Christus Homecare St Patrick

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient’s written individualized POC (Plan Of Care) was followed as evidenced by, the SN (Skilled Nurse) failing to obtain pulse oximetry readings for patient (#3 and #8), the SN failing to measure ankles for patient (#5), the SN failing to obtain weights for patient (#8, #9, and #11) and the SN failing to follow the physician’s wound care/treatment orders for patient (#11) for 6 out of 17 (#1-#17) sampled patients. 3. Patient #8. Review of the patient’s electronic clinical record revealed the start of care date was 06/30/2024. The patient diagnoses included Hypertensive Heart Disease with Heart Failure, and Depression. The certification period reviewed was 06/30/2024 to 08/28/2024. Review of the patient’s POC for certification period 06/30/2024 to 08/28/2024 revealed the following orders: SN 2wk1, 1wk1, 2wk1, 1wk6 (skilled nurse visit two times a week for one week, one visit a week for one week, two visits a week for one week, one visit a week for six weeks). Further review of the POC revealed orders for the SN to perform pulse oximetry each visit and to obtain a weight every visit. Review of the patient’s SN visit note dated 07/03/2024, 07/10/2024, and 07/17/2024 revealed no evidence the SN performed pulse oximetry for oxygen saturation readings. Review of the patient’s SN visit note dated 07/03/2024 and 07/10/2024 revealed no evidence the SN obtained the patient’s weight. On 07/22/2024 at 12:00 p.m., an interview was conducted with S1ED (Executive Director) and after a review of the patient’s electronic clinical records, she verified there was no evidence the SN performed pulse oximetry for oxygen saturation readings for the SN visits made on 07/03/2024, 07/10/2024, and 07/17/2024. S1ED verified there was no evidence the SN obtained the patient’s weight for the SN visits made 07/03/2024 and 07/10/2024. 4. Patient #9. Review of the patient’s electronic clinical record revealed the start of care date was 06/29/2024. The patient’s diagnoses included Diabetes Mellitus with Diabetic Neuropathy, Chronic Kidney Disease, and Atrial Fibrillation. The certification period reviewed was 06/29/2024 to 08/27/2024. Review of the patient’s POC for certification period 06/29/2024 to 08/27/2024 revealed the following orders: SN 1wk6, 1every2wk4 (skilled nurse visit one time a week for six weeks, one visit every two weeks for four weeks). Further review of the POC revealed orders for the SN to obtain a weight every visit. Review of the patient’s SN visit note dated 07/09/2024 and 07/16/2024 revealed no evidence the SN obtained the patient’s weight. On 07/22/2024 at 2:00 p.m., an interview was conducted with S1ED (Executive Director) and after a review of the patient’s electronic clinical records, she verified there was no evidence the SN obtained the patient’s weight for the SN visits made 07/09/2024 and 07/16/2024. 5. Patient #11. Review of the patient’s electronic clinical records revealed the start of care date was 07/06/2024. The patient’s diagnoses included Diabetes with Foot Ulcer and Congestive Heart Failure. The certification period reviewed was 07/06/2024 to 09/03/2024. Review of the patient’s POC for certification period 07/06/2024 to 09/03/2024 revealed the following order: SN 1wk1, 3wk8, 1wk1 (skilled nurse visit one time a week for one week, three visits a week for eight weeks, one visit a week for one week). Review of the patient’s physician’s orders dated 07/16/2024 revealed, “Wound care clinic Left plantar great toe clean with normal saline and 4x4 gauze, apply iodosorb, apply 4x4, wrap with cast padding and secure with ace wrap with no compression, change every other day…” Further review of the POC revealed orders for the SN to obtain weight every visit. Review of the patient’s SN visit notes dated 07/19/2024 revealed, “Narrative: …Wound care completed to right great toe: cleaned with NS (normal saline) and gauze, painted with betadine, applied betadine moist gauze, 2x2 gauze, cast, ace…” The wound care orders were not followed and wound care was not done on the correct toe. On 07/22/2024 at 4:00 p.m., a telephone interview was conducted with S2LPN (Licensed Practical Nurse). S2LPN stated she conducted the SN visit on 07/19/2024. S2LPN confirmed that she performed the patient’s wound care and painted the wound with betadine. She stated that she was not aware the wound care orders had changed on 07/19/2024 and confirmed she did not follow the current wound care orders. Review of the patient’s SN visit note dated 07/10/2024 and 07/17/2024 revealed no evidence the SN obtained the patient’s weight. On 07/23/2024 at 7:40 a.m., an interview was conducted with S1ED (Executive Director) and after a review of the patient’s electronic clinical records, she verified there was no evidence the SN obtained the patient’s weight for the SN visits made 07/10/2024 and 07/17/2024. 