North Idaho Home Health

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on medical record review, policy review, and staff interview it was determined the agency failed to ensure physicians were alerted to changes in patients conditions, physician orders were followed, and there was adequate communication between all disciplines including RN’s and LPN’s. These failures resulted in unmet patient needs and negatively impacted the continuity, safety, and quality of care for 3 of 17 patients (Patient #2, #3, and #17) whose records were reviewed. Findings include: 1. Refer to G578, as it relates to the failure of the agency to follow physician orders as outlined on patients’ plan of care. 2. Refer to G590, as it relates to the failure of the agency to alert physician of changes in patients’ condition. 3. Refer to G608, as it relates to the failure of the agency to ensure adequate communication between all disciplines including RN’s and LPN’s. The cumulative effect of these practices impeded the agency’s ability to provide quality care.”

“Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This Standard is not met as evidenced by: Based on medical record review and staff interview, it was determined the agency failed to follow physician orders for 1 of 17 patients (Patient #2) whose records were reviewed. This failure had the potential to result in unmet patient needs. Patient #2 was a 77 year old female admitted to the agency on 8/29/23 with a primary diagnosis of after care from a fall during a seizure. Additional diagnoses included CVA and COPD. She received PT and OT services. Her record for the certification period 8/29/23 to 10/27/23 was reviewed. Patient #2’s medical record included a PT admission note dated 8/29/23. The PT evaluation included that Patient #2 was ordered to have 3 L NC oxygen continuously and to maintain O2 saturation greater than 90%. The following visits did not include assessments of Patient #2’s O2 saturations. No O2 saturation was documented on 8/29/23 PT admission home visit. No O2 saturation was documented on 9/06/23 PT home visit. No O2 saturation was documented on 9/08/23 PT home visit. No O2 saturation was documented on 9/12/23 PT home visit. No O2 saturation was documented on 9/18/23 PT home visit. The ED was interviewed on 2/21/24 beginning at 2:40 PM and Patient # 2’s medical record was reviewed in her presence. The ED confirmed that O2 saturations were not documented each visit. She stated it is the expectation that O2 saturations should be evaluated on each visit. The agency failed to ensure that Patient #2 received care as outlined on her POC.”

“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 2 patients (Patients #2 and #3) 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 77 year old female admitted to the agency on 4/19/23 with a primary diagnosis of acute and chronic respiratory failure with hypoxia. Additional diagnoses of emphysema and type 2 diabetes. She received SN and PT services. Her record for the certification period 4/19/23 to 6/17/23 was reviewed. Patient #3 died at home on 4/23/23. Patient #3 was listed in the agency’s “Discharge Report” that stated length of stay 4 days and “Patient Expired.” There was no additional documentation about the death. There was no documentation how Patient #3 died. Incident reports regarding Patient #3’s death were requested but not provided. The area Administrator, RN was interviewed on 2/22/24 at 3:50 PM and Patient #3’s medical record was reviewed. The area Administrator confirmed there was no documentation about Patient #3’s cause of death. Additionally, she stated there should have been an incident report regarding Patient #3’s death, and there was not. 2. Patient #2 was a 77 year old female admitted to the agency on 8/29/23 with a primary diagnosis of after care from a fall during a seizure. Additional diagnoses of CVA and COPD. She received PT and OT services. Her record for the certification period 8/29/23 to 10/27/23 was reviewed. Patient #2 died at home on 9/27/23. A note documented 9/27/23 in Patient #2’s medical record stated, “GRANDDAUGHTER CALLED TO NOTIFY THAT PATIENT PASSED AWAY AT HOME THIS MORNING AT 10:20AM.” Incident reports regarding Patient #2’s death were requested but not provided. The ED, RN was interviewed on 2/21/24 at 2:40 PM and Patient #2’s medical record was reviewed in her presence. The ED confirmed there was no documentation about Patient #2’s cause of death. Additionally, she stated there should have been an incident report regarding Patient #2’s death, and there was not. The agency failed to ensure clinical documentation was complete in patients who died.”

