Three Rivers Health Homecare

“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 no later than 5 calendar days after the start of care in 1 (P-8) of 8 records reviewed, resulting in the potential for unmet care needs and poor patient outcomes. Findings include: **Policy titled “Patient Assessment” (reviewed 4/2024) stated, “At the start of care, the initial comprehensive assessment SOC/ROC Assessment will be initiated within 48 hours of referral or return home, and completed within 5 days.” P-8: This 75-year-old patient was admitted to this agency on 8/5/24 with the diagnoses of a right knee infection following a total knee replacement, pyogenic (septic) arthritis, and congestive heart failure (CHF). During record review on 8/20/24, it was noted the original referral (dated 8/2/24) ordered services from skilled nursing, physical therapy, and occupational therapy. Upon further review of the record, it was noted the start of care was initiated on 8/5/24 and the occupational therapy evaluation was not done until 8/13/24 – 8 days after the start of care. There was no documentation or new orders to explain the late evaluation. The Administrator (Staff A) was queried regarding the findings during an interview on 8/21/24 at 8:15 AM. Staff A stated the occupational therapist is part-time with the home care agency and has been on vacation, so it has been hard to complete services on time. However, Staff A reported the agency is currently interviewing for a full-time occupational therapist to help fulfill the need. Staff A acknowledged the findings.”

“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 accurately reflected the patient’s current health status at the time of admission for 4 (P-1, 2, 3, 8) of 8 records reviewed, resulting in incomplete clinical information to aide in determining the needs of these patients and assisting with developing the plan of care. Findings include: P-1: This 84-year-old patient was admitted to this agency on 8/5/24 with the diagnoses of chronic obstructive pulmonary disease (COPD) exacerbation, hypercalcemia (high levels of calcium in the blood), and weakness. During record review on 8/19/24, it was determined the physical therapist conducted the comprehensive assessment for the start of care on 8/5/24. During review of the comprehensive assessment, it was noted there was no manual muscle testing done to objectively assess the patient’s strength. P-2: This 64-year-old patient was admitted to this agency on 11/16/23 with the diagnoses of right hip arthritis, epilepsy, hypertension (high blood pressure), and type II diabetes. During record review on 8/20/24, it was determined the physical therapy evaluation was performed on 11/17/23. Upon review of the physical therapy evaluation, it was noted there was no manual muscle testing done to objectively assess the patient’s strength. Additionally, it was noted the Outcome Assessment Information Set (OASIS) dated 11/16/23 reported the patient was “4 – Chairfast, UNABLE to ambulate but is able to wheel self independently”. The OASIS also noted the patient was “dependent” (unable/fully reliant on the assistance of others) for ambulating (walking) 10 feet at the start of care and the goal was to remain “dependent”. Upon review of the physical therapy evaluation completed the following day, the patient was able to ambulate 25 feet with supervision assistance. This information is conflicting and does not paint a clear picture of the patient’s current or previous function. P-3: This 66-year-old patient was admitted to this agency on 10/15/23 with the diagnoses of left above the knee amputation (AKA), thrombosis (blood clots), and type II diabetes. During record review on 8/20/24, it was determined the physical therapy evaluation was performed on 10/17/23. Upon review of the physical therapy evaluation, it was noted there was no manual muscle testing done to objectively assess the patient’s strength. P-8: This 75-year-old patient was admitted to this agency on 8/5/24 with the diagnoses of a right knee infection following a total knee replacement, pyogenic (septic) arthritis, and congestive heart failure (CHF). During record review on 8/20/24, it was determined the physical therapy evaluation was performed on 8/6/24. Upon review of the physical therapy evaluation, it was noted there was no manual muscle testing done to objectively assess the patient’s strength. The Physical Therapist (Staff D) was interviewed following a joint home visit on 8/21/24 at 10:30 AM. Staff D reported he sometimes does manual muscle testing but admits that he doesn’t always assess it specifically. Staff D agrees that strength should be measured on patient’s being treated for weakness to assess their current status and assess progress with the treatment plan. Findings were also reviewed and acknowledged by the Administrator (Staff A) during an interview on 8/21/24 at 8:15 AM.”

