Lamm Family Care Home Health

“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 notify the physician that a patient had no BMs (Bowel Movements) in over 3 days for 1 (Patient #2) out of 10 (#1-#10) sampled patients. Review of the patient’s clinical record revealed the start of care date was 10/15/2024. The patient’s diagnoses included Hypertension, Atherosclerotic Heart Disease, and Leukemia. The certification period reviewed was 12/14/2024 to 02/11/2025. Review of the patient’s POC for certification period 12/14/2024 to 02/11/2025 revealed an order for skilled nurse 12/15/2024 1xweek x1week, 12/22/2024 1xweek x7weeks (skilled nurse visit week of 12/15/2024 one visit one time a week for one week, skill nurse visit week of 12/22/2024 one visit one time a week for seven weeks). Further review of the patient’s POC revealed an order for “SN to report to MD (Medical Doctor) parameters outside of the following range… Report if no BM > (greater than) 3 days…” Review of the patient’s skilled nurse visit note dated 12/18/2024 revealed that Patient #2’s last BM was on 12/12/2024, which was over 3 days. There was no evidence in the clinical record the physician was notified as ordered per the plan of care. On 01/13/2025 at 12:45 p.m., an interview was conducted with S3RN (Registered Nurse). S3RN was the SN that made the visit on 12/18/2024. S3RN reviewed the SN visit note and confirmed she documented that Patient #2’s last BM was on 12/12/2024 and confirmed that it was over 3 days. S3RN confirmed there was no evidence in the patient’s clinical record she notified the physician.”

“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 SN (Skilled Nurse) notified the physician of a medication being administered by the patient’s caregiver for 1 (#1) out of 10 (#1-#10) patients record reviewed. Review of the agency’s policy with an effective date of 10/01/2015 titled Coordination Of Care, From Admit Through Discharge read in part, “Procedure: …4. Coordination of care with physician: At admission, throughout care, and at discharge, coordination of services is promoted through routine communication with the patient’s physician… On 01/13/2025 at 3:15 p.m., during the home visit, a reconciliation of the patient’s current medications was conducted with S2 LPN (Licensed Practical Nurse). She stated the patient took several over –the –counter medications. The medications included Robitussin (cough syrup), Motrin (fever reducing and pain medication), and Milk of Magnesia (constipation, upset stomach and heartburn medication). A review of the patient’s POC (plan of care) revealed Milk of Magnesia was not included in the list of medications. S2LPN confirmed the patient received the medication when needed. Review of Patient #1’s electronic clinical record revealed a start of care date of 02/10/2020. The patient’s diagnoses included in part, Anoxic brain damage, generalized epilepsy and epileptic syndrome, and Gastrostomy. Review of the patient’s POC (Plan of Care) for certification period from 11/15/2024 to 01/13/2025 revealed there was no physician order for Milk of Magnesia. On 01/14/2025 at 12:15 p.m., an interview was conducted with S1ADM (Administrator) who stated that if the SN was administering a patient medication, it should be on the patient’s MAR (Medication Administration Record) and updated on the patient’s plan of care. S1ADM provided list of Patient#1’s current medications. A review of the list of Patient #1’s current medications list was reviewed and revealed Milk of Magnesia was not included as one of the patient’s current medications. On 01/14/2025 at 12:23 p.m., an interview and record review was conducted with S1ADM. S1ADM was informed that Patient #1’s medications were reconciled with S2LPN during the home visit on 01/13/2025. S2LPN reported that Patient#1 was currently receiving Milk of Magnesium as needed. At that time, a review of Patient #1’s medication list was conducted with S1ADM. She confirmed Milk of Magnesia was not included on the list and should be if the patient was currently receiving it. On 01/14/2025 at 12:27 p.m., S1ADM reported that S2LPN informed her Patient #1’s grandmother, not the nurses, was administering the Milk of Magnesia when needed. On 01/14/2025 at 12:32 p.m., an interview was conducted with S1ADM who confirmed the nurses should have notified the patient’s physician when they became aware the patient’s grandmother was administering Milk of Magnesia to ensure this was approved of or not by his physician.”