Advisacare

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient received the services outlined in the plan of care in 3 (P-5, 6, and 10) of 10 records reviewed, resulting in the potential for unmet care needs ( see G572), failed to ensure the plan of care included individualized, patient-specific, interventions, and measurable outcomes and goals in 8 (P-1, 4, 5, 6, 7, 8, 9, and 10) of 10 records reviewed, resulting in the potential for poor patient outcomes and unmet care needs (see G574), and failed to ensure the registered nurse promptly alerted the physician to changes in the patient’s condition for 1 (P-5) of 10 records reviewed. This resulted in Immediate Jeopardy (IJ) to the health and safety of P-5, with new onset of pain and burning with urination, resulting in a six-day hospitalization requiring intravenous antibiotics (see G590). The cumulative effect of these systemic problems resulted in the Agency’s inability to ensure the provision of quality health care in a safe environment for the Condition of Participation of 42 CFR §484.60 Care planning, coordination of services, and quality of care.”

“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 received the services outlined in the plan of care in 3 (P-5, 6, and 10) of 10 records reviewed, resulting in the potential for unmet care needs. Findings include: P-10: This 80-year-old patient was admitted to this agency on 2/7/24 with the diagnoses of chronic obstructive pulmonary disease (COPD), hypertensive heart disease with heart failure, and type II diabetes. During record review on 3/6/24, it was noted the Plan of Care dated 2/7/24 included orders for Occupational Therapy (OT) 2 times a week for 6 weeks. During further review of the record, it was noted there were no OT visits the week of 2/19/24. According to the “Missed Visit Form” on 2/20/24, the visit was canceled due to the clinician feeling ill. The note reported the physician was not notified and there was no new order generated to reflect the change. According to the “Missed Visit Form” on 2/22/24, the patient’s spouse canceled the visit due to another appointment. The note reported the physician was not notified and there was no new order generated to reflect the change. The Administrator (Staff A) was interviewed on 3/6/24 at 2:00 PM regarding the agency’s policy for missed visits. According to Staff A, the agency does not have a specific policy regarding the procedure for missed visits, but offered a policy that directly references the regulations regarding this. **Policy titled “III.6 Physician’s Plan of Treatment/Change Orders” (undated) stated, “Per the State Operations Manual Interpretive Guidance……G572: …..If the HHA misses a treatment or services as required by the plan of care, which results in any potential for clinical impact upon the patient, then the HHA must notify the responsible physician of such missed treatment or service.” Staff A acknowledged the findings during a follow-up interview on 3/7/24 at 10:00 AM. Additionally, the Plan of Care dated 2/7/24 included orders to report to the physician: “Respirations greater than (>) 24 or less than () 160 or less than (Upon review of the treatment records, it was noted the OT note dated 2/13/24 recorded the systolic blood pressure as 179 during treatment and 174 post treatment. There was no indication this was reported to the physician. On the OT note dated 2/15/24, it was noted there were no documented values for respiration during the entire visit. Findings were reviewed with and acknowledged by Staff A and the Alternate Administrator (Staff B) during an interview on 3/7/24 at 10:00 AM. P-5: This 94-year-old patient was admitted to home care on 11/3/23 with diagnoses of tibia fracture, muscle weakness, malnutrition, and congestive heart failure. During record review on 3/5/24, it was noted that the plan of care ordered skilled professionals to notify the physician of diastolic (bottom number) blood pressure greater than 90 or less than 60, variation of weight of 2 pounds in 24 hours or 5 pounds in 7 days, and pain level greater than 7 on a scale of 1-10. This patient received skilled nursing visits for 8 weeks, and a weight was documented on the start of care on 11/3/23. There was no evidence of weight documentation on the following 13 skilled nursing visits to monitor potential worsening of congestive heart failure. On 11/16/23, the skilled nurse documented a blood pressure reading of 95/54. There was no evidence the physician was notified. On 12/20/23 and 12/22/23, skilled nursing documented the patient’s pain as an “8” on a scale of 1-10. There was no evidence the physician was notified of pain level. P-6: This 89-year-old patient was admitted to home care on 2/9/24 with diagnoses of hypertensive heart disease, chronic congestive heart failure, and diabetes mellitus. During record review on 3/6/24, it was noted that the plan of care ordered skilled professionals to measure bilateral lower extremity edema and notify the physician of changes of 2 cm or greater, and to notify for pain level greater than 7 on a scale of 1-10. The registered nurse obtained baseline measurements during start of care assessment on 2/9/24. On 2/13/24, the right ankle measurements were 2 cm greater than baseline. On 2/17/24, the left ankle was 2 cm greater than baseline. On 2/23/24, the right calf measured 3.1 cm greater than baseline and remained the same for the next three skilled nursing visits. Additionally, the patient reported a pain level of 8 on a scale of 1-10 on 2/23/24. There was no evidence the physician was notified of the extremity measurements or pain. These findings were reviewed and acknowledged by the administrator (Staff A) and the clinical manager (Staff B) during an interview on 3/7/24 at 3:25 p.m.”