“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 potential adverse effects and drug interactions in 5 (P-1, 2, 3, 6, 8) of 8 records reviewed, resulting in the potential for harmful medication effects for all patients serviced by this agency. Findings include: P-6: The Start of Care (SOC) was dated 1/8/24. The Plan of Care (POC) identified diagnoses of Venous Insufficiency, Congestive Heart Failure and Diabetes Type 2. During record review on 8/20/24, it was noted that the Registered Nurse (RN) completed a comprehensive assessment on 1/8/24 and documented, “Drug Regimen Review: Yes, Issues found during review. Medication follow-up: Did the agency contact a physician by midnight of the next calendar day and complete prescribed/recommended actions in response to the identified potential clinically significant medication issues? Yes.” The agency’s “Interactions” report located within the “Medication Profile”, generated by the Electronic Medical Record (EMR) identified 2 potentially severe drug to drug interactions, Trimethoprim and Losartan, and Dextromethorphan and Tramadol. There was no documented evidence that a drug interaction review had in fact been conducted to identify any adverse reactions or effects, or documented evidence that the physician had been notified of the above findings. This finding was reviewed with and acknowledged by the Staff A (Administrator) during an interview on 8/21/24 at 10:50 am. **Policy titled “Medication Oversight” (revised 4/2024) stated, “E. A Registered Nurse will assess all medications a patient may be taking to identify possible duplicate or ineffective drug therapy, significant side effects, drug allergies, adverse effects, and drug reaction. Any problem will be documented in the medical record and reported to the physician.” P-1: This 84-year-old patient was admitted to this agency on 8/5/24 with the diagnoses of chronic obstructive pulmonary disease (COPD) exacerbation, hypercalcemia (high levels of calcium in the blood), and weakness. During record review on 8/19/24, it was noted the Outcome and Assessment Information Set (OASIS) indicated a drug regimen review was completed under “M2010 Drug Regimen Review” and “Yes - Issues found during review.” Additionally, it was noted on the OASIS under “M2003 Medication Follow-up” that the agency completed the “prescribed/recommended actions in response to the identified potential clinically significant medication issues” regarding contacting the physician. A drug interaction report run by the agency’s electronic medical record (EMR) system identified 5 “Major” drug to drug interactions. There was no documented evidence the physician was contacted to reconcile the potentially clinically significant interactions identified according to agency policy. P-2: This 64-year-old patient was admitted to this agency on 11/16/23 with the diagnoses of right hip arthritis, epilepsy, hypertension (high blood pressure), and type II diabetes. During record review on 8/20/24, it was noted the OASIS indicated a drug regimen review was completed under “M2010 Drug Regimen Review” and “Yes - Issues found during review.” Additionally, it was noted on the OASIS under “M2003 Medication Follow-up” that the agency completed the “prescribed/recommended actions in response to the identified potential clinically significant medication issues” regarding contacting the physician. A drug interaction report run by the agency’s EMR system identified 13 “Severe” drug to drug interactions and multiple “Major” drug to drug interactions. There was no documented evidence the physician was contacted to reconcile the potentially clinically significant interactions identified according to agency policy. P-3: This 66-year-old patient was admitted to this agency on 10/15/23 with the diagnoses of left above the knee amputation (AKA), thrombosis (blood clot), and type II diabetes. During record review on 8/20/24, it was noted the OASIS indicated a drug regimen review was completed under “M2010 Drug Regimen Review” and “Yes - Issues found during review.” Additionally, it was noted on the OASIS under “M2003 Medication Follow-up” that the agency completed the “prescribed/recommended actions in response to the identified potential clinically significant medication issues” regarding contacting the physician. A drug interaction report run by the agency’s EMR system identified 4 “Severe” drug to drug interactions and >25 “Major” drug to drug interactions. There was no documented evidence the physician was contacted to reconcile the potentially clinically significant interactions identified according to agency policy. The Administrator (Staff A) was queried regarding the agency’s practice for reporting drug interactions found on the medication review during an interview on 8/21/24 at 8:15 AM. Staff A stated the agency reports clinically significant interactions to the physician to reconcile, however, she was unable to define what types of interactions that included in regard to the wording in the drug interaction report. When asked about communication with the physician regarding the drug interactions identified, Staff A stated staff often document details regarding the reconciliation in a communication note or the next daily note to reflect any new orders or changes to the current regimen. However, Staff A was unable to find this information for the patients above and acknowledged the findings. P-8: This 75-year-old patient was admitted to this agency on 8/5/24 with the diagnoses of a right knee infection following a total knee replacement, pyogenic (septic) arthritis, and congestive heart failure (CHF). During record review on 8/20/24, it was noted the OASIS indicated a drug regimen review was completed under “M2010 Drug Regimen Review” and “No – No issues found during review.” A drug interaction report run by the agency’s EMR system identified 1 “Severe” drug to drug interaction and 24 “Major” drug to drug interactions. Staff A was unable to provide an explanation of why the OASIS indicated no issues were found during review and acknowledged the findings during an interview on 8/21/24 at 8:15 AM.”

