Multicare Home Health Services, Inc.

“Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient’s condition warrants due to a major decline or improvement in the patient’s health status, but not less frequently than- This Standard is not met as evidenced by: Based on clinical record review, policy review, and staff interview, it was determined the agency failed to ensure patients received an comprehensive assessment after a fall with injury for 1 of 17 patients ( Patient #15) whose records were reviewed. This had the potential to have unmet needs go unaddressed for patients receiving services. A facility policy titled “Indications for other follow-up assessment” undated, included: “A comprehensive assessment must be collected when there is a significant change in the condition of the patient including either a major decline or improvement that is not anticipated and the patient is not hospitalized. Significant changes in condition are defined as unexpected events, episodes or exacerbations that impact care… Examples included but not limited to be:… Fall with injury…” This policy was not followed, an example includes. Patient #15 was a 88 year old female admitted to the agency on 4/09/24. Her primary diagnosis was Alzheimer’s disease. Additional diagnoses included venous insufficiency, pressure ulcer, and cellulitis. She received SN, and PT services. Her record for the certification period 4/09/24 – 6/07/24, including her POC, was reviewed. Patient #15’s medical record included a PTA visit note dated 4/30/24, signed by the PTA. The note included: “Patient was transferred to St Als ED at approximately 7pm 4/29/24 after a fall in the hallway while attempting to enter her room after dinner. This resulted in a closed head injury. “ Patient #15’s medical record included a SN visit note dated 5/02/24 signed by the LPN. The note included: “Fall reported from two days ago. Pt was found outside her door in hallway on her back. Pt did hit her head and was talked to the ER. Pt was released. Pt C/o of headache in back of head today… Pt is noticeably more confused than usual… PCP office notified.” There was no documentation the RN case manager was notified of the fall and noticeably increase in confusion. Patient #15’s medical record included a RN visit note dated 5/09/24 signed by the RNCM. There was no documentation regarding Patient #15’s fall on 4/29/24. There was no follow-up assessment to the fall. Additionally, there was no follow up assessment to Patient #15’s increased confusion. It was unclear if the RNCM was aware that Patient #15 had a fall with head injury, and increased confusion on 4/29/24. The Administrator was interviewed on 9/6/24 beginning at 9:00 AM and Patient #15’s medical record was reviewed in his presence. He confirmed the RN should have followed up on Patient #15’s fall and assessed the patient prior to 9 days post fall and confusion. The Agency failed to ensure Patient #15 received a comprehensive assessment after a fall with injury.”

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. 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 consents were properly completed in advance of treatment for 1 of 17 patients (Patient #7) whose records were reviewed. This caused possible misunderstandings of the care to be furnished for Patient #7 and had the ability to affect all patients receiving services from the agency. Findings include: Patient #7 was an 84 year old female admitted to the agency on 8/21/24. She had a primary diagnosis of sarcopenia, with additional diagnoses including dementia and atrial fibrillation. She received PT services. Her record for the certification period 8/21/24 to 10/19/24 was reviewed. Patient #7’c SOC note, dated 8/21/24 was reviewed. Under the section titled, “mental status,” it stated Patient #7 was disoriented to time and situation. It also stated she was forgetful and had short term memory loss. Patient #7’s SOC note also stated, “POA [name] is reporting she is unable to attend in person to sign her mother’s admission paperwork. She also stated she did not want admission paperwork emailed to her or mailed to her to sign. POA reports her mom has worked with multi-care multiple times before and she would like for her mom to sign all of her own admissions paperwork.” Patient #7’s consent to treat was reviewed. Patient #7 signed her own consent despite having dementia and short-term memory loss and being disoriented to situation. It was unclear if Patient #7 understood what she consented to. The administrator was interviewed on 9/05/24 beginning at 1:46 PM and Patient #7’s medical record was reviewed in his presence. When asked if it was appropriate for Patient #7 to sign her own consent with her documented dementia and disorientation, he stated a verbal consent from the POA would have been more appropriate. The agency failed to ensure consents were properly completed for Patient #7.”

