Northern Home Care, Inc.

“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, the agency failed to ensure skilled professionals notify the physician of findings that fell outside the parameters ordered in the patient’s plan of care in 2 of 10 (P-8, 9) records reviewed, resulting in the potential for physical decline and unmet care needs for these patients. Findings include: P-8: This 72-year-old patient was admitted to home care on 1/7/24 with diagnoses of orthopedic aftercare post laminectomy and lumbosacral disc disorder. During record review on 1/23/24, it was noted that the plan of care orders disciplines to notify the physician when the patient’s pain is greater than 7 (scale 0 low to 10 high). During the physical therapy (PT) visit on 1/11/24, the PT documented the current pain level of 8 in the lumbar region on the right side. There was no evidence to indicate the PT notified the physician of the patient’s elevated pain level as ordered in the plan of care. P-9: This 70-year-old patient was admitted to home care on 1/2/24 with diagnoses of type 2 diabetes, chronic venous ulcer, and lymphedema. During record review on 1/23/24, it was noted that the plan of care orders disciplines to notify the physician when the patient’s pain is greater than 7 (scale 0 low to 10 high). During the start of care assessment, dated 1/2/24, the registered nurse documented the current pain level of 8 in the right arm and right leg. There was no evidence to indicate the RN notified the physician of the patient’s elevated pain level as ordered in the plan of care. These findings were reviewed and acknowledged during an interview with the alternate administrator (Staff-A) and the director of clinical services (Staff-B) on 1/25/24 at 8:45 a.m.”

“HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator’s name, business address, and business phone number in order to receive complaints. This Element is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure patients were informed of the administrator’s name and phone number, resulting in the potential for patient complaints or concerns to go unaddressed which could negatively affect the quality of care for all patients serviced by this agency. Findings include: During review of the agency’s start of care booklet on 1/22/24, it was noted the back page of the booklet had a blank space after “administrator name” that was to be filled in by staff. During joint survey home visits for P-7 with the PT/RN on 1/23/24 at 10:30 a.m. and for P-9 with the PT/RN on 1/24/24 at 10:00 a.m., it was observed that the administrators name was blank on the back pages of both start of care booklets. This finding was reviewed and acknowledged during an interview with the alternate administrator (Staff-A) on 1/25/24 at 8:45 a.m.”

“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 to determine any duplicate therapy or adverse effects, and failed to ensure the physician was notified of potential drug interactions in 3 of 10 (P-6, 7, 1) records reviewed, resulting in the potential for harmful medication effects for all patients serviced by this agency. Findings include: P-1: This patient was admitted to home care on 7/25/23 with diagnoses of stage 1 pressure ulcer of right posterior upper thigh, multiple sclerosis, and paraplegia. During record review on 1/22/24, it was noted that the 7/25/23 comprehensive assessment completed by the registered nurse states that no issues were found during the drug regimen review. The same comprehensive assessment documents one possible major drug interaction between the patient’s medications: Ibuprofen and Paxil. There was no evidence the physician was notified. The findings were reviewed with the alternate administrator (Staff-A) and the director of clinical services (Staff-B) during an interview on 1/25/24 at 9:15 a.m. Staff-A reviewed the medical record, acknowledged the findings, and explained that staff are to contact the physician by phone and document such contact in the medical record. Agency Policy 8.15.1-Medication Reconciliation (February 2021) states the agency will reconcile patient’s medications at time of admission and on an ongoing basis in order to identify and potential adverse effects and drug reactions… At the time of admission, the admitting RN, PT, or SLP will create and document a complete list of medications that patient is taking at home, including dose, strength, route, and frequency. P-6: This 83-year-old patient was admitted to home care on 6/26/23, with a diagnosis of type 2 diabetes with foot ulcer. During record review on 1/22/24, it was noted that the skilled nursing recertification assessment, dated 6/26/23, stated no issues were found during medication review while the same document indicated two major interactions between omeprazole & Plavix and between amiodarone & atorvastatin. There was no evidence that the physician was notified of the interactions. P-7: This 93-year-old patient was admitted to home care on 1/18/24, with diagnoses of pneumonia, hypertensive heart disease, and congestive heart failure. During a home visit on 1/23/24 at 10:30 a.m., a medication review was conducted comparing the medications listed on the plan of care and with a medication administration record obtained by the assisted living facility, Village House of Ludington. It was noted that the patient receives furosemide 40mg daily and metoprolol succinate 25mg twice per day, and neither medication was listed on the plan of care. During record review on 1/23/24, it was noted that the discharge summary from the hospital, dated 1/16/24, states the patient is to start taking furosemide and metoprolol. There was no documented evidence that a drug review was conducted on these medications. These findings were reviewed and acknowledged during an interview with the alternate administrator (Staff-A) and the director of clinical services (Staff-B) on 1/25/24 at 8:45 a.m.”

