concerns on 3/07/23. The DCS was interviewed on 2/07/24 at 12:23 PM and Patient #6’s medical record was reviewed. The DCS confirmed a Social Worker should have been ordered based on the identified issues with alcohol use and depression. The agency failed to provide a Social Worker for Patient #6.”

“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 policy review, medical record review and staff interview, it was determined the facility failed to ensure a patient’s physician was notified a discharge was being considered prior to the discharge for 1 of 5 patients (Patient #7) who were discharged and whose records were reviewed. This caused a lack of coordination of after care between the agency and the physician. Findings include: An agency policy titled, “Coordination of Care, From Admit through Discharge,” revised 9/01/23 stated, “At admission, throughout care, and at discharge, coordination of services is promoted through routine communication with the patient’s physician: … When changes occur in the patient’s condition or response to treatment … when a missed visit occurs altering the plan of care.” This policy was not followed. An example includes: Patient #7 was a 56 year old male admitted to the agency on 8/01/23 with a primary diagnosis of disruption of surgical wound. Additional diagnoses included colon and lung cancer. He received SN, PT, and OT services. His record for the certification period 8/01/23 to 9/29/23 was reviewed. Patient #7 had nursing visits ordered twice weekly for wound care. There were no visits made to Patient #7 the weeks of 9/10/23 and 9/17/23. There were no missed visit notes documenting why the visits were missed. Patient #7’s record included a case conference note dated 9/20/23 which stated, “Patient not answering texts/calls for dc [discharge] visit. Unknown if wound present. If unable to locate may desk dc.” There was no documentation this was communicated to the physician. Patient #7’s record included a physician order dated 9/28/23 which stated, “per patient request would like to discharge from agency and has been refusing in person visits with no further communication.” Patient #7’s record included a discharge note dated 9/28/23. There was no documentation Patient #7’s physician was notified prior to 9/28/23 that a discharge due to refusal was being considered. Additionally, the weeks of 9/10/23 and 9/17/23 did not include documentation of attempts made to contact Patient #7 for visits and notification to the physician the visits were missed. There was no documentation Patient #7’s physician was notified a discharge was being considered. The DCS was interviewed on 2/07/24 at 12:23 PM and Patient #7’s medical record was reviewed. She confirmed the physician was not notified a discharge was being considered for Patient #7 until the day he was discharged. She confirmed there was no documentation of missed visits the weeks of 9/10/23 and 9/17/23. She confirmed the physician should have been notified prior to the discharge. The agency failed to notify the physician prior to Patient #7’s discharge.”