1. Patient #3 Review of the patient’s electronic clinical record revealed a start of care date of 06/27/2024. The patient’s diagnoses included Chronic Obstructive Pulmonary Disease, and Essential Hypertension. The certification period reviewed was 06/17/2024 to 08/25/2024. Review of the patient’s POC (Plan of Care) for certification period 06/17/2024 to 08/24/2024 revealed the following order, SN 1wk9 (skilled nurse visit one time a week for 9 weeks). Further review of the POC revealed the Skilled Nurse was to perform a pulse oximetry reading each visit to monitor the patient’s respiratory status. Review of the patient’s SN Visit Note Report dated 07/10/2024 failed to reveal a pulse oximetry reading. On 07/24/2024 at 8:15 a.m., an interview was conducted with S1ED (Executive Director). She confirmed Patient #3’s orders included for the skilled nurse to perform a pulse oximetry reading at each visit. After a review of the patient’s electronic clinical record for the SN visit conducted on 07/10/2024, she verified that there was no evidence in the record the pulse oximetry reading was obtained. 2. Patient #5 Review of the patient’s electronic clinical record revealed a start of care date of 06/15/2024. The patient’s diagnoses included Hypertensive Heart Disease with Heart Failure, and Non-ST Elevation Myocardial Infarction. The certification period reviewed was 06/15/2024 to 08/13/2024. Review of the patient’s POC for certification period 06/15/2024 to 08/13/2024 revealed the following order, SN 1wk9 (skilled nurse visit one time a week for 9 weeks). Further review of the POC revealed the Skilled Nurse was to obtain a body measurement of the patient’s ankles every visit. Review of the patient’s SN Visit Note Reports dated 07/02/2024, 07/11/2024, and 07/18/2024 failed to reveal body measurements of the patient’s ankles. On 07/24/2024 at 8:20 a.m., an interview was conducted with S1ED. She confirmed Patient #5’s orders included for the skilled nurse to obtain body measurements of the patient’s ankles at each visit. After a review of the patient’s electronic clinical record for the SN visits conducted on 07/02/2024, 07/11/2024, and 07/18/2024, she verified that there was no evidence in the record a body measurement of the patient’s ankles was obtained.”

“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 record review and interview, the agency failed to ensure the individualized plan of care included orders to check blood sugar readings for 2 (#11, #12) patients diagnosed with Diabetes out of a sample of 17 patients. 1. Patient #11. Review of the patient’s electronic clinical records revealed the start of care date was 07/06/2024. The patient’s diagnoses included Diabetes with Foot Ulcer and Congestive Heart Failure. The certification period reviewed was 07/06/2024 to 09/03/2024. Review of the patient’s POC for certification period 07/06/2024 to 09/03/2024 revealed the following order: SN 1wk1, 3wk8, 1wk1 (skilled nurse visit one time a week for one week, three visits a week for eight weeks, one visit a week for one week). Further review of the patient’s POC revealed that there were no orders to check blood sugar readings. On 07/23/2024 at 7:40 a.m., an interview was conducted with S1ED (Executive Director) and after a review of the patient’s electronic clinical records, she verified the patient was diagnosed with Diabetes with Foot Ulcer. S1ED verified the patient did not have an order to check blood sugar readings and agreed that blood sugar checks should have been ordered. 2. Patient #12. Review of the patient’s electronic clinical records revealed the start of care date was 06/24/2024. The patient’s diagnoses included Aphasia Following Cerebral Infarction and Diabetes. The certification period reviewed was 06/24/2024 to 08/22/2024. Review of the patient’s POC for certification period 06/24/2024 to 08/22/2024 revealed the following order: SN 1wk9 (skilled nurse visit one time a week for nine weeks). Further review of the patient’s POC revealed that there were no orders to check blood sugar readings. On 07/23/2024 at 9:30 a.m., an interview was conducted with S1ED (Executive Director) and after a review of the patient’s electronic clinical records, she verified the patient was diagnosed with Diabetes. S1ED verified the patient did not have an order to check blood sugar readings and agreed that blood sugar checks should have been ordered.”

