Elara Caring

“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 for 1 (#17) out of 17 (#1 to #17) sampled patients as evidenced by the PT (Physical Therapist) failing to notify physician when Patient #17’s pain level was outside parameter. Patient #17. Review of the patient’s electronic clinical records revealed the start of care date was 08/17/2023. The patient’s diagnoses included Leprosy, Peripheral Vascular Disease, and Chronic Obstructive Pulmonary Disease. The certification period reviewed was 08/17/2023 to 10/15/2023. Review of the patient’s POC for certification period 08/17/2023 to 10/15/2023 revealed an order for “PT effective 08/20/2023 1 Every2wk2, 1wk2 (Physical Therapy visits effective 08/20/2023 one visit one time a week every two weeks for two weeks, one time a week for two weeks).” Further review of the POC revealed an order “Licensed professional to report vital signs outside the following established parameters…pain > (greater than) 5…” Review of the patient’s physical therapy visit note dated 09/13/2023 revealed the patient’s pain level was 6 out of 10 on pain scale, which was outside the parameter of 5. Further review of the patient’s PT visit note and electronic clinical record revealed that there was no evidence the patient’s pain was reported to the physician. On 03/19/2024 at 2:35 p.m., an interview and review of the patient’s clinical record was conducted with S1DON (Director of Nurses). S1DON confirmed that there was no evidence the patient’s pain was reported to the physician on 09/13/2023.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure that the SN (Skilled Nurse) reviewed all medications during the SN visits to confirm that the patient was currently administered the correct medications and dosages as ordered per the plan of care for 1 (#4) out of 17 (#1-17) patient records reviewed. Patient #4: Review of the patient’s electronic clinical records revealed the start of care date was 01/22/2024. The patient’s diagnoses included in part, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Hypertensive Chronic Kidney Disease—Stage 1-4, Chronic Kidney Disease, Personal History Of TIA (Transient Ischemic Attack) and Cerebral Infarction without Residual Deficits. Review of the patient’s POC (Plan Of Care) for certification period 01/22/2024 to 03/21/2024 revealed an order for “SN 1wk9 (skilled nurse visit one time a week for nine weeks).” Further review of the POC revealed an order “Skilled nurse to review patient medications…” Review of the Skilled Nurse visit notes dated 02/28/2024, 03/04/2024 and 03/15/2024 revealed the SN documented that the patient’s medications were not reviewed because the patient’s daughter had the medications. Further review of the patient’s electronic record revealed no additional attempts were made by the skilled nurses to review the patient’s medications with her daughter to ensure the patient was receiving the correct medications and dosages as indicated in her plan of care. On 03/19/2024 at 12:48 p.m., S3LPN (Licensed Practical Nurse) stated she visited the patient on 03/04/2024 and 03/15/2024. She confirmed that she did not reconcile the patient’s medications on those SN visits. She also confirmed that she did not make additional attempts to contact the patient’s daughter in order to reconcile the patient’s medications. She confirmed that the patient’s medications should be reconciled during every SN visit. On 03/19/2024 at 3 p.m., an interview was conducted with S2ADM (Administrator) and S1DON (Director of Nurses). A review of the patient’s SN visit notes for 02/28/2024, 03/04/2024 and 03/15/2024 was conducted with S2ADM and S1DON and both agreed that the nurses did not conduct a medication reconciliation during the visits. They both agreed there was no evidence in SN visit notes that additional attempts were made to contact the patient’s daughter in order to reconcile the patient’s medications. They both agreed that the patient’s medications should be reconciled on every SN visit to ensure the patient was taking the correct medications as per the POC or to ensure that new medication orders were added to the POC.”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure that medications were recorded on the patient’s POC (plan of care) for 1 (#4) out of 17 (#1-17) patient records reviewed. Patient #4: Review of the patient’s electronic clinical records revealed the start of care date was 01/22/2024. The patient’s diagnoses included in part, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Hypertensive Chronic Kidney Disease—Stage 1-4, Chronic Kidney Disease, Personal History Of TIA (Transient Ischemic Attack) and Cerebral Infarction without Residual Deficits. Review of the SN (skilled nurse) visit notes for the certification period 01/22/2024 to 03/21/2024 revealed in the SN visit note dated 02/14/2024, the nurse documented that the patient had an appointment with her medical doctor on 02/19/2024. Review of the SN visit notes dated 2/28/2024 revealed the patient informed the skilled nurse that the doctor had made changes to her blood pressure medication. Review of the patient’s electronic record revealed the following: A SOAP (Subjective, Objective, Assessment and Plan) note dated 02/19/2024 that read as following: Medication changes/recommendations: to change Diltiazem (blood pressure medication) ER (extended release) 420 mg (milligram), one daily for blood pressure and an order to restart Clonidine (blood pressure medication) patch TTS-2 transdermal (through the skin). Review of the patient’s current medication list revealed that the changes the doctor made to the patient’s medications on 02/19/2024 were not included in the patient’s plan of care. On 03/19/2024 at 3 p.m., an interview was conducted with S2ADM and S1DON. A review of the Soap note dated 02/19/2024 and the patient’s plan of care was conducted. They both confirmed that changes the doctor made to the patient’s medications on 02/19/2024 were not included in the patient’s POC.”