“Supervise skilled professional assistants CFR(s): 484.75(c) Standard: Supervision of skilled professional assistants. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure the registered nurse supervised the care of the licensed practical nurse for 1 (P-5) of 10 records reviewed, resulting in a lack of oversight regarding the services provided by the licensed practical nurse. Findings include: During the entrance conference on 3/4/24 at 10:10 a.m., the administrator (Staff A) stated that licensed practical nurses (LPN) are supervised by a registered nurse (RN) and this is documented in the skilled nursing visit notes every 30 days. P-5: This 94-year-old patient was admitted to home care on 11/3/23 with diagnoses of tibia fracture, muscle weakness, malnutrition, and congestive heart failure. During record review on 3/5/24, it was noted that the plan of care ordered skilled nursing visits once week one, twice a week for five weeks, and once a week for four weeks. The LPN provided a skilled nursing visit on 11/20/24. There was no documented evidence of supervision by the RN. This finding was reviewed and acknowledged by the administrator (Staff A) and the clinical manager (Staff B) during an interview on 3/7/24 at 3:25 p.m.”

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment was completed within 5 calendar days of the start of care in 3 (P-4, 5, 6) of 10 records reviewed, resulting in a delay in determining the immediate care and support needs for these patients. P-4: This 91-year-old patient was admitted to home care on 2/2/24 with diagnoses of atrial fibrillation, hypertensive chronic kidney disease and osteoarthritis. During record review on 3/4/24, it was noted that the order for home care included skilled nursing, physical therapy (PT), and occupational therapy (OT). The OT evaluation was conducted on 2/7/24, six days after the start of care. There was no evidence that the physician had been notified of the reason for delay. P-5: This 94-year-old patient was admitted to home care on 11/3/23 with diagnoses of tibia fracture, muscle weakness, malnutrition, and congestive heart failure. During record review on 3/5/24, it was noted that the order for home care included skilled nursing, physical therapy (PT), occupational therapy (OT), home health aide (HHa), and medical social work (MSW). The PT evaluation was conducted on 11/9/23, seven days after the start of care. The MSW evaluation was conducted on 11/16/23, 14 days after the start of care. There was no evidence that the physician had been notified of the reasons for delay. P-6: This 89-year-old patient was admitted to home care on 2/9/24 with diagnoses of hypertensive heart disease, chronic congestive heart failure, and diabetes mellitus. During record review on 3/6/24, it was noted that the order for home care included skilled nursing, physical therapy (PT), occupational therapy (OT), and home health aide (HHa). This patient has been receiving home care services for 28 days and there is no evidence that the occupational therapy assessment has been conducted or that the physician has been notified of the reason for delay. These findings were reviewed and acknowledged by the administrator (Staff A) and the clinical manager (Staff B) during an interview on 3/7/24 at 3:25 p.m.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment contained an accurate, complete picture of the patient’s current health, psychosocial, functional, and cognitive status in 2 (P-8, 10) of 10 records reviewed, resulting in the potential for unmet care needs. Findings include: P-8: This 91-year-old patient was admitted to this agency on 1/28/24 with the diagnoses of a laceration (wound) on the left lower extremity and edema (swelling). During record review on 3/5/24, it was noted the physical therapy evaluation dated 2/23/24 quoted the patient stating, “My legs and L knee hurts a lot along with I feel tightness in my upper and mid back causing disturbances in sleep.” Upon further review of the physical therapy evaluation, it was determined the “Pain Assessment” section on page 3 identified both legs and the left shoulder as areas with pain but did not report objective pain measurements to further assess the patient’s current status. During an interview on 3/7/24 at 11:00 AM, the Regional Director of Rehabilitation (Staff C) was asked if she was able to locate an assessment of the patient’s current pain levels in the physical therapy evaluation. Staff C reported it did not appear that the physical therapist addressed the patient’s pain levels at that time. She acknowledged the findings. P-10: This 80-year-old patient was admitted to this agency on 2/7/24 with the diagnoses of chronic obstructive pulmonary disease (COPD), hypertensive heart disease with heart failure, and type II diabetes. During record review on 3/6/24, it was determined the physical therapist and occupational therapist both evaluated the patient on 2/7/24. Upon further review of the documentation, it was noted there was a significant difference in the evaluation of the patient’s transfer status. The physical therapist noted the patient required the assistance of 2 people for transfers and required maximum assistance for the activities of sit to stand, stand to sit, and from bed to wheelchair. The occupational therapist noted the patient was a “supervision” level assist for the above activities – meaning the patient could complete the task without physical assistance but may require cuing or supervision to be safe. Staff C was queried during an interview on 3/7/24 at 11:00 AM on how there could be such a significant difference in evaluation of these activities. Staff C stated the occupational therapist was new to the agency and that could be why. Staff C also later reported she spoke to the physical therapist who performed the evaluation and confirmed that he believed the patient required maximum assistance at that time. Staff C was unable to contact the occupational therapist during the survey. Staff C acknowledged this significant difference would make it very difficult to identify the patient’s specific needs and to make accurate goals for treatment as it does not show an accurate representation of the patient’s status. Staff A and the Alternate Administrator (Staff B) were also present during the interview and acknowledged the findings.”