“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 appropriate interventions with objectively measurable goals specific to the individualized needs of the patient in 3 of 7 (P-6, 9, 10) records reviewed, resulting in the potential for poor patient outcomes and unmet care needs for these patients. Findings include: P-6: This 83-year-old patient was admitted to home care on 6/26/23, with a diagnosis of type 2 diabetes with foot ulcer. During record review on 1/22/24, 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 verbalize understanding of fall risk and all aspects of associated care” and “patient’s pain will be managed at the patient’s own comfort level.” There was no evidence of how these could be objectively measured to determine progress toward meeting the goals. P-9: This 70-year-old patient was admitted to home care on 1/2/24 with diagnoses of type 2 diabetes, chronic venous ulcer, and lymphedema. During record review on 1/23/24, 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 remain complaint with medication safety” and “patient will verbalize understanding of diabetes mellitus and all aspects of associated care.” There was no evidence of how these could be objectively measured to determine progress toward meeting the goals. P-10: This 74-year-old patient was admitted to home care on 12/8/23 with diagnoses of chronic obstructive pulmonary disease, chronic respiratory failure, and congestive heart failure. During record review on 1/24/24, 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 remain complaint with medication safety” and “patient will be able to verbalize knowledge regarding food and fluid restrictions.” There was no evidence of how these could be objectively measured to determine progress toward meeting the goals. It was also noted that the plan of care failed to include bleeding precautions as the patient is on Eliquis, an anticoagulant medication that can cause bleeding. These findings were reviewed and acknowledged during an interview with the alternate administrator (Staff-A) and the director of clinical services (Staff-B) on 1/25/24 at 8:45 a.m.”

“Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This Element is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure patients were informed of the clinical managers name and phone number, resulting in the potential for patient concerns to go unaddressed which could negatively affect the quality of care for all patients serviced by this agency. Findings include: During review of the agency’s start of care booklet on 1/22/24, it was noted the back page of the booklet had a blank space after “clinical manager name” that was to be filled in by staff. During joint survey home visits for P-7 with the PT/RN on 1/23/24 at 10:30 a.m. and with the PT/RN for P-9 on 1/24/24 at 10:00 a.m., it was observed that the clinical managers name was blank on the back pages of both start of care booklets. This finding was reviewed and acknowledged during an interview with the alternate administrator (Staff-A) on 1/25/24 at 8:45 a.m.”

“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 record review and interview, the agency failed to ensure physical therapy performed an assessment of the patient’s health status and needs in 1 of 8 (P-2) records reviewed with physical therapy services ordered, resulting in the potential for unidentified health concerns, decline in physical functioning, and poor patient outcomes for this patient. Findings include: P-2: This patient was admitted to home care on 1/15/24 with diagnoses of angioneurotic edema (swelling under the skin) and pneumonia. During record review on 1/23/24, it was noted that the physical therapy evaluation dated 1/16/24 was blank of information regarding this patient’s physical functioning and needs. The findings were reviewed with the alternate administrator (Staff-A) during an interview on 1/25/24 at 9:15 a.m. Staff-A reviewed the medical record and acknowledged that the physical therapy evaluation was blank 9 days after the evaluation was conducted. Staff-A explained that staff are expected to have documentation completed within 48 hours.”

“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 registered nurse provided services as ordered by the physician in the plan of care for 1 of 10 (P- 9) records reviewed, resulting in the potential for physical decline and unmet care needs for this patient. Findings include: P-9: This 70-year-old patient was admitted to home care on 1/2/24 with diagnoses of type 2 diabetes, chronic venous ulcer, and lymphedema. During record review on 1/23/24, it was noted that the plan of care orders clinicians to assess/detect fluid overload, assess cardiovascular status and to notify the physician of a weight variation of 2 pounds in a day or 5 pounds in a week. An initial weight was documented on the nursing start of care assessment dated 1/2/24. There was no evidence of documented weights on the following three nursing visits (1/9/24, 1/16/24, and 1/23/24). This finding was reviewed and acknowledged during an interview with the alternate administrator (Staff-A) and the director of clinical services (Staff-B) on 1/25/24 at 8:45 a.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 detailed discharge summary was sent to the physician within 5 business days of discharge for 1 of 3 (P-6) discharge records reviewed, and failed to ensure a detailed transfer summary was sent to the physician for 1 of 1 (P-10) transfer records reviewed, resulting in a lack of information to ensure continuity of care. Findings include: Agency Policy 9.31.1: Discharge Summary (revised 2/2021) states a discharge summary will be sent within 5 business days of patient discharge to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient. P-6: This 83-year-old patient was admitted to home care on 6/26/23, with a diagnosis of type 2 diabetes with foot ulcer. During record review on 1/22/24, it was noted that the patient was discharged from agency services on 10/13/23. There was no documented evidence that a detailed discharge summary report was sent to the physician within 5 days of the patient’s discharge. P-10: This 74-year-old patient was admitted to home care on 12/8/23 with diagnoses of chronic obstructive pulmonary disease, chronic respiratory failure, and congestive heart failure. During record review on 1/24/24, it was noted that the patient was transported to the hospital on 1/2/24 and admitted with diagnoses of acute urinary tract infection with sepsis, diarrhea, acute hyponatremia, and acute hyperkalemia. The transfer summary dated 1/4/24 failed to include reason for admission to home health care, the frequency of services provided, and medications the patient was on at time of transfer. These findings were reviewed and acknowledged during an interview with the alternate administrator (Staff-A) and the director of clinical services (Staff-B) on 1/25/24 at 8:45 a.m.”