At Home Rehab

“Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This Standard is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the needs of the patient were met when Physical Therapy (PT) had discharged the patient in a state of clinical decline in 1 (P-7) of 3 records reviewed with Agency discharge by PT services, from a total sample of 7 records reviewed, resulting in the patient being prematurely discharged without care needs and goals being met. Findings included: P-7: The start of care (SOC) date for the patient was 3/29/24 with diagnoses which included chronic congestive heart failure, chronic kidney disease, bilateral knee osteoarthritis, and pressure ulcer of right hip-stage 2. On 9/25/24, record review noted P-7 was transferred (4/4/24 through 4/21/24), to sub-acute rehabilitation for failure to adequately participate in PT services. PT services re-evaluated P-7 on 4/23/24, with a visit frequency of 2W5 (twice a week for 5 weeks). During review of the re-evaluation, no ambulation distance was noted, and PT services documented the following: “Even with lifted recliner, patient has difficulty getting up due to severity of OA/weakness in his knees and his height... Bed is too low, and patient is requiring 2-3 assist to get up.” The patient’s Plan of Care (POC) documented, “Will improve safety and independence during ambulation on even surfaces with 4WW (wheeled walker) and SBA (stand by assist) x 200 feet. Achieve by date: 05/24/2024 Start effective date: 04/23/2024.” PT services documented on the next visit (4/26/24) that “Pt (patient) reports no c/o (compliant) of pain. Was walking really well yesterday but struggling more today. Chief c/o increased fatigue and weakness.” Despite the noted difficulties of P-7 on 4/26/24, the documented ambulation was still 235 feet. During the third visit prior to Agency discharge, PT had documented on 5/17 24 that the patient’s ambulation had decreased to 200 feet, despite an additional 5 PT visits after 4/26/24. On 5/21/24, PT documented that P-7’s ambulation further decreased to 175 feet with 4 WW on even surfaces with SBA, and no adverse findings were found. The day of discharge (5/24/24), PT documented that P-7’s gait was only “100 feet in home with 2WW mod (moderate); patient is slow and unable to come to full upright standing...”. However, PT still discharged the patient from the Agency despite the significant clinical decline with “Goals Met” which was sent to the physician. No evidence was found in the medical record that the Agency or PT services had communicated to the physician P-7 was discharged from the Agency with functional goals not met. An interview was conducted with the Agency’s Administrator (Adm. #1) on 9/26/24 at 11:25 AM. Adm. #1 reviewed and acknowledged the above findings and noted this did not meet Agency expectations or its policy referenced below. Agency Policy: “Coordination of Patient Services” C-360, pg. 202 (undated) stated, “The coordination of care is provided by all disciplines and included communication with physicians. Coordination of care means assuring that the patient needs are continually assessed, addressed in the Plan of Care, that care is delivered in a timely and effective manner, and that goals are achieved.” The Agency failed to ensure the patient had progressed in ambulation to meet safety standards and goals established in the plan of care.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information: (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 resumption of care (ROC) comprehensive assessment accurately reflected the patient’s current health status in 1 (P-7) of 1 record reviewed with a ROC, out of a total of 7 sampled records, resulting in incomplete clinical information and the potential for unmet care needs. Findings include: P-7: The start of care date for the patient was 3/29/24 with diagnoses which included chronic congestive heart failure, chronic kidney disease, bilateral knee osteoarthritis, and pressure ulcer of right hip-stage 2. On 9/25/24, record review noted P-7 was transferred (4/4/24 through 4/21/24) to sub-acute rehabilitation for failure to adequately participate in PT services. Review of the discharge summary from the rehabilitation facility documented the following concerning a new clinical finding: “skin tear Left wrist- cleanse the NS (normal saline) and cover with clean dressing.” (sic) However, review of the ROC comprehensive assessment performed by skilled nursing (SN) on 4/22/24, found no evidence in the clinical record of SN acknowledging or updating the clinical status of the skin tear noted above. An interview was conducted with the Agency’s Administrator (Adm. #1) on 9/26/24 at 11:25 AM. Adm. #1 reviewed and acknowledged the above finding and noted the nurse should have had assessment documentation regarding the status of the skin tear on the left wrist.”

“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 (POC) covered all pertinent interventions with reportable parameters, and objectively measurable goals specific to the needs of the patient for 1 (P-7) of 1 record reviewed with diagnosis of congestive heart failure, from a total sample of 7 records reviewed, resulting in patients not receiving care specific to their individual needs and the potential for poor patient outcomes. Findings include: P-7: The start of care (SOC) date for the patient was 3/29/24 with diagnoses which included chronic congestive heart failure, chronic kidney disease, bilateral knee osteoarthritis, and pressure ulcer of right hip-stage 2. On 9/25/24, review of P-7’s POC found the primary diagnosis of diastolic congestive heart failure (CHF) had no safety parameters to monitor for CHF exacerbation (worsening). In addition, 9 of 9 skilled nursing goals were not written in measurable terms to track the progress made (or lack of) concerning how the patient responded to treatments provided. Examples include: “Pt’s pain level will improve by Pt/Pcg (patient caregiver) verbalizing/demonstrating: Medication management for comfort and relief by using PRN (as needed) Tylenol, changing positions, using ice per preference by 5/10/24; Patient/Caregiver will verbalize/demonstrate understanding of symptom management, resource utilization and medication management to reduce unplanned hospital or emergency department visits by 5/24/24.” The above findings were reviewed and acknowledged by the Administrator (Adm. #1) during an interview on 9/26/24 at 11:25 AM. Adm. #1 stated this is not typical of the nurse’s documentation in this case and did not meet Agency expectations as referenced in its policy below. Agency Policy: “Plan of Care” C-580 pg.264 (undated) stated, “The plan will be consistently reviewed to ensure that patient needs are met... All of the above items must always be addressed on the Plan of Care; ... p. Treatment goals.” No language was found in the POC policy that goals must be measurable which is a CMS (Centers for Medicare and Medicaid Services) requirement.”

“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 and interview, the Agency failed to ensure the physician was promptly notified of elevated blood pressure readings outside of the reportable parameters for 1 (P-5) of 7 records reviewed in total, resulting in the potential to negatively affect the health and well-being of this patient. Findings include: P-5: This 92-year-old patient was admitted to home care on 7/6/24 with diagnoses which included lower back pain, diabetes-type 2, and hypertensive chronic kidney disease. On 9/25/24, record review noted the Plan of Care (POC) effective 7/6/24, ordered the physician to be notified regarding the following parameters for the patient’s blood pressure (BP): systolic > (greater) 140 or 90 or < 60. Further record review revealed the initial comprehensive assessment performed by physical therapy (PT) on 7/6/24, had documented P-5’s BP as 158/112. The next visit (7/10/24) by PT had documented the patient’s BP as 154/90. There was no documented evidence in the clinical record that the physician was promptly alerted as ordered concerning P-7’s elevated BP readings above, which were outside of safety parameters noted in the patient’s POC. These findings were reviewed with and acknowledged by the Administrator during an interview on 9/26/24 at 10:40 AM.”