Franklin County Medical Center Home Care

“Patient rights CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient’s rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This Condition is not met as evidenced by: Based on review of medical records, agency policy, Idaho state statue review, and staff interview, it was determined the agency failed to ensure patients were free from all forms of neglect. Additionally, the agency failed to ensure patients received all services as outlined in their POCs. This resulted in patients’ rights not being upheld. Findings include: Refer to G436 as it relates to the failure of the agency to ensure patients received all services as outlined in their plan of care. Refer to G488 as it relates to the failure of the agency to ensure patients were free from verbal abuse, neglect, and injuries of unknown source. The cumulative effect of these systemic issues impeded the ability of the agency to protect the rights of patients.”

“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 POCs were accurate, included all pertinent items, and physicians were alerted to changes in patient condition. These failures resulted in unmet patient needs and negatively impacted the continuity, safety, and quality of patient care for 2 or 7 patients (Patient #1 and #2) whose records were reviewed. Findings include: 1. Refer to G574, as it relates to the failure of the agency to ensure POCs included all pertinent information. 2. Refer to G590, as it relates to the failure of the agency to alert physicians to changes in patient’s conditions or needs. The cumulative effect of these practices impeded the agency’s ability to provide quality care.”

“Content of the comprehensive assessment CFR(s): 484.55(c) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information: This Standard is not met as evidenced by: Based on medical record review, and staff interview, it was determined the agency failed to ensure the comprehensive assessment was accurate to reflect the patients status for 1 of 7 patients (Patient #2) whose records were reviewed. This had the potential to interfere with the accuracy of patients’ initial assessments. Findings include: Patient #2 was a 64 year old male admitted to the agency on 9/26/23, with a primary diagnosis of malignant neoplasm of the esophagus. Additional diagnoses included chronic embolism, and type 2 diabetes mellitus. He received SN and PT services. His record, including the POC, for the certification period 9/26/23 to 11/24/23, was reviewed. Patient #2’s medical record included a SOC assessment dated 9/26/23 signed by the RNCM. The SOC assessment included conflicting documentation on the current status of Patient #2. Examples include: 1. Patient #2’s SOC assessment included that he had a feeding tube for nutrition needs. Under the OASIS question K0520 “Nutritional Approaches,” the assessment indicated he had no feeding tube. Additionally, under the section titled “Physicians order” diet requirements it showed that he was on a regular diet. Patient #2’s RNCM was interviewed 11/28/23 beginning at 3:10 PM, and Patient #2’s medical record was reviewed in her presence. She stated Patient #2 did not have a feeding tube. She confirmed the assessment data was conflicting information and not accurate. It was unclear how Patient #2’s nutritional needs were being met. 2. Patient #2’s SOC assessment included the question, “does the patient have IV access?” The answer to the above question was marked “no.” However, in the same section the RNCM marked that the patient had a “port,” with an insertion date of 9/22/23. A port is used as IV access for long term usage. Patient #2’s RNCM was interviewed 11/28/23 beginning at 3:10 PM, and Patient #2’s medical record was reviewed in her presence. She stated Patient #2 did have an IV port. She confirmed the assessment data was conflicting information and not accurate. The agency failed to ensure the comprehensive assessment for Patient #2 was accurate.”

“Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA’s policies and procedures. This Standard is not met as evidenced by: Based on medical record review, policy review, and staff interview, it was determined the agency failed to ensure skilled services were provided in accordance with established agency polices, for 1 of 7 patients (Patient #2). This had the potential to result in unmet patient needs. Findings include: Patient #2 was a 64 year old male admitted to the agency on 9/26/23, with a primary diagnosis of malignant neoplasm of the esophagus. Additional diagnoses included chronic embolism, and type 2 diabetes mellitus. He received SN and PT services. His record, including the POC, for the certification period 9/26/23 to 11/24/23, was reviewed. An agency policy titled, “Total Parenteral Nutrition Infusion,” undated, included: “When TPN is indicated the following procedure will be followed.” The patient receiving TPN with have a “dietary consult.” Additionally, the policy included “TPN tubing must have a 1.2um filter for solutions containing albumin or lipids.” This policy was not followed. Examples include: 1. Patient #2 did not have a dietary consult. Patient #2’s medical record included a form titled, “Nutritional assessment of Tube Fed Resident,” dated 9/26/23, documented by the discharging hospital dietitian. The note included “If TPN not started at home recommend Clinimix 4.25% 75 cc/hr [times] 24 hours [clinimix IV nutritional medication].” Patient #2’s medical record included a Nutrition referral from the hospital when he was discharged from the hospital to home health on 9/25/23. There was no documentation a dietitian was involved with Patient #2’s home care. Additionally, there were no documented nutritional interventions on Patient #2’s POC. The home health agency’s Registered Dietitian was interviewed on 11/29/23 beginning at 11:05 AM and Patient #2’s medical record was reviewed in her presence. The Dietitian confirmed she did not perform a nutritional consult as ordered for home health. Additionally, the Dietitian confirmed that TPN should have started on 9/26/23. The Dietitian confirmed she was unaware that TPN did not start until 8 days later. 2. Patient #2’s nurse did not use a filter for TPN with lipids. Patient #2’s order for TPN included “lipids 35 gm/day, 175ml/day of 20 percent smoflipids” Patient #2’s medical record included a SN nursing visit on 10/07/23, signed by a APRN. The note included that Patient #2 received TPN. The narrative note included: “Noted new administration tubing has no filter and is easier to no [sic] allow air into the line.” There was no documentation on why tubing without a filter was used. Patient #2’s RNCM was interviewed on 11/28/23 beginning at 3:10 PM and Patient #2’s medical record was reviewed in her presence. She confirmed the TPN should have been administered with filter in the tubing per policy. The Agency failed to follow policy on the administration of TPN for Patient #2.”

“Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This Element is not met as evidenced by: Based on medical record review and staff interview, it was determined the agency failed to ensure that patients received all services outlined in the plan of care for 1 of 7 patients (Patient #2) whose records were reviewed. This had the potential for unmet patient needs. Findings include: Patient #2 was a 64 year old male admitted to the agency on 9/26/23, with a primary diagnosis of malignant neoplasm of the esophagus. Additional diagnoses included chronic embolism, and type 2 diabetes mellitus. He received SN and PT services. His record, including the POC, for the certification period 9/26/23 to 11/24/23, was reviewed. Patient #2’s medical record included a Physician order dated 10/24/23. The order included, “Increase Warfarin to 6mg daily and recheck PT/INR on Friday 10/27/23.” Patient #2’s medical record did not have a documented PT/INR documented until 10/31/23. Patient #2’s RNCM was interviewed on 11/28/23 beginning at 3:40 PM. She confirmed there was no documentation the PT/INR was completed until 10/31/23. Patient #2 did not receive services as outlined in his POC.”

