Central Home Health Care

“Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This Standard is not met as evidenced by: Based on record review and interview, it was determined the home health agency failed to ensure the physician orders were followed in 1 of 7 records (P-6) from a total of 7 records reviewed, resulting in the potential for unmet care needs for agency patients. Findings include: P-6: The start of care (SOC) was dated 9/13/23. The plan of care (POC) dated 9/13/23, identified the diagnoses of lumbar fusion and spinal stenosis. The POC documented physical therapy (PT) services ordered at a visit frequency of 2w2 and 1w7. During review of the record on 1/9/24, it was discovered that PT had a missed visit between 9/23/23 and 10/6/23. There was no documentation in the record explaining the missed visit. During an interview on 1/9/24 at 10:10 p.m., the administrator (Adm#1) acknowledged the findings.”

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on observation, interview and record review, the agency failed to ensure that 2 (P’s #2, 3) patients observed during home visits, were included in the overall planning of their care including informing the patient/caregiver in advance of the days in which services would be provided, from a total of 7 sampled records reviewed, resulting in a lack of inclusion in planning, lack of informed consent, the potential for missed visits and unmet care needs. Findings include: P-2: The patient’s start of care (SOC) was 1/1/24 with diagnoses that included Anterior Cervical Decompression with fusion. During the record review on 1/9/24 at 2:00 p.m., it was noted that the plan of care (POC) ordered Skilled Nursing (SN), Physical Therapy (PT) and Occupational Therapy (OT) services to be provide. On 1/9/24, during a scheduled survey home visit with the Skilled Nurse (RN #1), it was noted that the patient’s admission packet was void of a completed calendar of proposed visits to be made by the nurse or any of the other ordered disciplines. During the visit, the patient questioned, “Are you coming back to see me? RN #1 stated a day in which to report, however the patient stated, “No. That won’t work due to plans.” RN #1 then stated, “Well, I can come back Thursday around 9.” The patient reported, “No. That’s too early.” RN #1 then changed the time to later in the day. During the visit, the nurse stepped away to dispose of items. During that time, the patient reported, “They (staff) come out whenever they want to, and my husband doesn’t like it.” These findings were reviewed with and acknowledged by the Administrator (Adm #1) and Alternate Administrator (Adm #2) during an interview on 1/10/24 at 2:50 p.m. P-3: The patient’s SOC was 12/29/23 with diagnoses that included Lumbar Radiculopathy and Greater Trochanter Bursitis. The POC ordered PT services to be provided. On 1/9/24, during a scheduled survey home visit with PT #1, it was noted that the patient’s admission packet was void of a completed calendar of proposed visits to be made by the PT. During the visit, the patient asked PT #1 when he would be coming back for the next PT visit as it had not been noted on the provided calendar. These findings were reviewed with and acknowledged by Adm #1 and Adm #2 during an interview on 1/10/24 at 3:15 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 Initial Comprehensive Assessment accurately reflected the patient’s condition at the time of admission and documented the events that lead to the need for home care for 4 (P#’s 4, 5, 6, 7) patients admitted to this agency, from a total of 7 sampled records reviewed, resulting in the potential for unidentified health concerns and unmet care needs. Findings include: P-4: The patient’s start of care (SOC) was 8/24/23, with diagnoses that included diabetes mellitus, cerebral infarct, and heart disease. On 1/8/24, during the clinical record review, it was noted that the initial Comprehensive Assessment listed all diagnoses with an onset date of 8/24/23. There were no documented diagnoses history, onset, or previous treatments in the SOC assessment. Under each body system section of the SOC assessment, there was a lack of information documented to ascertain home care needs. P-5: The patient’s start of care (SOC) was 11/20/23, with diagnoses that included orthopedic aftercare, spondylosis, and spinal stenosis. On 1/9/24, during the clinical record review, it was noted that the initial Comprehensive Assessment listed all diagnoses with an onset date of 11/20/23. There were no documented diagnoses history, onset, or previous treatments in the SOC assessment. Under each body system section of the SOC assessment, there was a lack of information documented to ascertain home care needs. P-6: The patient’s start of care (SOC) was 9/13/23, with diagnoses that included lumbar fusion, and spinal stenosis. On 1/9/24, during the clinical record review, it was noted that the initial Comprehensive Assessment listed all diagnoses with an onset date of 9/13/23. There were no documented diagnoses history, onset, or previous treatments in the SOC assessment. Under each body system section of the SOC assessment, there was a lack of information documented to ascertain home care needs. P-7: The patient’s start of care (SOC) was 12/29/23, with diagnoses that included multiple fracture of ribs, and acute pain. On 1/10/24, during the clinical record review, it was noted that the initial Comprehensive Assessment listed all diagnoses with an onset date of 12/29/23. There were no documented diagnoses history, onset, or previous treatments in the SOC assessment. Under each body system section of the SOC assessment, there was a lack of information documented to ascertain home care needs. During an interview on 1/11/24 at 10:10 a.m., the administrator (Adm#1) and the alternate administrator (Adm#2) acknowledged the above findings.”