“Strengths, goals, and care preferences CFR(s): 484.55(c)(2) The patient’s strengths, goals, and care preferences, including information that may be used to demonstrate the patient’s progress toward achievement of the goals identified by the patient and the measurable outcomes identified by the HHA; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment contained goals identified by the patient with measurable outcomes in 3 (P-7, 8, 9) of 10 records reviewed, resulting in the potential for a lack of individualized care and unmet care needs. Findings include: P-7: This 77-year-old patient was admitted to this agency on 2/10/24 with the diagnoses of Parkinson’s Disease and repeated falls. During record review on 3/6/24, the following goal was noted by physical therapy on the Plan of Care dated 2/10/24: “Patient Stated Outcome to be achieved within this episode of care is: PATIENT WANTED TO GET MORE STRONGER AND WANTED TO FALL FREE DURING TRANSFER AND AMBULATION.” [sic] This goal does not contain measurable outcomes to detect progress or changes in the patient’s health status. P-8: This 91-year-old patient was admitted to this agency on 1/28/24 with the diagnoses of a laceration (wound) on the left lower extremity and edema (swelling). During record review on 3/6/24, the following goal was noted by skilled nursing on the Plan of Care dated 1/28/24: “Patient Stated Outcome to be achieved within the episode of care is: ‘I want you to make sure my leg gets better.’” This goal does not contain measurable outcomes to detect progress or changes in the patient’s health status. P-9: This 79-year-old patient was admitted to this agency on 12/27/23 with the diagnoses of an unspecified fracture of the first lumbar vertebra, type II diabetes, high blood pressure, and chronic kidney disease. During record review on 3/5/24, the following goal was noted by skilled nursing on the Plan of Care dated 12/27/23: “Patient Stated Outcome to be achieved within this episode of care is: to understand how to take medications and decrease in pain.” This goal does not contain measurable outcomes to detect progress or changes in the patient’s health status. The Administrator (Staff A) was queried regarding these goals during an interview on 3/7/24 at 10:00 AM. Staff A reported they are required by corporate to put a goal identified by the patient in the Plan of Care, however acknowledged the above findings are not measurable and therefore are unable to show the patient’s progress towards achievement.”