“Immediate reporting of abuse by all staff CFR(s): 484.50(e)(2) Any HHA staff (whether employed directly or under arrangements) in the normal course of providing services to patients, who identifies, notices, or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual, and/or physical abuse, including injuries of unknown source, or misappropriation of patient property, must report these findings immediately to the HHA and other appropriate authorities in accordance with state law. This Element is not met as evidenced by: Based on medical record review, Idaho state statute review, and staff interview, it was determined the agency failed to ensure staff reported and documented potential patient neglect to appropriate authorities in accordance with state law for 1 of 1 patient (Patient #1) who had documented potential neglect and whose record was reviewed. This resulted in a missed opportunity to uphold patient rights. Findings include: “IDAHO STATUTES TITLE 39 HEALTH AND SAFETY CHAPTER 53 ADULT ABUSE, NEGLECT AND EXPLOITATION ACT,” updated 7/01/18, states “39-5303. Duty to report cases of abuse, neglect or exploitation of vulnerable adults. (1) Any physician, nurse, employee of a public or private health facility, or a state licensed or certified residential facility serving vulnerable adults, medical examiner, dentist, osteopath, optometrist, chiropractor, podiatrist, social worker, police officer, pharmacist, physical therapist, or home care worker who has reasonable cause to believe that a vulnerable adult is being or has been abused, neglected or exploited shall immediately report such information to the commission. Provided however, that nursing facilities defined in section 39-1301(b), Idaho Code, and employees of such facilities shall make reports required under this chapter to the department. When there is reasonable cause to believe that abuse or sexual assault has resulted in death or serious physical injury jeopardizing the life, health or safety of a vulnerable adult, any person required to report under this section shall also report such information within four (4) hours to the appropriate law enforcement agency.” This statute was not followed. An agency policy “Abuse, Neglect and Exploitation undated, stated, “Any Employee of [agency] who has reasonable cause to believe that a vulnerable child or adult is being or has been abuse, neglected or exploited shall immediately report such information to their Department Manager.” Additionally, the policy stated, “Criteria to identify possible victims…Inadequate supervision with resulting effect on ADL provision, e.g., bathing toileting, food, etc.” This policy was not followed. An example includes Patient #1 was a 77 year old female admitted to the agency on 2/18/23, with a primary diagnosis of a left foot fracture. Additional diagnoses included chronic respiratory failure, and CHF. She received SN, PT, OT, and aide services. Her record, including the POC, for the certification period of 2/18/23 to 4/18/23, was reviewed. Patient #1’s medical record included a OASIS SOC assessment,” dated 2/18/23, signed by the RNCM, which included: “The Patient Lives at her house and is usually alone. She currently has her son living with her who just got out of jail… The sun[sic] said that he is available to take care of her during the daytime and night…The son however, does not appear to be taking care of his mother [Patient #1]. The patient was soaked with urine on the day of the admit and stated that she was hungry and had not eaten all day…. SM [sic SN] went to look in her bathroom and found piles of feces all throughout her bedroom and bathroom. They appear to be both human feces and dog feces. … The daughter in law stated that she is only able to assist the patient for small amounts of time due to her busy work schedule and raising four children on her own.” Additionally, the SOC assessment included: “It is my assessment that the patient is not safe at home. She cannot take care of herself, and she does not have a capable sitter to watch her during the day and night. She is neglected by her family and seems to be unable to see the situation she is in.” Patient #1 started Physical Therapy the same day on 2/18/23, Occupational Therapy on 2/21/23 and Home Health Aide services after this assessment. There was no documentation in Patient #1’s medical record that APS was called and notified of the above issues of potential neglect. Additionally, there was no documentation in Patient #1’s medical record the department manager was made aware of the above issues. The Home Health Manager and Compliance Director were interviewed together on 11/29/23, beginning at 1:00 PM, and Patient #1’s medical record was reviewed in their presence. The Home Health Manager stated she was aware of the above issues and have contacted APS multiple times prior to the SOC assessment. She stated Patient#1 was on PCS service that the Home Health agency also operated. She confirmed there was no documentation in Patient #1’s medical record APS was contacted. The Home Health Manager confirmed the RNCM should have documented the conversation with her and should have documented APS was called and aware of the ongoing situation. There was no documentation Patient #1’s potential neglect was reported to appropriate authorities in accordance with Idaho state law.”