“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 record review and interview, the agency failed to ensure the physician was informed of patient’s complaint of pain of 8 on a pain scale 0-10 for 1 (#9) out of 17 sampled patients. Patient #9. Review of the patient’s electronic clinical record revealed the start of care date was 06/29/2024. The patient’s diagnoses included Diabetes Mellitus with Diabetic Neuropathy, Chronic Kidney Disease, and Atrial Fibrillation. The certification period reviewed was 06/29/2024 to 08/27/2024. Review of the patient’s POC (Plan of Care) for certification period 06/29/2024 to 08/27/2024 revealed the following orders: SN 1wk6, 1every2wk4 (skilled nurse visit one time a week for six weeks, one visit every two weeks for four weeks). PT (Physical Therapy) effective 07/07/2024 1wk8 (Physical Therapy effective 07/07/2024 one time a week for eight weeks). Further review of the POC revealed, “When vital signs are obtained licensed professional to report vital signs falling outside the following established parameters… pain > (greater than) 6.” Review of the patient’s PT visit note dated 07/15/2024 revealed under the pain section of the note, the patient’s pain intensity was 8 on a pain scale of 0-10 with 10 being the worst pain. Further review of the patient’s electronic clinical record revealed no evidence the physician was informed of the patient’s pain. On 07/22/2024 at 2:00 p.m., an interview was conducted with S1ED (Executive Director). S1ED reviewed the patient’s electronic clinical record and confirmed there was no evidence PT (Physical Therapist) informed the physician of the patient’s pain.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure a Registered Nurse (RN) made an onsite visit for 2 patients who were receiving home health aide (HHA) services no less frequently than every 14 days for 2 (#8, #9) out of 17 sampled patients. 1. Patient #8. Review of the patient’s electronic clinical record revealed the start of care date was 06/30/2024. The patient diagnoses included Hypertensive Heart Disease with Heart Failure and Depression. The certification period reviewed was 06/30/2024 to 08/28/2024. Review of the patient’s plan of care (POC) for certification period 06/30/2024 to 08/28/2024 revealed the following orders: HHA 1wk4 (home health aide visit one time a week for four weeks). Review of the patient’s HHA Visit Note Reports dated 07/03/2024 and 07/10/2024 revealed the aide was performing the visits with the patient as ordered. There was no documentation found from 07/04/2024 to 07/22/2024, (19 days) that the RN made a supervised visit for the home health aide between this time frame. On 07/22/2024 at 12:00 p.m., an interview was conducted with S1ED (Executive Director) and after a review of the patient’s electronic clinical records, she verified the RN did not make a supervisory visit for the HHA no less frequently than every 14 days. 2. Patient #9. Review of the patient’s electronic clinical record revealed the start of care date was 06/29/2024. The patient’s diagnoses included Diabetes Mellitus with Diabetic Neuropathy, Chronic Kidney Disease, and Atrial Fibrillation. The certification period reviewed was 06/29/2024 to 08/27/2024. Review of the patient’s plan of care (POC) for certification period 06/29/2024 to 08/27/2024 revealed the following orders: HHA effective 06/30/2024 1wk4 (home health aide visit start 06/30/2024 one time a week for four weeks). Review of the patient’s HHA Visit Note Reports dated 07/03/2024, 07/10/2024, and 07/17/2024 revealed the aide was performing the visits with the patient as ordered. There was no documentation found from 07/04/2024 to 07/22/2024, (19 days) that the RN made a supervised visit for the home health aide between this time frame. On 07/22/2024 at 2:00 p.m., an interview was conducted with S1ED and after a review of the patient’s electronic clinical records, she verified the RN did not make a supervisory visit for the HHA no less frequently than every 14 days.”