“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 the comprehensive assessment included a review of all medications prescribed to the patient, and include those medications in the patient’s medication profile in its entirety for possible adverse effects or drug interactions in 1 (P-2) of 10 records reviewed and failed to have skilled nursing perform a comprehensive drug review for possible significant drug interactions or duplicate drug therapy in 5 (P-4, 6, 7, 8 and 10) of 10 records reviewed, resulting in the potential for undetected harmful medication side effects or interactions. Findings include: Agency policy titled, “ADVISACARE III.17 MEDICATION MANAGEMENT”, (undated), was reviewed on 3/7/24. On page 1., it stated “A Medication Profile comprised of a list of all medications… shall be completed for each patient at the time of admission by the admitting clinician... and sent to the physician as part of the patient’s plan of care… The medications will be reviewed for potential adverse effects, drug reactions, ineffective drug therapy, significant drug interactions, duplicate drug therapy, and for patient non-compliance with drug therapy. The admitting clinician or the nurse reviewing the profile will contact the patient’s physician immediately if there are any questions or concerns regarding the medications a patient is taking. P-2: This 89-year-old was admitted to the agency on 3/2/24 with diagnoses which included, heart failure; diabetes; and Chronic Obstructive Pulmonary Disease (progressive lung disease). The medical record was reviewed on 3/5/24. On 3/5/24 at 10:30 a.m., a joint home visit was made with the registered nurse (RN). A surveyor interview was conducted with the patient at 11:30 a.m. to compare the patient’s medications listed in the agency profile with the medication list in the home. The patient stated that she had been taking Lasix (a diuretic) and Farxiga (a blood sugar reducer) since discharge from the hospital on 2/29/24. The patient also stated that she used another medication long term, Albuterol inhaler (opens airways in lungs to ease breathing). Those 3 medications were not found on the agency “Patient Medication Record” signed by the admitting RN on 3/4/24 and were also not found on an additional “Patient Medication Record” signed by the Administrator (Staff A) on 3/5/24. There was no evidence in the medical record that the RN assessed the above medications for potential interactions or duplicate therapy. These findings were reviewed and acknowledged during interview on 3/7/24 at 1:30 p.m. with Staff A and the Alternate Administrator (Staff B). P-4: This 91-year-old patient was admitted to home care on 2/2/24 with diagnoses of atrial fibrillation, hypertensive chronic kidney disease and osteoarthritis. During record review on 3/4/24, it was noted that there were three major medication interactions noted on the Drugs.com medication review conducted by the agency between amiodarone and warfarin, warfarin and fenofibrate, and atorvastatin and fenofibrate. This report was faxed to the physician on 2/13/24, 11 days after the start of care. Additionally, the start of care assessment, dated 2/2/24, stated there were no issues found during review (M2001 Drug Regimen Review), and the medication follow up (M2003) was blank. P-6: This 89-year-old patient was admitted to home care on 2/9/24 with diagnoses of hypertensive heart disease, chronic congestive heart failure, and diabetes mellitus. During record review on 3/6/24, it was noted there was one major medication interaction noted on the Drugs.com medication review conducted by the agency between calcitriol and ergocalciferol. This report was faxed to the physician on 2/13/24, four days after the start of care. Additionally, the start of care assessment, dated 2/9/24, stated there were no issues found during review (M2001 Drug Regimen Review), and the medication follow up (M2003) was blank. These findings were reviewed and acknowledged by the administrator (Staff A) and the clinical manager (Staff B) during an interview on 3/7/24 at 3:25 p.m. P-7: This 77-year-old patient was admitted to this agency on 2/10/24 with the diagnoses of Parkinson’s Disease and repeated falls. During record review on 3/6/24, it was noted there was a medication duplication identified by the Drugs.com medication review conducted by the agency between “MiraLAX (polyethylene glycol 3350)” and “senna”. During further review, it was noted the form labeled “Patient Medication Record” dated 2/10/24 stated there were no medication discrepancies or severe interactions to contact the physician about. Furthermore, the OASIS (Outcome and Assessment Information Set) form from the Start of Care (SOC) dated 2/10/24 noted there were “No issues found during review.” P-8: This 91-year-old patient was admitted to this agency on 1/28/24 with the diagnoses of a laceration (wound) on the left lower extremity and edema (swelling). During record review on 3/5/24, it was noted there was 1 major medication interaction noted on the Drugs.com medication review conducted by the agency between “aspirin” and “apixaban”. During further review, it was noted the form labeled “Patient Medication Record” dated 1/28/24 stated there were no medication discrepancies or severe interactions to contact the physician about. Furthermore, the OASIS (Outcome and Assessment Information Set) form from the Start of Care (SOC) dated 1/28/24 noted there were “No issues found during review.” P-10: This 80-year-old patient was admitted to this agency on 2/7/24 with the diagnoses of chronic obstructive pulmonary disease (COPD), hypertensive heart disease with heart failure, and type II diabetes. During record review on 3/6/24, it was noted there was a medication duplication identified by the Drugs.com medication review conducted by the agency between “albuterol” and “wixela inhub (fluticasone/salmeterol)”. During further review, it was noted the form labeled “Patient Medication Record” dated 2/7/24 stated there were no medication discrepancies or severe interactions to contact the physician about. Furthermore, the OASIS (Outcome and Assessment Information Set) form from the Start of Care (SOC) dated 2/7/24 noted there were “No issues found during review.” The Administrator (Staff A) was queried regarding why the interactions and duplications noted above were not reported to the physician during an interview on 3/7/24 at 10:00 AM. Staff A reported the agency does not report duplicative therapies and that corporate said they did not need to report major interactions with long-standing medications. Staff A was asked to provide a policy outlining how the clinicians are to know which types of interactions should be reported to the physician. Policy titled “III.17 MEDICATION MANAGEMENT” (undated) stated, “The medications will be reviewed for potential adverse effects, drug interactions, ineffective drug therapy, significant drug interactions, duplicate drug therapy, and for patient non-compliance with drug therapy. The admitting clinician or the nurse reviewing the profile will contact the patient’s physician immediately if there are any questions or concerns regarding the medications a patient is taking.” Staff A and the Alternate Administrator (Staff B) agreed the policy is not specific as to what should be reported and would need to be revised. They acknowledged the findings at the time of the interview.”

