Seasons Home Health Care

“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 to home care for 2 of 7 (P-1 and 5) records reviewed, resulting in incomplete clinical information to aid in determining the needs of this patient and for measuring the patient’s progress toward goals/outcomes. Findings include: P-5: This 94-year-old patient was admitted to home care on 8/14/23 with diagnoses of congestive heart failure, chronic respiratory failure, and type II diabetes mellitus. During record review on 11/16/23, it was noted that the start of care comprehensive assessment dated 9/14/23, failed to indicate whether initial weight was actual or stated to accurately assess and monitor potential worsening of congestive heart failure. This finding was reviewed and acknowledged by the administrator (ADM-1) and compliance officer (CO-1) during interview on 11/16/23 at 2:35 p.m. P-1: The Start of Care (SOC) was dated 9/15/2023. The Plan of Care for the certification period 9/15/23 to 11/13/23 identified diagnoses of Hypertensive on Chronic Diastolic Congestive Heart Failure (CHF), Cardiomyopathy, Type 2 diabetes (DM2), with hyperglycemia and diabetic polyneuropathy, Atherosclerotic heart disease of coronary arteries (CAD), and Atrial Fibrillation (A-fib). Upon review of the Comprehensive Assessment dated 9/15/23, it was noted that the skilled nurse documented an initial weight of 250 lbs., however, there was no documentation indicating whether the weight was stated or actual to determine if the patient’s congestive heart failure was improving or worsening during the course of care. In addition, the Skilled Nurse failed to document the patient’s blood sugar and/or the patient’s normal range of blood sugars on the Comprehensive Assessment to use as a baseline to determine if the patient’s blood sugars were stable, improving, or worsening during the course of care by the home health agency. These findings were reviewed and acknowledged by the administrator (ADM-1) and the compliance officer (CO-1) during an interview on 11/17/23 at 10:30 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 an accurate review of all medications to determine potential adverse effects or duplicate drug therapy in 2 of 7 (P-7 and P-1) records reviewed, resulting in the potential for harmful medication effects for all patients serviced by this agency. Findings include: Agency Policy No. 4-024.1: MEDICATION PROFILE, Revised May 2023 A drug regimen will be performed at the time of admission…performed by qualified personnel and will identify drug/food interactions, potential adverse effects and drug reactions, ineffective drug therapy, duplicative drug therapy, and noncompliance with drug therapy. P-7: This 90-year-old patient was admitted to home care on 9/28/23 with diagnoses of cerebral infarction and muscle weakness. During record review on 11/15/23, it was noted that the start of care RN assessment, dated 9/28/23, stated (under M2001 Drug Regimen Review) that no issues were found during review. The patient medication record indicated there were no medication discrepancies and no severe medication interactions. During interview on 11/16/23 at 2:35 p.m., the administrator ran a medication interaction report through the electronic medical record software that indicated two duplicate therapies: Blue Gel External 2%/Biofreeze Roll-On External Gel 4% and amlodipine 10mg/Losartan 50mg. There was no evidence the primary care provider was notified. The administrator (ADM-1) and the compliance officer (CO-1) acknowledged this finding, stating, “the nurse did not document the duplicate drug therapy” during an interview on 11/16/23 at 2:35 p.m. P-1: The Start of Care (SOC) was dated 9/15/2023. The Plan of Care for the certification period 9/15/23 to 11/13/23 identified diagnoses of Hypertensive on Chronic Diastolic Congestive Heart Failure (CHF), Cardiomyopathy, Type 2 diabetes (DM2), with hyperglycemia and diabetic polyneuropathy, Atherosclerotic heart disease of coronary arteries (CAD), and Atrial Fibrillation (A-fib). Upon review of the comprehensive under the category of (M2001: Medication Review, it was noted that the start of care RN assessment, dated 9/27/23, stated, “no issues found”, however, during a drug review via Drugs.com, there were two major interactions identified as follows: “The concurrent use of spironolactone and losartan can result in Kidney Failure and increased potassium levels resulting in paralysis and cardiac arrest.” In addition, the concurrent use of hydrocodone and pregabalin can result in respiratory distress, coma, and death. These findings were reviewed and acknowledged during an interview on 11/17/23 at 10:30 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 6 of 7 (P-5, 7, 3, 4, 1, and 2) records reviewed, resulting in the potential for poor patient outcomes and