Horizon Home Health West

“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, policy review, and staff interview, it was determined the agency failed to ensure patients received services outlined in the plan of care for 2 of 12 patients (Patients #8 and #10) whose records were reviewed. This caused potential for patient needs not being met. Findings include: An agency policy titled, “Care Planning Process,” revised November 2020 stated, “Based on the assessment and findings, the approved medical provider-ordered plan of care will include … specific services and treatments to be provided.” The policy also stated, “Documentation of changes in the plan of care will include … progress towards measurable outcomes and goals.” This policy was not followed. Examples include: 1. Patient #8 was an 80 year old male admitted to the agency 4/15/24 with a primary diagnosis of hypertensive heart and chronic kidney disease with heart failure. Additional diagnoses included type 2 diabetes and respiratory failure. He received PT and OT services. His record for the certification period 4/15/24 to 6/13/24 was reviewed. Patient #8’s SOC visit note was reviewed. It stated, “PATIENT IS SEATED AT DINING TABLE, FINISHING LUNCH, INLUDING POTATO CHIPS. HE CHOKED ON A SIP OF WATER, TURNING A DEEP RED, WHEN HE WAS ABLE TO START TO BREATH AGAIN. PER PATIENT AND AMY, PATIENT HAS HAD THESE EPISODES BEFORE BUT HAS HAD MORE LATELY,” and, “PLAN TO OBTAIN VERBAL AUTHORIZATION FOR: ADD-ON SLP EVAL [evaluation].” Patient #8’s POC, dated 4/15/24, and verbally authorized by the physician on the same day, included a speech therapy assessment. It stated, “SPEECH THERAPY EVALUATION. SPEECH THERAPIST TO ASSESS PATIENT AND INFORM PHYSICIAN OF FINDINGS TO ENABLE PHYSICIAN TO ESTABLISH AND INITIATE A PLAN OF CARE.” Patient #8’s record included a hospital hold order dated 4/23/24 which stated, “RESUME HOME HEALTH SERVICES FOR PHYSICAL THERAPY, SPEECH THERAPY UPON DISCHARGE FROM HOSPITAL/SNF AS APPROPRIATE.” Patient #8’s visit notes were reviewed. There was no speech therapy assessment documented during the certification period. The DCS was interviewed on 10/17/24 beginning at 9:30 AM and Patient #8’s medical record was reviewed in her presence. She stated Patient #8 was admitted to the hospital a few days after the SOC. She stated speech therapy was not added on the ROC order when Patient #8 was discharged from the hospital. She was unable to provide documentation why speech therapy was not ordered after Patient #8 was discharged from the hospital. She confirmed Patient #8 would have benefitted from a speech therapy assessment. 2. 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. An example includes: Patient #10 was a 90 year old female admitted to the agency on 7/09/24 with a primary diagnosis of hypertensive heart disease with heart failure. Additional diagnoses included atrial fibrillation and respiratory failure. She received PT and OT services. Her record for the certification period 7/09/24 to 9/06/24 was reviewed. Patient #10’s POC, dated 7/09/24 included, “PATIENT/CAREGIVER WILL UNDERSTAND AND DEMONSTRATE COMPLIANCE WITH MANAGEMENT OF CHF AS EVIDENCED BY … STABILIZED WEIGHT.” Patient #10’s medical record was reviewed. It included one weight documented on the SOC on 7/09/24. There were no other weights documented for the certification period. It was unclear how the agency tracked Patient #10’s weight if it was not assessed. The DCS was interviewed on 10/17/24 beginning at 9:30 AM and Patient #10’s medical record was reviewed in her presence. She confirmed there were no weights documented for Patient #10 after 7/09/24. She confirmed Patient #10’s weight should have been assessed on a regular basis. The agency failed to ensure patients received services as outlined in the POC.”

“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 policy review, medical record review, and staff interview, it was determined the POC did not include all medications for 3 of 12 patients (Patients #1, #11, and #12) whose records were reviewed. Failure to include all medications created the potential for duplicate drug therapy or medication interactions. Findings include: An agency policy titled, “Medication Profile,” revised November 2020 stated, “Patient receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications, new, and/or discontinued medications.” This policy was not followed. Examples include: 1. Patient #1 was a 71 year old female admitted to the agency on 5/10/24 with a primary diagnosis of hypothyroidism. Additional diagnoses included anxiety and dementia. She received PT services. Her record for the certification period 9/07/24 to 11/05/24 was reviewed. A visit to Patient #1’s ALF was conducted on 10/15/24 beginning at 10:05 AM. During the visit, a medication list was obtained from the facility. Patient #1’s medication list from the ALF was compared with the medication list from the agency. The following discrepancies were noted: - Acetaminophen 2 325 mg tablets: The ALF medication list stated to take every 4 hours. The agency medication list stated to take every 6 hours - Acetaminophen 650 mg extended release tablet: This medication was on the ALF medication list but not the agency medication list - Loperamide 2 2 mg tablet: This medication was on the ALF medication list but not the agency medication list - Mirtazapine 15 mg tablet: This medication was on the ALF medication list but not the agency medication list The DCS was interviewed on 10/17/24 beginning at 9:30 AM and Patient #1’s medications were reviewed in her presence. She confirmed the ALF medications did not match the agency medications. 2. Patient #11 was an 81 year old male admitted to the agency on 7/15/24 with a primary diagnosis of osteoarthritis. Additional diagnoses included dementia and Alzheimer’s disease. His visit notes, infection report, and medication list were reviewed. Patient #11’s medical record included a PTA visit note dated 8/01/24. It stated, “ADD; DOXYCYLINE FOR UTI.” Patient #11’s medical record included an infection report dated 8/01/24 which stated he had a suspected urinary infection and had “CLOUDY FOUL URINE.” Patient #11’s medications were reviewed. There was no doxycycline added to Patient #11’s medication list. The DCS was interviewed on 10/17/24 beginning at 9:30 AM and Patient #11’s medications were reviewed in her presence. She confirmed doxycycline was not added to Patient #11’s medication list. 3. Patient #12 was a 92 year old female admitted to the agency 7/23/24 with a primary diagnosis of subarachnoid hemorrhage. Additional diagnoses included subdural hematoma and heart disease. Her visit notes, infection report, and medication list were reviewed. Patient #12’s medical record included a PTA visit note dated 9/05/24 which stated, “PATIENT WENT TO URGENT CARE ON SUNDAY AND TO HER PCP ON TUEDAY [sic] DUE TO THROAT PAIN. PATIENT HAS A THROAT INFECTION AND WAS PRESCRIBED ANTIBIOTICS FOR THE NEXT 14 DAYS.” Patient #12’s medical record included an infection report dated 9/05/24 which stated she had a throat infection and was prescribed fluconazole for the infection. Patient #12’s medications were reviewed. There was no fluconazole added to Patient #12’s medication list. The DCS was interviewed on 10/17/24 beginning at 9:30 AM and Patient #12’s medications were reviewed in her presence. She confirmed fluconazole was not added to Patient #12’s medication list. The agency failed to ensure the POC included all medications.”