“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 plan of care included individualized, patient-specific, interventions and measurable outcomes and goals in 8 (P-1, 4, 5, 6, 7, 8, 9 and 10) of 10 sampled records reviewed potentially resulting in insufficient information to adequately assess patient progress. Findings include: P-1: This 78-year-old was admitted to the agency on 2/9/24 with diagnoses which included, Ataxia (poor muscle control) following a stroke; paralysis of the right side of body; and high blood pressure. The medical record was reviewed on 3/4/24. During review of the plan of care dated 2/9/24, the following skilled nursing (SN) goals were noted: Patient will have diagnosis specific interventions throughout this episode of care to monitor co-morbidities and potential adverse events, to reduce the risk of acute hospitalization; and Patient stated goal is to increase strength and improve memory. There were no other SN goals for care. It was unclear how these goals were specific to this patient’s diagnoses, and how they would be measured in terms that would enable nursing staff to accurately perform an objective evaluation of the patient’s progress toward the goals. This finding was reviewed and acknowledged during interview on 3/7/24 at 1:30 p.m. with the Administrator (Staff A) and the Alternate Administrator (Staff B). P-7: This 77-year-old patient was admitted to this agency on 2/10/24 with the diagnoses of Parkinson’s Disease and repeated falls. During record review on 3/6/24, it was noted the occupational therapy (OT) treatment interventions on 2/22/24 were recorded as follows: “UB (upper body) strengthening; yellow theraband, 2 sets of 10, all planes” and “Performed UB strengthening HEP (home exercise program).” It is unclear what patient-specific exercises were performed by the patient. The Regional Director of Rehabilitation (Staff C) was interviewed on 3/7/24 at 11:00 AM regarding how to know which exercises were performed by the patient. Staff C stated the specific exercises should be documented and acknowledged it was not clear what exercises this patient had performed on this day. P-8: This 91-year-old patient was admitted to this agency on 1/28/24 with the diagnoses of a laceration (wound) on the left lower extremity and edema (swelling). During record review on 3/5/24, it was noted the Plan of Care dated 1/28/24 did not have any goals set regarding wound size or edema, although both had been measured and evaluated at the start of care. It was also noted on the Plan of Care dated 1/28/24 under “SN (skilled nursing) Interventions” to, “Report to the physician if patient experiences pain level not acceptable to the patient, pain level greater than 7/10 with objective data…”. Further down under “SN Interventions” it stated, “Report to physician…...unrelieved pain >5 on a 0-10 scale…”. It is unclear which intervention to follow, therefore these interventions are not patient-specific. P-9: This 79-year-old patient was admitted to this agency on 12/27/23 with the diagnoses of an unspecified fracture of the first lumbar vertebra, type II diabetes, high blood pressure, and chronic kidney disease. During record review on 3/5/24, the following interventions were noted under orders on the Plan of Care dated 12/27/24: SN (Skilled Nursing) Interventions: “Instruct pt/cg to maintain daily weights and report any weight gain of >3 lbs in any 24 hour period or 3-5 lbs in a week to SN or MD.” and, PT (Physical Therapy) Interventions: “Instruct Pt/Caregiver to weigh daily and to report variations of 2 lb/24 hours or 5 lb/7 days to MD. Instruct pt to log weights daily, clinicians to monitor. If unable to weigh, measure BLE edema and report changes of 2 cm or greater to the MD.” It is unclear which order should be followed, therefore these interventions are not patient-specific. Staff A was queried regarding the conflicting interventions during an interview on 3/7/24 at 10:00 AM. Staff A reported the interventions are generated based on diagnoses and acknowledged it is unclear which intervention to follow. Staff A stated the clinician should be reviewing these to ensure they are specific to the patient and not conflicting. She acknowledged the findings. P-10: This 80-year-old patient was admitted to this agency on 2/7/24 with the diagnoses of chronic obstructive pulmonary disease (COPD), hypertensive heart disease with heart failure, and type II diabetes. During record review on 3/6/24, the following SN goal was noted on the Plan of Care dated 2/7/24: “Patient will be free from signs and symptoms of respiratory distress during the episode.” This goal contains no measurable data. Staff A acknowledged the findings. Additionally, the following goal was noted in records for P-7, 8, 9, and 10: “Patient will have diagnosis specific interventions throughout this episode of care to monitor co-morbidities and potential adverse events, to reduce the risk of acute hospitalization.” Staff A was questioned about this goal being located in every record reviewed during an interview on 3/7/24 at 10:00 AM. Staff A reported corporate instructed them to use this goal