“Licensed Practical (Vocational) Nurse CFR(s): 484.115(e) Standard: Licensed practical (vocational) nurse. A person who has completed a practical (vocational) nursing program, is licensed in the state where practicing, and who furnishes services under the supervision of a qualified registered nurse. This Standard is not met as evidenced by: Based on medical record review, idaho statute review, on call schedules, and staff interview it was determined the agency failed to ensure LPN’s practicing at the agency functioned in dependant roles and under the supervision of a Registered Nurse for 2 of 17 patients (Patient #2 and #17) whose record was reviewed. This had the potential for patients needs to go unmet and LPN’s operating outside their scope of practice. Idaho Board of Nursing rules were reviewed. Section 24.34.01.002.15 states, “Licensed Practical Nurse (LPN). In addition to the definition set forth in Section 54-1402, Idaho Code, licensed practical nurses function in dependent roles...” IDAPA code 54-1402 states “ (3) “Licensed practical nurse” means a person licensed by the board who practices nursing by: (a) Functioning at the direction of a licensed registered nurse...” The Agency after hours oncall calendar for the month of January 2024 was reviewed. It included a primary nurse on call and a backup nurse on call. The schedule included 5 days where an LPN was the only nurse on call functioning as primary and backup. There was no Agency process or procedure for how the LPN would function in a dependant role to the RN when she was primary oncall. 1. Patient #17’s record included a coordination note, dated 1/15/24, signed by an LPN, which included That Patient #17 called on 1/12/24 at 9:23PM and was complaining of abdominal pain, Nausea Vomiting, and constipation. The Note included that the LPN stated for Patient #17 to go to the Emergency room for evaluation. Under the section “PRN SN visit required.” It was marked “no.” Under the section “Physician Notified” it was marked “no.” Patient #17’s medical record did not include visit from any discipline until 1/16/24. The day of 1/12/24 was compared on the on-call schedule. There was no documented RN on call that day. There was no documented discussion in Patient #17’s medical record between the LPN and the RN. It was unclear how the LPN on call was functioning in a dependent role, under the supervision and at the direction of the RN. The Area Administrator was interviewed 2/22/24 beginning at 1:00 PM, and Patient #17’s medical record was reviewed in her presence. She confirmed there was no additional PRN visit done for Patient and the SN visit made was 6 days after the call. She stated she was unsure why an additional PRN home visit by SN was not done. She stated it was agency expectation that the backup RN would have been notified at the time of the call to evaluate and assess Patient #17. She state She confirmed there appeared no communication documented between the disciplines The agency failed to ensure LPN were acting under the supervision of an RN, and within their scope of practice. 2. Patient #2 was a 77 year old female admitted to the agency on 8/29/23 with a primary diagnosis of after care from a fall from a seizure. Additional diagnoses of CVA and COPD. She received PT and OT services. Her record for the certification period 8/29/23 to 10/27/23 was reviewed. Patient #2’s medical record included A coordination note dated 9/23/23 at 5:25 PM, signed by the LPN. The note included: “GRANDAUGHTHER {sic} CALLING THAT PATIENT IS LETHARGIC AND HAS A COUGH. INTERVENTION(S): (LPN NAME) LPN CALLED GRANDDAUGHTER BACK AND ADVISED THAT IF PATIENT IS HAVING A CHANGE OF CONDITION, SHE SHOULD CALL EMS TO EVALUATE PATIENT.” There was no documentation the LPN contacted the RN on call to evaluate or assess Patient #2. A “Client Coordination Note Report” completed by a patient care manager, an RN, dated 9/25/23 at 5:37 PM, stated, “Follow -up phone call to patient? N/A… Comments: NO RECORDS OF PATIENT GOING TO ER.” The ED, RN was interviewed on 2/21/24 beginning at 2:40 PM and Patient #2’s medical record was reviewed. She confirmed Patient #2’s physician was not made aware of symptoms and emergent condition. Additionally, she confirmed there was no documentation of coordination or communication between the RN and LPN Patient #2’s medical record. The agency failed to ensure the LPN was acting under the supervision of an RN and within her scope of practice. .”

