L & C Home Health Agency Inc.

“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 document review, policy review and interview, the Home Health Agency (HHA) failed to ensure the physician was promptly alerted to changes in the patient’s condition or need that suggested that outcomes were not being achieved and/or that the plan of care should be altered for 1 (Patient 1) of 7 patients reviewed. Findings Include: A review of agency policy titled “Rights, Responsibilities and Ethics, Coordination of Patient Care, Number 3.009.1”, undated, showed All service providers involved in the care of a patient would be engaged in an effective interchange, reporting and coordination of care regarding the patient and that all such coordination of care would be documented in the patient record. The policy required communication with all physicians involved in the plan of care to assure the coordination of all services and interventions provided to the patient; staff shall communicate patient’s condition, care, treatment, medications, services and any recent or anticipated changes to all relevant staff member to ensure quality care in a timely manner. A review of Patient 1’s “Home Health Certification and Plan of Care”, for the certification period of 02/08/24 to 04/07/24, showed the patient was admitted with a primary diagnosis of hypertensive heart and chronic kidney disease with heart failure (chronic elevated blood pressure due to failure of heart and kidneys) and other conditions such as Polyneuropathy (damage to peripheral nerves on both sides of the body causing weakness, numbness and pain) and chronic pain. She received home health agency nursing visits 1 time per month, physical therapy 2 times per week and home health aide services 2 times per week. Review of Physical Therapy Assistant (PTA) visit note dated, 01/08/24 showed patient was aggregable to treatment but stated “I almost cancelled as my ankle is killing me” Patient stated she is having more difficulty walking. Pain Assessment showed an intensity of “9” (Pain scale where “0” represents no pain and 10 represents the worst pain imaginable) and pain increased by standing, gait and more pain in feet due to neuropathy and interfered with functional mobility, noting patient’s ankle was “too painful to perform” heal raises. The note showed the patient participation in treatment session was “fair” due to demonstrating a decline in functional mobility due to left ankle pain. There was no documentation to support the physician was promptly notified of the new onset of pain at an intensity of “9” that interfered with the patient’s functional ability to participate in the therapy plan of care and that demonstrated a decline in functional mobility. There was no documented change to the plan of care for the patient. Review of PTA visit note dated, 02/20/24 showed the patient reported significantly increased left knee pain over the weekend. The patient stated she has been having difficulty putting full wight bearing on left lower extremities. The patient stated she is calling her primary care physician and requesting a Magnetic Resonance Imaging (MRI). No bilateral lower extremity exercises done today due to increased pain in left knee. The note showed the patient’s ability to fully participate in treatment session was limited today due to increased left knee pain. There was no documentation to support the supervising therapist was contacted by the PTA to review or update the plan of care nor to promptly notify the physician of the patient’s continuing and new onset of lower extremity pain, the patient’s request for an MRI, limitations in mobility nor inability to fully participate in the therapy plan of care. Review of PTA visit note dated, 02/22/24 showed “The patient reported continued pain in left lateral knee and left ankle, patient states she called her doctor’s office to report the pain.” The note showed the doctor’s office confirmed they would call patient back when MRI scheduled. The note showed the patient’s participation in the treatment session was fair “but continued to be limited due to left knee and ankle pain.” There was no documentation to support the supervising therapist was contacted by the PTA to review/update the plan of care nor to promptly notify the physician of the patient’s continuing lower extremity knee and ankle pain, nor to clarify MRI order/scheduling for the patient. Review of Physician Progress notes dated 03/01/24 showed, “Multifocal bone infarcts [tissue death] within the distal femur [break of the thigh bone just above the knee] and proximal tibia [upper part of the shin bone] raising concerns for a nondisplaced fracture of the head of the fibula [smaller of the two lower leg bones] with moderate surrounding bone marrow edema; horizontal oblique [not straight] tear of the posterior horn of the medial meniscus [crescent-shaped bands of thick, rubbery cartilage attached to the shin bone].” The progress note confirmed notification to the patient of several findings on her MRI of the knee that needed an orthopedic referral and showed fluid in the joint, possible medical meniscus tear and possible concerns for fracture at the head of the fibula, and fibula and stated, “I would refrain from full weightbearing on this knee until seen by ortho this week.” Review of Patient Communication note dated 03/07/24, showed the Physical Therapist (PT) notified nursing staff that patient had an MRI on her left leg and noted to have multiple small fractures to left fibula and that she had increased edema to left foot and ankle with warmth noted. During an interview on 03/12/24 at 10:20 AM, Patient 1 confirmed during a home visit with the surveyor, that her doctor said there was a possible fracture to her left leg and a tear in her knee that had been there a while. She confirmed she was awaiting a call from her doctor for an orthopedic consultation. During an interview on 03/12/24 at 11:45 PM, Staff A, Administrator confirmed there was no documentation to confirm physical therapy had promptly notified the physician of the new onset pain rated at a “9”, continued high levels of pain during subsequent therapy visits and the inability of the patient to fully complete the ordered plan of care due to functional limitations.”