Home Health Care 2000-Lake Charles

“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 PT (Physical Therapy) failing to make visits as ordered per POC for patient (#1), the SN (Skilled Nurse) failing to follow the physician’s wound care/treatment orders for patient (#4) and failing to ensure the SN weighed patient (#5) per the POC for 3 (#1 , #4, #5) out 7 sampled patients. Patient 1: Review of the Patient #1’s electronic clinical record revealed the start of care date was 11/03/2022. The patient’s diagnoses included Osteoarthritis of right ankle and foot, Right foot Hallux rigidus, Sciatica, and Pain right foot and left hip. Review of the patient’s POC for the certification period 04/26/2024 to 06/24/2024 revealed an order for “PT (physical therapy) evaluate and treat balance problems.” Review of the patient’s electronic clinical record revealed a patient communication note dated 05/13/2024 read in part, “…chart audit review done cert period 04/26/2024 -06/24/2024, physical therapy not available week of 04/29/2024, and week of 05/06/2024 due to physical therapy not available until week of 05/12/2024 for re-evaluation for physical therapy needs. “ On 05/20/24 at 12:30 p.m., Patient #1 stated that she had not received visits from the physical therapist for the last few weeks. She stated that the therapist did not call to let her know when she was not making the visit. On 05/20/2024 AT 3:30 p.m., S1ADM/DON (Administrator/Director of Nursing) stated that the previous physical therapist resigned on 04/14/2024 and the agency had not obtained a contract for physical therapy services until 05/04/2024. After review of the patient’s visit schedule, S1 ADM/DON confirmed that Patient #1 had not received her PT visits as per her POC for the week of 04/29/2024 and the week of 05/06/2024. 1. Patient #4. Review of the patient’s electronic clinical records revealed the start of care date was 04/25/2024. The patient’s diagnosis included Infection Due to Peritoneal Dialysis Catheter and Diabetes. The certification period reviewed was 04/25/2024 to 06/23/2024. Review of the patient’s POC for certification period 04/25/2024 to 06/23/2024 revealed an order for “SN 2w1, 3w8 (skilled nurse visit two times a week for one week, three visits a week for eight weeks).” Further review of the patient’s POC revealed an order for “…SN to perform… the following wound care daily: Clean abdominal wound with NS (normal saline) and gauze, pack wound with wet to dry and cover with dry dressing…” New wound care orders dated 05/02/2024 revealed, “SN to perform… clean abdominal incision with NS and cover with dry dressing daily.” Review of the patient’s skilled nurse visit notes dated 05/04/2024 and 05/11/2024 revealed, “… Cleansed abdomen with saline and gauze… Pack with moistened gauze, covered with dry gauze and abd (abdominal) pad, secured with tape…” Review of the physician’s orders dated 05/02/2024 revealed the orders changed from packing the wound with wet to dry to cleaning the wound with normal saline and cover with dry dressing. The SN did not follow the wound care/treatment orders on 05/04/2024 and 05/11/2024. On 05/20/2024 at 12:52 p.m., a telephone interview was conducted with S2LPN (Licensed Practical Nurse). S2LPN confirmed she was packing the wound with moistened gauze and covering with dry dressing for the skilled nurse visits conducted on 05/04/2024 and 05/11/2024. On 05/20/2024 at 1:25 p.m., an interview was conducted with S1ADM/DON (Administrator/Director of Nursing). She reviewed the patient’s electronic clinical record and confirmed that S2LPN did not follow the physician’s orders for wound care. 2. Patient #5. Review of the patient’s electronic clinical record revealed the start of care date was 12/27/2023. The patient’s diagnosis included Heart Failure. The certification period reviewed was 04/25/2024 to 06/23/2024. Review of the patient’s POC for certification period 04/25/2024 to 06/23/2024 revealed an order for skilled nurse 1wk9 (skilled nurse visit one time a week for nine weeks). Further review of the patient’s POC revealed an order for, “Nurse to… assess weight weekly (patient’s own scale if available). Notify physician with unexplained weight gain of 3 or more pounds in one day and weight gain of 5 lbs (pounds) or more within one week. Nurse to obtain measurements from left and right lower ankle or calf circumference each visit when patient is not able to weigh. Notify RN (Registered Nurse), physician with increase of 3 cm (centimeters)…” Review of the patient’s SN visit notes dated 04/26/2024, 05/10/2024, and 05/17/2024 revealed there was no evidence the patient’s weight was obtained by the skilled nurse. On 05/20/2024 at 2:10 p.m., a telephone interview was conducted with S3LPN. S3LPN confirmed she did not obtain the patient’s weight and did not measure the patient’s ankles or calf circumference for the skilled nurse visits made on 04/26/2024, 05/10/2024, and on 05/17/2024. On 05/20/2024 at 2:12 p.m., an interview was conducted with S1ADM/DON. S1ADM/DON stated S3LPN should have weighed or measured the patient’s ankles or calf circumference as ordered per the POC.”

“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 pain scale 0-10 for 1 (#4) out of 7 sampled patients. Patient #4. Review of the patient’s electronic clinical records revealed the start of care date was 04/25/2024. The patient’s diagnosis included Infection Due to Peritoneal Dialysis Catheter and Diabetes. The certification period reviewed was 04/25/2024 to 06/23/2024. Review of the patient’s POC for certification period 04/25/2024 to 06/23/2024 revealed an order for “SN 2w1, 3w8 (skilled nurse visit two times a week for one week, three visits a week for eight weeks).” The POC included orders to, “Report to physician pain greater than 7 on 0-10 scale…” Review of the patient’s skilled nurse visit note dated 04/27/2024 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 05/20/2024 at 12:52 p.m., a telephone interview was conducted with S2LPN (Licensed Practical Nurse). S2LPN confirmed she did not recall informing the physician of the patient’s pain intensity of 8. On 05/20/2024 at 1:25 p.m., an interview was conducted with S1ADM/DON (Administrator/Director of Nursing). S1ADM/DON reviewed the patient’s electronic clinical record and confirmed there was no evidence the skilled nurse informed the physician of the patient’s pain.”