“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 policy review, medical record review, and staff interview, it was determined the agency failed to ensure patient’s physician was notified of a change in a patient’s medical status and to coordinate care with physicians for 3 of 17 Patients (Patient #2, #3 and #17) whose records were reviewed. This caused a lack of coordination of care between the agency and the physician. Findings include: 3. Patient #17 was a 81 year old female admitted to the agency on 1/10/24, for aftercare following an left hip replacement. Additional diagnoses included osteoporosis, COPD and Hypertension. She received SN, PT, and OT services. Her record, including the POC, for the certification period 1/10/24 to 3/09/24, was reviewed. Patient #17’s record included a coordination note, dated 1/15/24, signed by an LPN, which included That Patient #18 called on 1/12/24 at 9:23PM and was complaining of abdominal pain, Nausea Vomiting, and constipation. The Note included that the LPN stated for Patient #17 to go to the Emergency room for evaluation. Under the section “PRN SN visit required.” It was marked “no.” Under the section “Physician Notified” it was marked “no.” Patient #17’s medical record included an Emergency Room visit noted from the evening of 1/12/24. There was no documentation Patient #17’s Physician was notified of her new complaints of abdominal pain, constipation, nausea, and vomiting. Additionally, there was no notification of her subsequent visit to the emergency room. The Area Administrator was interviewed 2/22/24 beginning at 1:00 PM, and Patient #18’s medical record was reviewed in her presence. She confirmed there was no documentation Patient #17’s physician was notified of her new complaints or Emergency Room visit. She stated it was the expectation of the company to contact the physician of changes that could warrant new orders. The agency failed to ensure Patient #17’s physician was notified of her new symptoms. 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 … In the event that a physician cannot be reached to communicate the status of a patient the following will occur: Medical Director and/or Supervisor will be contacted for assistance with contacting physician/authorized practitioner.” This policy was not followed. Examples include: 1. Patient #3 was a 77 year old female admitted to the agency on 4/19/23 with a primary diagnosis of acute and chronic respiratory failure with hypoxia. Additional diagnoses of emphysema and type 2 diabetes. She received SN and PT services. Her record for the certification period 4/19/23 to 6/17/23 was reviewed. Patient #3’s “Medical Record Coordination Note” dated 4/19/23 stated, “…WHEN RN ARRIVED PATIENT WAS AT 3 L NC AND AT 76% O2. PATIENT WAS A&O X3. PATIENT IS SHORT OF BREATH AND DESATURATES WITH TALKING AND IS REQUIRING AN INCREASED NEED OF OXYGEN. RN EDUCATED PATIENT TO GO TO EMERGENCY DEPARTMENT DUE TO OXYGEN LEVEL AND SHORTNESS OF BREATH AND PATIENT REFUSED STATING, “THIS IS HER NEW NORMAL”. PATIENT HAD A DOCTOR’S APPOINTMENT WITH PCP AT 345 TODAY. RN LEFT A MESSAGE FOR PCP TO NOTIFY OF PATIENT’S CONDITION. NO FURTHER ORDERS AT THIS TIME.” There was no documentation that Patient #3’s PCP received notification of Patient #3’s emergent condition. There was no follow up with the Medical Director or Supervisor. Patient #3 was reported deceased at home on 4/23/23 to the agency by family. The Area Administrator, RN was interviewed on 2/22/24 beginning at 3:50 PM, and Patient #3’s medical record was reviewed in her presence. The Administrator was asked if Patient #3 was seen by her PCP on 4/19/23. The Administrator confirmed that there was no documented PCP visit note and no return communication documented from the PCP. Additionally, the Administrator stated that there was no documentation that the RN contacted the Medical Director or Supervisor. The Area Administrator confirmed there were no additional SN visits to Patient #3 after 4/19/23. The agency failed to notify Patient #3’s physician about her symptoms. 2. Patient #2 was a 77 year old female admitted to the agency on 8/29/23 with a primary diagnosis of after care from a fall during a seizure. Additional diagnoses of CVA and COPD. She received PT and OT services. Her record for the certification period 8/29/23 to 10/27/23 was reviewed. Patient #2’s medical record included a coordination note dated 9/23/23 at 5:25 PM. The note included: “GRANDAUGHTHER {sic} CALLING THAT PATIENT IS LETHARGIC AND HAS A COUGH. INTERVENTION(S): (LPN NAME) LPN CALLED GRANDDAUGHTER BACK AND ADVISED THAT IF PATIENT IS HAVING A CHANGE OF CONDITION SHE SHOULD CALL EMS TO EVALUATE PATIENT.” A “Client Coordination Note Report” completed by a patient care manager dated 9/25/23 at 5:37 PM, stated, “Follow -up phone call to patient? N/A… Comments: NO RECORDS OF PATIENT GOING TO ER.” The ED, RN was interviewed on 2/21/24 beginning at 2:40 PM and Patient #2’s medical record was reviewed in her presence. She confirmed Patient #2’s physician was not made aware of her change in condition. The agency failed to notify Patient #2’s physician about her symptoms.”