“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 7 patients (Patient#1 and #2) whose records were reviewed. This failure resulted in incomplete POCs and had the potential to result in unmet patient needs. Findings include: 2. Patient #2 was a 64 year old male admitted to the agency on 9/26/23, with a primary diagnosis of malignant neoplasm of the esophagus. Additional diagnoses included chronic embolism, and type 2 diabetes mellitus. He received SN and PT services. His record, including the POC, for the certification periods 9/26/23 to 11/24/23, was reviewed. Patient #2’s POC for the cert period 9/26/23 to 11/24/23 did not include all medications, and necessary interventions for identified problems. Examples include: a. Patient #2’s Medical record included a SOC assessment dated 9/26/23 signed by the RNCM. The assessment included that Patient #2 had a diagnosis of type 2 diabetes. The assessment listed Patient #2’s type 2 diabetes as a severity code of 4, which indicated that symptoms poorly controlled; history of re-hospitalizations. Patient #2’s POC did not include necessary interventions related to his Type 2 diabetes. Patient #2’s RNCM was interviewed on 11/29/23 beginning at 1:15 and Patient #2’s medical record was reviewed in her presence. The RNCM confirmed that the POC did not have any interventions to manage or monitor Patient #2’s diabetes. b. Patient #2’s medical record included a SOC assessment dated 9/26/23 signed by the RNCM. The assessment included that Patient #2 had a diagnosis of “chronic embolism and thrombus.” The assessment listed Patient #2’s chronic embolism and thrombus as a severity code of 4, which indicated that symptoms poorly controlled; history of re-hospitalizations. Patient #2’s POC did not include necessary interventions or goals related to his need for the use of anticoagulation medications. Patient #2’s RNCM was interviewed on 11/29/23 beginning at 1:15 PM and Patient #2’s medical record was reviewed in her presence. The RNCM confirmed that Patient #2’s POC did not have any interventions to manage or monitor Patient #2’s chronic embolism or coagulation status. c. Patient #2 Medical record included a SOC assessment dated 9/26/23 signed by the RNCM. The assessment included that Patient #2 was at “moderate nutritional risk.” Additionally, it was documented that Patient #2 “without reason, has lost more than 10 lbs. [pounds], in the last 3 months, has an illness or condition that made pt change the type and/or amount of food eaten, and eats fewer than 2 meals a day.” Patient #2’s medical record included a form titled, “Nutritional assessment of Tube Fed Resident,” dated 9/26/23, documented by the discharging hospital dietician. The note included “It TPN not started at home recommend Clinimix 4.25% 75 cc/hr [times] 24 hours [clinimix IV nutritional medication].” Patient #2’s medical record included a Nutrition referral from the hospital when he was discharged from the hospital to home health on 9/25/23. There was no documentation a dietician was involved with Patient #2’s home care. Additionally, there were no documented nutritional interventions on Patient #2’s POC. The home health agency’s Registered Dietician was interviewed on 11/29/23 beginning at 11:05 AM and Patient #2’s medical record was reviewed in her presence. The Dietician confirmed she did not perform a nutritional consult as ordered for home health. Additionally, the Dietician confirmed that TPN should have started on 9/26/23. The Dietician confirmed she was unaware that TPN did not start until 8 days later. Patient #2’s RNCM was interviewed on 11/28/23 beginning at 3:10 PM and Patient #2’s medical record was reviewed in her presence. She confirmed no dietician consult was done and no nutritional interventions were documented for Patient #2. Patient #2’s POC did not include necessary interventions, goals, and medications related to his nutritional risk. d. Patient #2’s medical record included. Patient #2’s medical record included a form titled, “Nutritional assessment of Tube Fed Resident,” dated 9/26/23, documented by the discharging hospital dietician. The note included “It TPN not started at home recommend Clinimix 4.25% 75 cc/hr [times] 24 hours [clinimix IV nutritional medication].” Patient 32’s medical record included an order for his physician. the order included to start TPN electrolytes. Patient #2’s order for TPN included “lipids 35 gm/day, 175ml/day of 20 percent smoflipids” Patient #2’s medical record included a SN nursing visit on 10/07/23, signed by an APRN. The note included that Patient #2 received TPN. The narrative note it included: “Noted new administration tubing has no filter and is easier to no [sic] allow air into the line.” There was no documentation on why tubing without a filter was used. Patient #2’s medical record included a coordination note on 