unmet care needs. Findings include: P-5: This 94-year-old patient was admitted to home care on 8/14/23 with diagnoses of congestive heart failure, chronic respiratory failure, and type II diabetes mellitus. During record review on 11/16/23, it was noted that the plan of care failed to include safety measures/bleeding precautions as the patient was on Eliquis, an anticoagulant medication that may cause bleeding. It was also noted that the plan of care failed to include measurable nursing goals that are individualized to address patient needs. For example, one goal stated, “patient/caregiver will verbalize an understanding of factors that contribute to shortness of breath.” There was no evidence of how the goals could be objectively measured to determine progress toward meeting the goals. P-7: This 90-year-old patient was admitted to home care on 9/28/23 with diagnoses of cerebral infarction and muscle weakness. During record review on 11/15/23, it was noted that the plan of care failed to include measurable nursing goals that are individualized to address patient needs. For example, one goal stated, “The patient/caregiver will verbalize understanding of diagnosis and complications for COPD.” There was no evidence of how the goals could be objectively measured to determine progress toward meeting the goals. These findings were reviewed and acknowledged by the administrator (ADM-1) and the compliance officer (CO-1) during an interview on 11/16/23 at 2:35 p.m. P-3: This 82-year-old patient was admitted to home care on 9/6/23 with diagnoses of impingement syndrome of right shoulder, emphysema, and chronic respiratory failure with hypoxia. The patient was recertified for an additional episode of care on 11/5/23. During record review on 11/15/23, it was noted that the 9/6/23 plan of care failed to include measurable nursing goals. For example, one goal stated that the patient/caregiver will be able to identify the correct dose, route, and frequency of each medication with a target date of 11/4/23. The 11/05/23 plan of care had the same goal with a target date of 1/3/24. It was unclear how this goal was to be objectively measured to determine progress toward meeting the goal. There was no indication whether the patient/caregiver was expected to identify the correct dose, route, and frequency of all medications each visit, one medication each visit, or one medication for two or three consecutive visits. P-4: This 65-year-old patient was admitted to home care on 10/11/23 with diagnoses of sepsis, right lower extremity cellulitis, and chronic kidney disease. During record review on 11/14/23, it was noted that the 10/11/23 plan of care failed to include measurable nursing goals. The following goals were listed on the plan of care: decrease edema in legs, patient/caregiver will be independent with medication management, and the patient will be free from signs and symptoms of respiratory distress during the episode. There was no indication of how these goals would be objectively measured to determine progress toward meeting the goals. These findings were reviewed and acknowledged by ADM-1 and CO-1 during an interview on 11/16/23 at 2:15 p.m. P-1: The Start of Care (SOC) was dated 9/15/2023. The Plan of Care for the certification period 9/15/23 to 11/13/23 identified diagnoses of Hypertensive on Chronic Diastolic Congestive Heart Failure (CHF), Cardiomyopathy, Type 2 diabetes (DM2), with hyperglycemia and diabetic polyneuropathy, Atherosclerotic heart disease of coronary arteries (CAD), and Atrial Fibrillation (A-fib). Upon review of the record, it was noted that the goals on the Plan of Care were not objectively measurable. Examples include: “The patient/caregiver will verbalize signs/symptoms of hypo/hyperglycemia, measures to manage and report to Skilled Nurse (SN) or M.D. (Medical Doctor) {sic}; The patient/caregiver will understand signs/symptoms of depression; The patient/caregiver will verbalize and demonstrate factors that contribute to shortness of breath. The Skilled Nurse will assess the patient’s weight log,” (This goal is for the nurse rather than a patient specific goal) These goals are not measurable to determine the patient’s progress towards achieving the goals. P-2: The SOC was dated 10/24/2023. The Plan of Care for the certification period 10/24/23 to 12/22/23 identified diagnoses of Acute and Chronic respiratory failure with hypoxia, Hypertensive Heart & Chronic Kidney Disease with heart failure and stage 5 Chronic Kidney Disease; Acute on Chronic Congestive Heart Failure. Upon review of the record, it was noted that the goals on the Plan of Care were not objectively measurable to determine the progress towards achieving the goals. Examples included: “Patient’s Blood Pressure will remain within established parameters during the episode; The patient/caregiver