Up Health System Home Care and Hospice Portage

“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 include objectively measurable goals on the plan of care for 5 of 10 records reviewed (P-1, P-2, P-4, P-8, P-10) resulting in the inability to determine the patient’s progress towards obtaining the goals. Findings include: P-1: The Start of Care (SOC) was dated 3/9/2024. The Plan of Care (POC) for the Certification Period 7/1/24 to 8/29/24 identified diagnoses of Diabetes type 2, Atrial Fibrillation, Alzheimer’s Disease, Coronary Artery Disease, Hypertension, Depression, and Alzheimer’s Disease. This patient was receiving Skilled Nursing and Physical Therapy Services. This patient was receiving Skilled Nursing (SN) services. Upon review of the Plan of Care, it was noted the goals were not objectively measurable to determine the patient’s progress towards obtaining the goals. An example included: “Patient/Caregiver will demonstrate ability to administer medications via Planner Device by being compliant with medications by 8/24/24”. These goals are not objectively measurable to determine the patient’s progress towards obtaining the goals. P-2: The Start of Care was dated 4/28/2024. The Plan of Care for the Certification Period 4/28/24 to 6/26/24 identified diagnoses of Hypertensive Heart Disease with Heart Failure (HTN), Diabetes type 2 (DM2), Chronic Systolic and Diastolic Heart Failure (CHF), Anemia, Wheelchair Dependent, and History of Falling. The patient was receiving Skilled Nursing (SN) and Physical Therapy (PT) services. Upon review of the Plan of Care, it was noted the goals were not objectively measurable. Examples included: “Patient/Caregiver will Verbalize/Demonstrate adequate knowledge of safe provision of ADLs (Activities of Daily Living) as evidenced by appropriate home management without complications or injury by 6/25/24; Patient/Caregiver will understand and demonstrate compliance with treatment regimen for diabetes as evidenced by patient verbalizing definition of diabetes by 6/1/24; Patient will achieve highest functional level as outlined in Therapy Plan of Care Objective Goals with Active Range of Motion and/or muscle strength and performance of Home Exercise Program order to maximize lower extremity function by 8 weeks; Patient/Caregiver will verbalize/demonstrate understanding of recommended safety and fall risk reduction strategies by 8 weeks. These goals are not objectively measurable to determine the patient’s progress towards achieving the goals. These findings were reviewed with and acknowledged by the Administrator (Staff A) and the patient care manager (Staff B) during an interview on 7/10/24 at 3:00 p.m. P-4: This patient was admitted to home care on 6/7/24 with diagnoses of Alzheimer’s disease and dementia. The patient was receiving physical therapy services. During record review on 7/9/24 it was noted the 6/7/24 plan of care included the following goals: patient will achieve highest functional level, as outlined in therapy plan of care objective goals with safe transfer(s) with appropriate technique and equipment to allow for in home by 8 weeks; and patient will achieve highest functional level, as outlined in therapy plan of care objective goals, with gait quality, ability to ascend/descend steps/ramps and/or functional ambulation to navigate within the home by 8 weeks. These goals were not stated in measurable terms that would enable staff to perform an objective evaluation of the patient’s progress towards her goals. The finding was reviewed with and acknowledged by the Administrator (Staff A) and the patient care manager (Staff B) during an interview on 7/10/24 at 12:35 p.m. P-8: This 69-year-old patient was admitted to home care on 4/16/24 with diagnoses of hemiplegia post stroke and type 2 diabetes. During record review on 7/9/24, it was noted that the plan of care failed to include measurable nursing goals that were individualized to address patient needs. For example, one goal stated, “patient will achieve highest functional level, as outlined in therapy POC (plan of care) objective goals with safe transfer(s) with appropriate technique and equipment to allow for in home by 8 weeks.” [sic] Another goal stated, “patient/caregiver will verbalize/demonstrate understanding of recommended safety and fall risk reduction strategies by 8 weeks.” There was no evidence of how these goals could be objectively measured to determine progress toward meeting the goals. P-10: This 88-year-old patient was admitted to home care on 6/24/24 with diagnoses of pneumonitis, benign prostatic hyperplasia, and hypertensive heart disease with heart failure. During record review on 7/10/24, it was noted that the plan of care failed to include measurable nursing goals that were individualized to address patient needs. For example, one goal stated, “patient will achieve highest functional level, as outlined in therapy POC objective goals, with AROM (active range of motion), and/or muscle strength and performance of HEP (home exercise program) order to maximize lower extremity function.” Another goal stated, “patient will achieve highest functional level, as outlined in therapy POC objective goals, with sitting and/or standing balance in order to reduce the risk for falls.” 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 patient care manager (Staff B) during an interview on 7/10/24 at 12:25 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 skilled nurse failed to provide baseline data in the Comprehensive Assessment to use in determining if the patient’s Diabetes was improving or worsening with each visit assessment during the course of care in 1 of 7 records reviewed (P-3). Findings included: P-3: The Start of Care was dated July 2, 2023. The Plan of Care for the recertification period of 1/10/24 to 3/7/24 included diagnoses of Diabetes type 2, Right and Left Hand Pain, Left knee pain, Osteoarthritis, Poly arthropathy, History of Falling, Hypertension, Migraine Headaches, Sinusitis, Long-term use of smoking cigarettes, and Post-Traumatic Stress Disorder (PTSD). Upon review of the Comprehensive Assessment, it was noted there was no baseline data or range of the patient’s blood sugar readings to use to determine if the patient’s diabetes was stable, improving, or worsening. This finding was reviewed with and acknowledged by the Administrator (Staff A) and the patient care manager (Staff B) during an interview on 7/10/24 at 3:00 p.m.”