10/12/23 signed by an ARPN. The note included that Patient #2 was receiving TPN. Patient #2’s Medication record did not include an order for TPN in current or discontinued medications. Patient #2’s RNCM was interviewed on 11/29/23 beginning at 1:15 PM. The RNCM confirmed TPN and heparin were not documented on Patient #2’s MAR (Medication administration record). Patient #1 was a 77 year old female admitted to the agency on 2/18/23, with a primary diagnosis of a left foot fracture. Additional diagnoses included chronic respiratory failure, and CHF. Patient #1 was on home health for SN medication management and OT, PT rehab. She received SN, PT, OT, and aide services. Her record, including the POC, for the certification periods 2/18/23 to 4/18/23, was reviewed. Patient #1’s medical record included a OASIS SOC assessment,” dated 2/18/23, signed by the RNCM, which included the following identified needs: - OASIS question A1250 “Transportation: Has lack of transportation kept you from medical appointments, meetings, work of from getting things needed for daily living?” The Question was answered yes. - Under the section titles Psychosocial the assessment included. “The patient lives in her home with her son who does not take care of her. She was left alone for over 24 hours in a chair without using the bathroom. Patient was soaked through her clothes and onto the chair. Patient does not seem to mind and just hold[sic] her little dog. The patience [sic] has human feces and dog feces all over in the bedroom and bathroom and cannot get out of the chair physically. The patient needs max assistance and is not getting it.” - Under the section titled “Patient Mood interview” which was a depression screening to see if the patient was depressed. The screening included 2 of the 9 questions answered. The 2 questions that were answered were. “Little interest or pleasure in doing things.” Patient #1 answered “yes” “Feeling down, depressed, or hopeless.” Patient #1 answered “yes.” It was unclear why the other 7 questions of the assessment were not answered. - OASIS question M1745 “Frequency of disruptive Behavior symptoms (reported of observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.” The question was answered that Patient #1 experienced the above “at least daily.” The SOC assessment indicated that the patient was at risk or experiencing psychosocial issues and required a MSW assessment. There was no documented MSW referral or psychosocial interventions or Patient #1’s POC. The Compliance Director and Home Health Manager were interviewed together on 11/29/23 beginning at 12:30 PM, and Patient #1’s medical record was reviewed in her presence and the above identified issues were reviewed with them. When asked if a Social Work referral was made. The Home Health Manager stated she didn’t think so. When asked if a Social Worker should have been involved with Patient #1 she stated “yes.” When asked if there were any psychosocial interventions or goals on Patient #1’s POC. The Compliance Director and Home Health Manager were unable to identify interventions or goals. Patient #1’s POC did not include necessary interventions and goal to address her identified psychosocial issues”

“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 review of medical records, and staff interview, it was determined the agency failed to ensure physicians were promptly alerted to changes in patients’ conditions or needs that suggested a need to alter the POC for 1 of 7 patients (Patient #2) whose medical records was reviewed. This had the potential to result in unaddressed patient conditions or needs. Findings include: Patient #2 was a 64 year old male admitted to the agency on 9/26/23, with a primary diagnosis of malignant neoplasm of the esophagus. Additional diagnoses included chronic embolism, and type 2 diabetes mellitus. He received SN and PT services. His record, including the POC, for the certification period 9/26/23 to 11/24/23, was reviewed. Patient #2’s medical record, including lab values were reviewed. Patient #2’s magnesium level from 9/27/23 and 9/28/23 were 1.3 and 1.4. The reference ranges documented from the agency are 1.6-2.3 mg/dL. Patient #2’s magnesium levels were out of the reference ranges. There was no documentation Patient #2’s low magnesium level was reported to Patient #2’s physician. The Compliance Director, RN was interviewed on 11/28/23 beginning at 3:10 PM. She confirmed the RNCM should have documented that Patient #2’s PCP was made aware of low magnesium level. Patient #2’s RNCM was interviewed on 11/29/23 beginning at 1:15 PM. She confirmed there was no documentation that Patient #2’s PCP was made aware of low magnesium levels for 9/27/23 and 9/28/23. Patient #2’s low magnesium level was not documented as discussed with the physician to determine if any changes to his POC were needed.”