“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 that the agency failed to ensure the Plan of Care included objectively measurable and individualized goals in 4 (P-4, 5, 6, 7) of 8 records reviewed; safety precautions in 4 (P-2, 3, 6, 7) of 8 records reviewed; and covered all pertinent interventions with reportable parameters in 1 (P-7) of 8 records reviewed, resulting in patients not receiving care specific to their needs and the potential for poor patient outcomes. Findings included: P-2: This 64-year-old patient was admitted to this agency on 11/16/23 with the diagnoses of right hip arthritis, epilepsy, hypertension (high blood pressure), and type II diabetes. During record review on 8/20/24, it was determined the plan of care (POC) failed to include diabetic precautions under safety measures. P-3: This 66-year-old patient was admitted to this agency on 10/15/23 with the diagnoses of left above the knee amputation (AKA), thrombosis (blood clots), and type II diabetes. During record review on 8/20/24, it was determined the POC failed to include diabetic precautions under safety measures. Findings were reviewed with and acknowledged by the Administrator (Staff A) during an interview on 8/22/24 at 8:15 AM. **Agency Policy: “Plan of Care,” (Last Approved 04/2024). The policy states, “C. The Plan of Care must include the type of services to be provided and the frequency and duration of these services, including: 2. Specific procedures and treatments, including frequency and duration.” **Agency Policy: “Clinical Records - Documentation,” (Last Approved 01/2024). The policy states, “8. Plan of Care (485) which includes but is not all inclusive of: h. DME (Durable Medical Equipment) and supplies. j. Safety measures.” P-6: The Start of Care (SOC) was dated 1/8/24. The Plan of Care (POC) identified diagnoses of Venous Insufficiency, Congestive Heart Failure and Diabetes Type 2. During record review on 8/20/24, it was noted that the goals within the POC were not measurable. For example, one goal stated, “Pt (Patient) free from falls.” Additionally, another goal stated, “Pt verbalize changing peri pad when damp.” Additionally, the POC failed to include the safety measures of diabetic precautions. The agency failed to ensure the POC covered all pertinent treatments and interventions with measurable goals and safety measures. P-7: The Start of Care (SOC) was dated 2/17/23. The Plan of Care (POC) identified diagnoses of Cystostomy, Chronic Obstructive Pulmonary Disease and Diabetes Type 2. During record review on 8/19/24, it was noted that the goals within the POC were not measurable. For example, one goal stated, “Indwelling catheter/drainage system patent and functioning without complication.” Additionally, another goal stated, “Patient/caregiver demonstrate proper administration of inhalation therapy.” Additionally, the POC failed to include the safety measures of diabetic precautions. Furthermore, the POC failed to include any diabetic supplies. On 6/13/24, the Registered Nurse documented, “Diabetes: Glucose Monitoring: Blood Glucose Monitor.” Lastly, the POC failed to include an intervention to assess vital signs with reportable parameters. The agency failed to ensure the POC covered all pertinent treatments and interventions with measurable goals, safety precautions, diabetic supplies and reportable parameters. These findings were reviewed with and acknowledged by the Staff A (Administrator) during an interview on 8/21/24 at 10:30 am. P-4: The Start of Care was dated 7/11/24. The Plan of Care for the certification period 7/11/2024 to 9/8/2024 identified diagnoses of Diabetes Type 2 with foot ulcer; Diabetes Type 2 with diabetic neuropathy; non-pressure ulcer of left heel and midfoot with fat layer exposed; Hypertension; Presence of coronary angioplasty implant with bypass graft. Upon review of the record on 8/20/24, it was noted the goals on the Plan of Care were not objectively measurable to determine the patient’s progress towards achieving the goals. Examples included: “Patient/Caregiver will verbalize understanding and demonstrate compliance with recommended ADA diet. This goal is not objectively measurable to determine the patient’s progress towards achieving the goal. P-5: The Start of Care was dated 8/10/2024. The Plan of Care for the certification period 8/10/24 to 10/8/24 identified diagnoses of Acute and subacute infective endocarditis; Sepsis due to specified staphylococcus; Encounter for surgical aftercare following surgery on the circulatory system; Acute respiratory failure with hypoxia; Congestive Heart Failure and Diabetes Type 2. Upon review of the Plan of Care, it was noted the goals were not objectively measurable to determine the patient’s progress towards achieving the goals. Examples include: “Patient/Caregiver verbalize understanding of disease process including prognosis, signs/symptoms, complications, effect of disease on body systems and what to report; Patient/Caregiver will verbalize understanding of anticoagulant precautions, signs/symptoms of bleeding to report; Patient/Caregiver understands and adheres to prescribed diet.” These goals are not objectively measurable to determine the patient’s progress towards achieving the goals. These findings were reviewed and acknowledge by Staff A (Administrator) during an interview on 8/21/24 at 11:30 am.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the clinical record contained all assessments from the most recent home health admission in 1 (P-8) of 8 records reviewed, resulting in the potential for unmet or overlooked care needs. Findings include: **Policy titled “Clinical Records – Documentation” (revised 1/2024) stated, “9. Documentation must be timely and accurate. Staff are to document all direct care delivery during the visit immediately after the visit, on the day service is rendered. Documentation must be incorporated into the clinical record now less often than weekly.”’ P-8: This 75-year-old patient was admitted to this agency on 8/5/24 with the diagnoses of a right knee infection following a total knee replacement, pyogenic (septic) arthritis, and congestive heart failure (CHF). During record review on 8/20/24, it was noted the occupational therapist evaluated the patient on 8/13/24. As of 8/21/24 at 8:30 AM, the evaluation was not completed – 8 days after the visit took place. During the entrance interview on 8/19/24 at 10:00 AM, the Administrator (Staff A) was asked what the expectation is for completion of documentation. Staff A reported her expectation is 48 hours, however, later provided the policy above. During a second interview on 8/21/24 at 8:15 AM, Staff A was shown missing documentation for P-8. Staff A was unable to provide an explanation for the late/missing documentation and acknowledged the findings.”