“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 clinical record reviews, current guideline review, and staff interviews, it was determined the agency failed to ensure the patients’ individualized plan of care/treatment included all the required interventions and medications to address the identified needs for 2 of 17 patients (Patients #8 and #10) whose records were reviewed. This caused potential for unmet patient needs and had the potential to affect all patients receiving services at the agency. Findings include: 2. Patient #10 was a 52 year old female admitted to the agency on 6/07/24 with a primary diagnosis of hypertensive heart and chronic kidney disease stage 5. Additional diagnoses included heart failure and type 2 diabetes. She also received hemodialysis treatments three times weekly. She received SN, PT, and OT services. Her record for the certification period 6/07/24 to her discharge on 7/05/24 was reviewed. According to the American Kidney Foundation, (https://www.kidney.org/news-stories/dos-and-don-ts-fluid-management-kidney-disease#:~:text=Most%20hemodialysis%20patients%20try%20to,need%20more%20fluid%20or%20salt. Accessed 9/10/24) “Most hemodialysis patients try to limit weight gain per treatment to no more than 2.2 pounds or 1 kilogram per day. Check your blood pressure along with daily weights. If it is low, contact your healthcare team as you may need more fluid or salt.” This guideline was not followed. According to the American Heart Association, (https://www.heart.org/en/health-topics/heart-failure/warning-signs-of-heart-failure/managing-heart-failure-symptoms accessed 9/10/24), “Daily weight. Many people are first alerted to worsening heart failure when they notice a weight gain of more than two or three pounds in a 24-hour period or more than five pounds in a week. This weight gain may be due to retaining fluids since the heart is not functioning properly. It’s a good idea to track your weight and check in with your health care professional if you notice sudden changes.” This guideline was not followed. Patient #10’s SOC note dated 6/07/24 was reviewed. The initial nursing assessment note stated, “she is weighed before and after each dialysis session every Tuesday, Thursday, and Saturday so no need to be weighed at home.” Patient #10’s record included weights on the SOC on 6/07/24 and again on 6/14/24. Her weights were 151 lbs and 143.7 lbs. These were the only weights recorded for Patient #10. Patient number 10s POC dated 6/07/24 was reviewed. The interventions did not include to weigh patient #10 to measure if her heart failure or kidney failure were worsening. The Administrator was interviewed on 9/05/24 beginning at 1:46 PM and Patient #10’s record was reviewed in his presence. When asked if there should have been weights included on the POC for patient #10 he stated he didn’t feel she needed to be weighed. After reviewing her diagnoses, he agreed daily weights should have been included on Patient #10’s POC. 1. Patient #8 was a 75 year old female admitted to the agency on 2/17/23. Her primary diagnosis was Amyotrophic lateral sclerosis. Additional diagnoses included breast cancer, hypertension, dysphagia, and a gastrostomy tube. She received SN, and PT services. Her record for the cert period 2/17/23 – 4/17/23 including her POC was reviewed. Patient #8’s POC did not include all necessary interventions and medications. Examples included: a. Patient #8’s medical record included a SN visit note dated 2/24/23 signed by the LPN. The note included Pt is getting some nausea from formula feedings. Pt taking Tums which has been effective. Pt also c/o pain at night only when sleeping on her right hip which is preventing her from getting a full night’s sleep. Pt will try taking Tylenol and Ibuprofen before going to bed.” Patient #8’s POC, historical medication list and current medication list. They did not include the Tums, Tylenol, and Ibuprofen medications. Additionally Patient #8’s POC and Medication list did not include the tube feed information, i.e. amount and frequency, of tube feedings for Patient #8. The agency clinical manager was interviewed on 9/6/24 beginning at 9:00 AM and patient #8’s medical record was reviewed in his presence. He confirmed the missing medications and information. Additionally, he stated the above medications should be on Patient #8’s medication list. The agency failed to ensure Patient #8’s POC included all medications. b. Patient SOC assessment dated 2/17/23 signed by the RNCM was reviewed. It included that Patient #8 “has had a 60 lb weight loss over the past 9 months and had an emergency g tube placed in early February.” The note also included that Patient #8 had a current weight of 160 lbs. Patient #8’s medical record included and SN visit on 2/24/23 signed by the LPN. The note included that Patient #8’s weight at the time of the visit was 154 lbs. Showing a 6 lb weight loss in 7 days. Patient #8’s POC was reviewed it did not include monitoring of weights based on her historical weight loss and gastrostomy tube, what was considered excessive weight loss, and when to notify md of weight loss. The agency clinical manager was interviewed on 9/6/24 beginning at 9:00 AM and Patient #8’s medical record was reviewed in his presence. He confirmed tracking of weight and parameters should have been listed on the POC for Patient #8. The agency failed to ensure Patient #8’s POC included interventions and parameters for the monitoring of her weight.”