for everyone as it would “cover” the goal requirements. However, Staff A admitted that this is goal is not measurable or patient-specific and acknowledged the findings. The Alternate Administrator (Staff B) was also present during the above interviews and acknowledged the findings. P-4: This 91-year-old patient was admitted to home care on 2/2/24 with diagnoses of atrial fibrillation, hypertensive chronic kidney disease and osteoarthritis. During record review on 3/4/24, it was noted that the plan of care failed to include measurable nursing goals that are individualized to address patient needs. The plan of care contained the following goals, “Patient will have diagnosis specific interventions throughout this episode of care to monitor co-morbidities and potential adverse events, to reduce the risk of acute hospitalization,” and “Patient/caregiver will state understanding of measures to manage hypertension and identify signs and symptoms to report throughout episode of care.” There was no evidence of how these goals could be objectively measured to determine progress toward meeting the goals. P-5: This 94-year-old patient was admitted to home care on 11/3/23 with diagnoses of tibia fracture, muscle weakness, malnutrition, and congestive heart failure. During record review on 3/5/24, it was noted that the plan of care failed to include measurable nursing goals that are individualized to address patient needs. The plan of care contained the following goals, “Patient will have diagnosis specific interventions throughout this episode of care to monitor co-morbidities and potential adverse events, to reduce the risk of acute hospitalization.” There were no patient specific skilled nursing goals related to admitting diagnoses of tibia fracture, muscle weakness, malnutrition, or congestive heart failure. P-6: This 89-year-old patient was admitted to home care on 2/9/24 with diagnoses of hypertensive heart disease, chronic congestive heart failure, and diabetes mellitus. During record review on 3/6/24, it was noted that the plan of care failed to include measurable nursing goals that are individualized to address patient needs. The plan of care contained the following goals, “Patient will have diagnosis specific interventions throughout this episode of care to monitor co-morbidities and potential adverse events, to reduce the risk of acute hospitalization,” and “patient and caregiver will verbalize an understanding of factors that contribute to shortness of breath.” There was no evidence of how these goals could be objectively measured to determine progress toward meeting the goals. These findings were reviewed and acknowledged by the administrator (Staff A) and the clinical manager (Staff B) during an interview on 3/7/24 at 3:25 p.m.”

“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, the agency failed to ensure the registered nurse promptly alerted the physician to changes in the patient’s condition for 1 (P-5) of 10 records reviewed, resulting in increased pain, and burning with urination, resulting in a six-day hospitalization requiring intravenous antibiotics. Findings include: Policy III.7 – Professional/Ancillary Care Plans (no date) states care coordinator (RN who opened the case) shall be responsible for informing the physician of changes in the patient’s condition. No time frame was noted in the agency policy. P-5: This 94-year-old patient was admitted to home care on 11/3/23 with diagnoses of Tibia fracture, muscle weakness, malnutrition, congestive heart failure, and history of frequent urinary tract infections. The plan of care, dated 11/3/23, contained orders to notify physician of temperature greater than 99.6 degrees. During review of the skilled nursing visit notes on 3/5/24, the following was noted: 12/1/23 – Registered Nurse (RN) documented, Temperature of 99.9, “Received call from daughter Wendy that the patient wasn’t feeling well. Upon arrival patient was drowsy and fatigue. Vitals was WNL (within normal limits) besides the temperature,” [sic] there was no evidence the physician was notified. 12/5/23 – New onset of pain, rated as 5 out of 10, and RN documented, “patient having burning while urinating. Patient already on Keflex daily. This is a huge problem as patient ends up in hospital over bladder infection. Will call daughter Wendy to discuss intervention to staying out of hospital.” [sic] 12/6/23 - Pain level of 7 out of 10 and RN documented, “burning with urination” and “Daughter stated if we don’t get medical attention patient will end up in hospital. Burning is usually the first signs before things take a turn for the worse. Wendy will take mother to ER tomorrow morning. Hopefully we can avoid long stay in hospital since the doctor can’t see the patient until 12/18/23.” P-5 was hospitalized from 12/7/23 to 12/12/23, required intravenous antibiotics for dysuria and UTI with hematuria, and returned home with home care. The patient was discharged from home care and admitted to hospice on 12/25/23. The administrator was interviewed on 3/6/24 at 2:30 p.m., who acknowledged the record failed to include documentation that the RN notified