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on policy review, medical record review and staff interview, it was determined the agency failed to ensure coordination of patient care among disciplines for 2 of 17 patients (Patient #2, and #17) whose records were reviewed. This had the potential to result in delayed or missing services and unmet patient needs. Findings include: An agency policy titled “on-call process(to include during and after hours care)” dated 7/27/23, included: … 5. Clinicians will provide follow-up appropriate to the call via: - Telephonic intervention with the patient/ caregiver - Perform onsite visit to the patient, if necessary - Obtain physician orders as needed. 6. A home visit from the clinician may be indicated when: - New onset of symptoms are reported - Exacerbation of symptoms are reported - Issue cannot be resolved via telephonic intervention… An agency policy titled, “COORDINATION OF CARE, FROM ADMIT THROUGH DISCHARGE,” revised 9/01/23 stated: “Coordination of care among disciplines:…Appropriate, timely communication with the patient caregivers, and staff involved in the patient’s care regarding patient need, goals and care as well as changes in these.” These policies were not followed examples include: 1. Patient #17 was a 81 year old female admitted to the agency on 1/10/24, for aftercare following an left hip replacement. Additional diagnoses included osteoporosis, COPD and Hypertension. She received SN, PT, and OT services. Her record, including the POC, for the certification period 1/10/24 to 3/09/24, was reviewed. Patient #17’s record included a coordination note, dated 1/15/24, signed by an LPN, which included that Patient #17 called on 1/12/24 at 9:23PM and was complaining of abdominal pain, nausea, vomiting, and constipation. The note included that the LPN stated for Patient #17 to go to the emergency room for evaluation. Under the section “PRN SN visit required,” It was marked “no.” Under the section “Physician Notified” it was marked “no.” Patient #17’s medical record did not include another visit until 1/16/24. Patient #17’s medical record included a discharge summary from the local emergency room on 1/12/24. Patient #17’s medical record included and OT evaluation on 1/16/24. Under the section titled Emergent Care included “does the patient report any falls or emergent care since the last skilled visit: no.” There was no documentation, evaluation, discussion or assessment regarding the symptoms that caused Patient #17 to seek emergency care. Patient #17’s medical record included and PT visit on 1/17/24. Under the section titled Emergent Care included “does the patient report any falls or emergent care since the last skilled visit: no.” There was no documentation, evaluation, discussion, or assessment regarding the symptoms that caused Patient #17 to seek emergency care. Patient #17’s medical record included and SN visit on 1/18/24. Under the section titled Emergent Care included “does the patient report any falls or emergent care since the last skilled visit: no.” There was no documentation, evaluation, discussion, or assessment regarding the symptoms that caused Patient #17 to seek emergency care. The Area Administrator was interviewed 2/22/24 beginning at 1:00 PM, and Patient #17’s medical record was reviewed in her presence. She confirmed there was no additional PRN visit done for Patient #17 and the SN visit made was 6 days after the call. She stated she was unsure why an additional PRN home visit by SN was not done. She stated it was agency expectation that the backup RN would have been notified at the time of the call to evaluate and assess Patient #17. She confirmed there appeared to be no communication documented between the disciplines. Patient #17’s medical record did not included documentation between the LPN who took the after hours call from Patient #17 and any disciplines. Additionally, it was unclear why a home visit by SN was not made for 6 days for further assessment. The agency failed to ensure adequate and complete communication between disciplines regarding Patient #17’s care. 2. Patient #2 was a 77 year old female admitted to the agency on 8/29/23 with a primary diagnosis of after care from a fall from a seizure. Additional diagnoses of CVA and COPD. She received PT and OT services. Her record for the certification period 8/29/23 to 10/27/23 was reviewed. Patient #2’s medical record included A coordination note dated 9/23/23 at 5:25 PM, signed by the LPN. The note included: “GRANDAUGHTHER {sic} CALLING THAT PATIENT IS LETHARGIC AND HAS A COUGH. INTERVENTION(S): (LPN NAME) LPN CALLED GRANDDAUGHTER BACK AND ADVISED THAT IF PATIENT IS HAVING A CHANGE OF CONDITION, SHE SHOULD CALL EMS TO EVALUATE PATIENT.” There was no documentation the LPN contacted the RN on call to evaluate or assess Patient #2. A “Client Coordination Note Report” completed by a patient care manager, an RN, dated 9/25/23 at 5:37 PM, stated, “Follow -up phone call to patient? N/A… Comments: NO RECORDS OF PATIENT GOING TO ER.” The ED was interviewed on 2/21/24 beginning at 2:40 PM and Patient #2’s medical record was reviewed. She confirmed Patient #2’s physician was not made aware of symptoms and emergent condition. Additionally, she confirmed there was no documentation of coordination or communication between the RN and LPN Patient #2’s medical record. The agency failed to ensure adequate and complete communication between RN’s and LPN’s regarding Patient #2’s care.”