Bluebird Home Health

“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 medical record review and staff interview, it was determined the agency failed to ensure the POCs included all interventions, measurable outcomes, medications, and goals for 2 of 13 patients (Patient #6 and #7) whose records were reviewed. This failure resulted in incomplete POCs and had the potential to result in unmet patient needs. Findings include: Patient#6’s POC did not include all necessary goals, interventions and services. Examples include: Patient #6 was a 64-year-old male admitted to the agency 9/27/23 with a primary diagnosis of sepsis. Additional diagnosis included bipolar disorder, schizoaffective disorder, dysphagia and pneumonitis. He received PT, OT and ST services while SN assessment concluded SN services were not needed. His record, including the POC, for the certification period 9/27/23 to 11/25/23 was reviewed. 1.Patient # 6‘s record included an PT OASIS admission note, dated 9/27/23, signed by a PT. The visit’s note stated Patient#6 was “not always physically able to shop, cook and/or feed self. … Patient is at a high nutritional risk.” Patient #6’s record included a RN add on evaluation note, dated 10/2/23, signed by an RN. The visit’s note stated Patient #6 “doesn’t always have the financial means to obtain food. … Patient is at a moderate nutritional risk.” Patient #6 ‘s record included a POC, dated 10/11/23, signed the physician. The POC did not included goals or interventions for his nutritional risk including food insecurity. The DSC was interviewed 12/14/23 at 11:15 AM. She confirmed that the POC for Patient #6 did not include an intervention or goal related to nutritional risk. 2. Patient #6’s record included a coordination of care note, dated 10/23/23. The coordination of care note stated “[Patient #6]’s wife called to let OT know he was in a n ambulance and going to ER, she was worried he was having a stroke.” Patient #6’s record included a physician com [communication] note, dated 10/26/23. The physician com note stated “she [wife] called 911 due to [patient #6] having altered mental status, ER findings were that he was feeling the aftereffects excess drinking the night before. He was treated and released.” Patient #6’s record included the next visit, an OT discharge note, dated 10/26/23, signed by OT. The visit’s note stated “[Patient #6] was in the ER Monday, due to feeling lightheaded … he was found to be dehydrated from being intoxicated the night before. [Patient #6] denies alcohol use.” The DSC was interviewed 12/14/23 at 11:15 AM. DSC further confirmed that no intervention for alcohol use was made, no change to POC, no referral for agency social work was made. She further stated that Patient #6 was a Medicaid patient who should have had a case work and social worker. DSC confirmed that Patient #6’s Medicaid case worker/social work was not contacted. The agency failed to include all pertinent goals, services and interventions on Patient #6’s POC. 2. Patient #7 was a 81-year-old male admitted to the agency 8/14/23 with a primary diagnosis of Protein Calorie Malnutrition. Additional diagnosis included weakness and malaise. He received PT, OT services. His record, including the POC, for the certification period 8/14/23 – 10/12/23 was reviewed. Patient #7’s POC for the certification period 8/14/23 – 10/12/23 did not include all medications, and necessary interventions for identified problems. Examples include: a. Patient #7’s Medical record included a SOC assessment dated 8/14/23 signed by the PT. The assessment included that Patient #7 had a diagnosis of unspecified protein-calorie malnutrition. The SOC assessment listed Patient #7’s unspecified protein-calorie malnutrition as a severity code of 3, which indicated, “symptoms were poorly controlled, patient needs frequent adjustments in treatment and dose monitoring.” Additionally, the SOC assessment included “Patient is at a high nutritional risk.” Patient #7’s POC did not include necessary interventions related to his unspecified protein-calorie malnutrition. The agency DCS was interviewed on 12/13/23 beginning at 3:15 and Patient #7’s medical record was reviewed in her presence. The DCS confirmed that the POC did not have any interventions to manage or monitor Patient #7’s protein-calorie malnutrition. b. Patient #7’s Medical record included a SOC assessment dated 8/14/23 signed by the PT. The assessment included that Patient #7 had a diagnosis of “Full incontinence of feces.” The assessment listed Patient #7’s Full incontinence of feces as a severity code of 2, which indicated, “symptoms controlled with difficulty, affection daily functioning; patient needs ongoing monitoring.” Patient #7’s POC did not include necessary interventions or goals related to his fecal incontinence. The Agency DCS was interviewed on 11/29/23 beginning at 1:15 PM and Patient #7’s medical record was reviewed in her presence. The DCS confirmed that Patient #7’s POC did not have any interventions to manage or monitor Patient #7’s fecal incontinence c. Patient #7’s medical record included a form hospital discharge referral order. The order included the following medications: - Sertaline 50 mg “take 2 tabs (100mg total) by mouth daily.” - ferrous sulfate 325mg “take 325mg by mouth every other day.” - ondansetron 4mg “dissolve 1-2 tablets by moth every 8 hours as needed for nausea of vomiting. Take 1 tablet for mild or 2 tablets for moderate to severe.” Additionally, the discharge referral order included “[Patient #7] reports that his appetite has been non-existent. He remains on tube feedings and they request that an updated order be sent to [DME provider].” Patient #7’s POC and Medication Administration Record were reviewed. They did not include the ondansetron medication, or tube feeding prescription. Additionally, the Sertaline was listed at take 1 tablet daily, and ferrous sulfate was listed to take daily not as “every other day,” as prescribed. The Agency DCS was interviewed on 11/29/23 beginning at 1:15 PM and Patient #7’s medical record was reviewed in her presence. The DCS confirmed Patient #7’s POC and Medication Administration Record were not accurate. Patient #7’s POC did not include all medications, and necessary interventions for identified problems.”