the physician of temperature, new onset of pain, or burning with urination. When queried what is the expectation, the administrator replied, clinicians must report changes to the physician. The RN (Staff-D) was interviewed on 3/7/24 at 12:05 p.m. and stated, “On December 1, I was there with the patient’s daughter when she called and left a message for the doctor.” When queried if she had attempted to contact the physician, she replied that she did not as the daughter had a good relationship with the physician. When queried if she was aware of the agency policy to inform the physician of changes in patient condition, she replied, “Yes, I am aware of the policy. I should have documented.” The nurse failed to notify the physician of the elevated temperature, new onset of pain, and burning with urination, with patient who has a history of frequent urinary tract infections.”

“Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure care was coordinated between disciplines to assure identification of patient needs, safety and treatment effectiveness in 2 (P-7, 9) of 10 records reviewed, resulting in the potential for poor patient outcomes and unmet care needs. Findings include: P-7: This 77-year-old patient was admitted to this agency on 2/10/24 with the diagnoses of Parkinson’s Disease and repeated falls. During record review on 3/6/24, the following occupational therapy (OT) intervention was noted under orders on the Plan of Care dated 2/10/24: “Instruct Pt/Caregiver to weigh daily and to report variations of 2 lb / 24 hours or 5 lb / 7 days to MD. Instruct pt to log weights daily, clinicians to monitor.” During review of the OT notes from 2/15/24, 2/22/24, and 2/29/24, it was determined that no weight measurements were recorded or reviewed on those days. The Administrator (Staff A) was queried where to find weight measurements on an OT note during an interview on 3/7/24 at 10:00 AM. Staff A reported there is not a spot for it on the OT notes, but the nurse should be doing it since there was one involved in the care of this patient. She was unsure why OT would pick that intervention. Upon further review of the nursing notes, it was determined that no weight was recorded or reviewed by nursing on the visits dated 2/20/24 and 2/28/24. Staff A then reported there should be a list of daily weights in the patient’s home for the clinician to review but was unable to provide evidence that this was the case or any evidence that the patient’s weight was being monitored. Care was not coordinated between OT and nursing to determine who would monitor the patient’s weight. Staff A acknowledged the findings. P-9: This 79-year-old patient was admitted to this agency on 12/27/23 with the diagnoses of an unspecified fracture of the first lumbar vertebra, type II diabetes, high blood pressure, and chronic kidney disease. During record review on 3/5/24, the following interventions were noted under orders on the Plan of Care dated 12/27/24: SN (Skilled Nursing): “Instruct pt/cg to maintain daily weights and report any weight gain of >3 lbs in any 24 hour period or 3-5 lbs in a week to SN or MD.” PT (Physical Therapy): “Instruct Pt/Caregiver to weigh daily and to report variations of 2 lb/24 hours or 5 lb/7 days to MD. Instruct pt to log weights daily, clinicians to monitor. If unable to weigh, measure BLE edema and report changes of 2 cm or greater to the MD.” As above, Staff A was asked where to find weights on the physical therapy notes. Staff A reported there is not a place on the PT notes, but the nurse should be doing it since there was one involved in the care of this patient. She was unsure why PT would pick that intervention. Upon further review of the nursing notes, it was noted that it was documented on 1/2/24 that the patient is unable to stand on a scale. The skilled nursing notes did not contain edema measurements on 1/2/4/24 or 1/4/24. As a result, the patient’s weight/edema was not being monitored by any clinician at that time. Care was not coordinated between OT and nursing to determine who would monitor. Staff A and the Alternate Administrator acknowledged the findings during the interview on 3/7/24 at 10:00 AM.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the skilled professionals provided services as ordered by the physician in the plan of care for 1 (P-5) of 10 records reviewed, resulting in the potential for physical decline and unmet care needs for this patient. Findings include: P-5: This 94-year-old patient was admitted to home care on 11/3/23 with diagnoses of tibia fracture, muscle weakness, malnutrition, and congestive heart failure. During record review on 3/5/24, it was noted that the patient was ordered physical therapy once a week for 7 weeks, and occupational therapy once a week for 6 weeks. During the week of 12/11/23, there was no evidence the patient received physical therapy or occupational therapy visits. There was no evidence of missed visit documentation or that the physician was notified. This finding was reviewed and acknowledged by the administrator (Staff A) and the clinical manager (Staff B) during an interview on 3/7/24 at 3:25 p.m.”