“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-8) of 10 records reviewed, resulting in the potential for unmet care needs. Findings include: P-8: This 69-year-old patient was admitted to home care on 4/16/24 with diagnoses of hemiplegia post stroke and type 2 diabetes. During record review on 7/9/24, it was noted that the plan of care ordered licensed professionals to report pain level greater than 5 to the primary care provider (PCP). On 5/24/24, the speech language pathologist documented sharp pain located in the center low back, rated as a 7 on a scale of 0-10. There was no evidence the PCP was notified. This finding was reviewed and acknowledged by the administrator (Staff A) and patient care manager (Staff B) during an interview on 7/10/24 at 12:25 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 transfer summary was sent to the receiving facility within 2 days of becoming aware of an unplanned transfer for 1 of 1 (P-6) records reviewed in which the patient was transferred, and failed to ensure a discharge summary was sent to the physician within 5 business days of the patient’s discharge for 1 of 3 (P-6) records reviewed in which the patient was discharged from the agency, resulting in the physician or receiving facility not having knowledge of the patient’s health status at the time of transfer/discharge and the potential for unidentified care needs. Findings include: P-6: This patient was admitted to home care on 4/26/24 with diagnoses of a toe amputation on the right foot, type 2 diabetes, and acute respiratory failure with hypoxia. During record review on 7/10/24, it was noted the patient was discharged/transferred to the hospital on 6/24/24. The discharge/transfer summary was faxed to the patient’s physician and the receiving hospital on 7/1/24, which is 7 days post discharge/transfer. There was no evidence the hospital received a transfer summary within 2 days of the agency becoming aware of the transfer, and no evidence the physician was informed of the discharge within 5 days of discharge. The finding was reviewed with and acknowledged by the Administrator (Staff A) and the patient care manager (Staff B) during an interview on 7/10/24 at 12:35 p.m.”

“Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This Element is not met as evidenced by: Based on record review and interview, the agency failed to contact the physician in 1 of 10 records reviewed (P-10) for wound care, from a total of 10 records reviewed, resulting in the potential for unresolved healthcare concerns. Findings include: P-10: This patient was admitted to home health care on 8/9/2023, with diagnoses of hemiplegia (Recent stroke affecting right dominant side, occurred in July of 2023), urinary tract infection (UTI), type 2 diabetes, dysphagia (Difficulty swallowing), peripheral vascular disease (reduced blood flow to extremities), and long-term use of insulin. Record review on 3/6/24 showed the plan of care (POC) dated 8/9/23, had skilled nursing visits ordered at a frequency of 2 visits a week for 1 week, then 1 visit a week for 8 weeks. Physical Therapy was ordered at a frequency of 1 visit a week for 2 weeks, 2 visits a week for 2 weeks, then 1 visit a week for 2 weeks. Speech Therapy was ordered at a frequency of 1 visit for 1 week. Home Health Aid services were ordered at a frequency of 1 visit a week for 4 weeks. A Start of Care nursing assessment visit note dated 8/9/24, documented that the nurse was unable to obtain a weight. The patient was unable to walk or stand. The patient is confined to bed. The patient depends entirely upon someone else for all needs. A lower right leg amputation was observed. A blood glucose of 162 was documented. Blood glucose parameters were ordered on the POC, and to notify the physician of blood glucose below 70 or above 250. Caregiver is non-compliant with medication administration. Caregiver stated, “I do not give insulin if the blood sugar is below 200.” Patient is currently not taking any medications on the medication list. This was confirmed by the caregiver and patient’s primary care provider office. Caregiver was educated on medications and nutrition. Patient has a poor appetite and eats one third or less of food provided. No wound documented at this visit. Skilled nurse visit note dated 8/12/23 documented a new wound to left heel and MD was notified. Skilled nursing visit note on 8/17/23 documented an assessment of the left heel stage II pressure ulcer wound site. Educated caregiver on elevating the foot and keeping pressure off the wound. The caregiver was also educated on keeping the patient hydrated and signs and symptoms of dehydration. The caregiver acknowledged the teaching. Caregiver said they are happy with the aide services provided by the agency. A nursing visit note documented a visit scheduled for 8/25/23 and was declined by the patient’s caregiver due to other appointments. A skilled nursing visit note dated 8/28/23 documented that the patient saw the podiatrist last Friday, 9/22/23, due to wound, with orders obtained for skilled nursing to monitor wound weekly. Wound skin is intact, boggy to touch and dark purple. No open areas and no signs of infection. Caregiver educated on daily cleansing and drying area. Also educated on importance of offloading pressure to the wound area including using device/booty and floating heel with pillow. A skilled nursing visit note dated 8/29/23 documented the wound was assessed, no open area, dark in color, no signs of infection. Patient’s heels were floated upon arrival, but patient did kick off pressure boot. Caregiver educated. Blood sugar was 303 this morning, MD notified. A1C was obtained (Results came back at 9.6). A skilled nursing visit on 9/5/23 documented assessment, education and wound care done. Blood sugar is 350 at this time. Blood sugar was 395 at 10:30. Caregiver states blood sugar yesterday was 275 and ranging between 226-395 the past week. Caregiver states she would like to start using the insulin again. MD notified of blood sugar levels and inability to obtain blood draw, awaiting call back for follow-up. A skilled nurse note dated 9/6/23 documented the patient went to the ER for hyponatremia (Low blood sodium). Skilled nurse note dated 9/9/23 documented assessment of wound, no signs or symptoms of infection, still monitoring. Pressure relieving boot in place for wound. Order for wound to be left open to air with pressure boot in place. Skilled nurse note dated 9/15/23 documented no wound concerns at this time, no change in wound status, boot in place. Skilled nurse note dated 9/19/23 documented no wound concerns at this time, no change in wound status, boot in place. Skilled nurse note dated 9/26/23 documented no wound concerns at this time, boot in place. Nurse practitioner visit on 9/27/23, no new orders. Skilled nurse visit note dated 10/4/23 documented education on wound care and medications. Skilled nurse visit dated 10/11/23 documented no changes to wound. No concerns noted. Skilled nurse note dated 10/16/23 documented no wound concerns at this time, no necrotic tissue was documented, boot in place. Nurse Practitioner visit on 10/17/23. No new orders. Skilled nurse visit on 10/25/23. Wound is closed, necrotic with hard tissue. No documentation in the record that the physician was notified of the necrotic tissue. Orders were to notify the physician of any changes to the wound. Skilled nurse visit on 10/30/23 with no changes. No documentation in the record that the physician was notified of the necrotic tissue. Orders were to notify the physician of any changes to the wound. 11/7/23 podiatrist visit with orders to start Doxycycline for foot infection. 11/8/23 nurse visit note documented wound covered with necrotic tissue. Skilled nurse visit note dated 11/11/23, home health care on hold due to patient admitted to U.P. Health System with left foot osteomyelitis and hypokalemia. On 10/16/23 the wound had no necrotic tissue. On the 10/25/23 Skilled Nurse visit, necrotic tissue on the wound was documented with no evidence in the record of communication to the doctor. On 10/30/23 a Skilled Nurse visit note documented necrotic tissue covering the wound. There was no documentation in the record that the physician was notified of the necrotic tissue. On 11/7/23 the podiatrist saw the patient and started antibiotics for a foot infection. 11/11/23 order to hold home care services due to the patient had been admitted to the hospital for osteomyelitis and hypokalemia.”