“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 an accurate review of all medications to determine potential adverse effects or duplicate drug therapy in 1 of 7 (P- 6) records reviewed, resulting in the potential for harmful medication effects for all patients serviced by this agency. Findings include: P-6: The patient’s start of care (SOC) was 9/13/23, with diagnoses that included lumbar fusion, and spinal stenosis. On 1/9/24, during the clinical record review, it was noted that the initial medication profile dated 9/13/23, was signed by the physical therapist (PT), had no medication reconciliation attached, and documented no interactions or adverse reactions found. A registered nurse cosigned the original medication profile on 9/21/23, 8 days later, and had a medication reconciliation attached that documented major interactions found. The physical therapist missed the major interactions that the RN found 8 days later. During an interview on 1/11/23 at 10:10 a.m., the administrator (Adm#1) and the alternate administrator (Adm#2) acknowledged the above findings.”

“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, it was determined the agency failed to ensure the plan of care included all safety measures to prevent injury in 1 of 7 records reviewed (P-7). resulting in the potential for a poor patient outcome. Findings include: P-7: The SOC was dated 12/29/23, with diagnoses that included multiple fracture of ribs and acute pain. During review of the Plan of Care (POC) on 1/9/24, it was documented that the patient had Plavix (Anticoagulant) ordered. No bleeding or anticoagulant precautions were documented on the POC. During an interview on 1/11/24 at 10:10 p.m., the administrator (Adm#1) acknowledged the findings and said the precautions should have been on the POC.”

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure the skilled nurse performed ongoing assessments of the patient’s surgical site for 1 (P-2) patient who underwent surgery and reported feeling a lump near the surgical site, from a total of 7 sampled records reviewed, resulting in the potential for worsening of condition, development and spread of infection and unmet care needs. Findings include: P-2: The patient’s start of care was 1/1/24 with diagnoses that included Anterior Cervical Decompression surgery with Fusion. On 1/9/24 during a scheduled survey home visit with the Registered Nurse (RN #1), the patient was observed with a horizonal incision to her anterior neck. During the visit, the patient reported, “I feel a lump above my incision and some itching.” RN #1 glanced at the patient’s neck yet took no additional action. The plan of care instructed, “Assessment of Cervical surgical area for palpable edema...” RN #1 failed to follow the plan of care and assess/palpate the surgical area for edema. These findings were reviewed with and acknowledged by RN #1 upon completion of the visit and discussed with the Administrator and Alternate Administrator during an interview on 1/10/24 at 2:50 p.m. On 1/11/24, the Administrator approached this writer and stated, “I spoke with the nurse (RN #1), and she acknowledged that she didn’t assess the patient’s surgical incision. We’re sending her back out there to do another assessment.””

“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 Occupational Therapy services were provided as ordered for 1 (P-2) patient who underwent cervical surgery, and 1 (P-6) patient with lumbar surgery, from a total of 7 sampled records reviewed, resulting in the potential for decline in physical functioning and unmet care needs. Findings include: P-2: The patient’s start of care was 1/1/24 with diagnoses that included Cervical Disc Disorder and Anterior Cervical Decompression with Fusion. On 1/9/24 at 2:00 p.m., during the clinical record review, it was noted that the referral for home care services dated 12/28/23, ordered Skilled Nursing (SN), Physical Therapy (PT) and Occupational Therapy (OT) services to be provided. At the time of this review, OT services had not been provided. These findings were reviewed with and acknowledged by the Administrator (Adm #1) during an interview on 1/10/24 at 2:50 p.m. who reviewed the record and reported, “I don’t think the nurse offered the services (OT) to the patient.” No OT services had been provided by the survey’s exit. P-6: The patient’s start of care was 9/13/23, with diagnoses that included spinal stenosis with spinal fusion. During record review on 1/9/24, it was noted that the home care referral dated 9/6/23, had occupational therapy (OT) services ordered. There was no documentation in the record of any OT services being provided to the patient. These findings were acknowledged by the administrator (Adm #1) and the alternate administrator (Adm#2) during an interview on 1/11/24 at 10:10 a.m. Adm#1 said it looks like OT never went out to the patient.”