“Aides are members of interdisciplinary team CFR(s): 484.80(g)(4) Home health aides must be members of the interdisciplinary team, must report changes in the patient’s condition to a registered nurse or other appropriate skilled professional, and must complete appropriate records in compliance with the HHA’s policies and procedures. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure home health aides reported changes in the patient’s condition to a registered nurse or other appropriate skilled professional in 2 (P-6 and 9) of 4 records reviewed with home health aide services, resulting in the potential for unmet care needs and poor patient outcomes. Findings include: P-9: This 79-year-old patient was admitted to this agency on 12/27/23 with the diagnoses of an unspecified fracture of the first lumbar vertebra, type II diabetes, high blood pressure, and chronic kidney disease. During record review on 3/5/24, it was noted the home health aide note dated 1/4/24 stated, “Bruising on back. Small skin tear on forehead. Left foot is swelling up a little.” There was no indication in the record this had been reported to the nurse. During further record review, it was noted the home health aide note dated 1/11/24 documented the patient’s systolic blood pressure (top number) to be 167. According to the parameters on the Plan of Care dated 12/27/23 and the daily aide notes, a systolic blood pressure over 160 should be reported to the nurse and ultimately to the physician. There was no indication in the record this had been reported to anyone. The Administrator (Staff A) and Alternate Administrator (Staff B) acknowledged the findings during an interview on 3/7/24 at 10:00 AM. P-6: This 89-year-old patient was admitted to home care on 2/9/24 with diagnoses of hypertensive heart disease, chronic congestive heart failure, and diabetes mellitus. During record review on 3/6/24, it was noted that the plan of care ordered home care staff to notify physician of diastolic blood pressure (bottom number) greater than 90 or less than 60. On 2/16/24, the home health aide documented a blood pressure of 113/57. There was no evidence the blood pressure finding was reported to the nurse. This finding was reviewed and acknowledged by the administrator (Staff A) and the clinical manager (Staff B) during an interview on 3/7/24 at 3:25 p.m.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure a completed transfer summary was sent to the physician within 2 business days of becoming aware of an unplanned transfer in 2 (P-4, and 9) of 3 records reviewed with a transfer, resulting in the potential for unmet patient care needs. Findings include: P-4: This 91-year-old patient was admitted to home care on 2/2/24 with diagnoses of atrial fibrillation, hypertensive chronic kidney disease and osteoarthritis. During record review on 3/4/24, it was noted that the patient was admitted to the hospital on 2/8/24 with hematuria and discharged home on 2/12/24. There was no documented evidence that a transfer summary was sent to the receiving agency within 2 business days of becoming aware of transfer. This finding was reviewed and acknowledged by the administrator (Staff A) and the clinical manager (Staff B) during an interview on 3/7/24 at 3:25 p.m. **Policy titled “III.10 TRANSFER/ TRANSFER OASIS” (undated) was reviewed stated, “The patient’s physician will be notified of any transfer and a transfer summary sent to the physician within 2 days of the patient’s transfer, or within 2 days of the Agency becoming aware of the transfer.” P-9: This 79-year-old patient was admitted to this agency on 12/27/23 with the diagnoses of an unspecified fracture of the first lumbar vertebra, type II diabetes, high blood pressure, and chronic kidney disease. During record review on 3/5/24, it was noted a patient transfer summary was completed for this patient on 1/26/24 following an unplanned transfer due to a fall. During an interview on 3/7/24, the Administrator (Staff A) was queried whether the transfer summary was sent to the doctor. Staff A reported there should be a completed fax transmission form scanned with the document after it is sent. Staff A was unable to locate one for this patient. Staff A then noted she typically hand delivers notes to this physician once per week. Staff A was asked how the agency keeps track of which records are hand delivered. Staff A acknowledged that the agency does not keep a list of what records are hand delivered, so there would be no evidence of it being done. She acknowledged the findings at the time of the interview.”