will understand signs and symptoms of depression; Regain strength and endurance to be able to walk the halls again.” These goals are not objectively measurable to determine the patient’s progress towards obtaining the goals. These findings were reviewed and acknowledged by the administrator (ADM-1) and the compliance officer (CO-1) during an interview on 11/17/23 at 10:30 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 skilled professionals performed assessments of the patient’s health status and needs in 2 of 7 (P-5 and P-1) records reviewed, resulting in the potential for unidentified health concerns, decline in physical functioning, and poor patient outcomes. Findings include: Agency Policy No. 4-019.1: ONGOING ASSESSMENTS, Revised May 2023 During each home visit the appropriate clinician will re-evaluate the patient according to the problems identified during the initial visit and thereafter. P-5: This 94-year-old patient was admitted to home care on 8/14/23 with diagnoses of congestive heart failure, chronic respiratory failure, and type II diabetes mellitus. Skilled nursing was ordered once a week for five weeks. The patient was discharged from the agency after four visits on 9/8/23. During record review on 11/16/23, it was noted that the medical record failed to consistently monitor chronic medical conditions. The patient’s blood sugar level was documented on the initial visit but there was no record of blood sugar monitoring for the following three visits. The patient’s weight was documented on the first two visits and at discharge, however, no weight was documented on 8/31/23. The medical record indicated edema (swelling) as +2 for the first three visits and failed to include documentation of edema status on discharge. These findings were reviewed and acknowledged by the administrator (ADM-1) and the compliance officer (CO-1) during an interview on 11/16/23 at 2:35 p.m. P-1: The Start of Care (SOC) was dated 9/15/2023. The Plan of Care for the certification period 9/15/23 to 11/13/23 identified diagnoses of Hypertensive on Chronic Diastolic Congestive Heart Failure (CHF), Cardiomyopathy, Type 2 diabetes (DM2), with hyperglycemia and diabetic polyneuropathy, Atherosclerotic heart disease of coronary arteries (CAD), and Atrial Fibrillation (A-fib). Upon review of the record, it was noted the Skilled Nurse failed to assess and document information related to the patient’s current diagnoses of Congestive Heart Failure and Type 2 Diabetes (DM2). Examples include: For the patient’s diagnosis of Diabetes Type 2 (DM2), the skilled nurse failed to document the results of blood sugars on 9/26/23, 10/13/23, 10/17/23, 10/17/23, 10/18/23, 10/20/23, 10/24/23, 10/26/23, 10/27/23, and 10/31/23. In addition, for the Skilled Nurse (SN) Visit on 9/22/23, the SN failed to document if the Blood Sugar result was fasting, non-fasting or 2-hour post-prandial. For the patient’s diagnosis of Congestive Heart Failure (CHF), the skilled nurse failed to document the patient’s weights on 9/22/23, 9/26/23, 10/13/23, 10/17/23. 10/18/23, 10/18/23, 10/24/23, 10/26/23, 10/27/23, and 10/31/23. Also, for the patient’s diagnosis of CHF, the skilled nurse failed to document the patient’s lower extremity edema on 9/22/23, 9/26/23, 10/13/23, 10/18/23, 10/20/23, 10/24/23, and 10/31/23. These findings were reviewed and acknowledged by the administrator (ADM-1) and the compliance officer (CO-1) during an interview on 11/17/23 at 10:30 am.”

“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 skilled professionals provided services as ordered by the physician in the plan of care for 5 of 7 (P-6, 7, 3, 4, and 1) records reviewed, resulting in the potential for poor patient outcomes for these patients. Findings include: P-3: This 82-year-old patient was admitted to home care on 9/6/23 with diagnoses of impingement syndrome of right shoulder, emphysema, and chronic respiratory failure with hypoxia. The 9/6/23 plan of care ordered physical therapy services one time the first week, two visits each week for four weeks, and then one visit each week for four weeks. During record review on 11/15/23, it was noted that the physical therapy assistant (PTA) missed a once weekly visit on 10/20/23. The missed visit note documented the reason for the missed visit was due to clinician illness. On 10/31/23, the physical therapist documented a missed evaluation visit note due to family/caregiver able to assist patient. There was no documented evidence of attempts to reschedule the missed visits within the same week. The findings were reviewed with ADM-1 and CO-1 during an interview on 11/16/23 at 2:15 p.m. ADM-1 stated when a clinician is ill, they are expected to see if another therapist will cover the visit. There was no documented evidence of communication between therapists to cover the missed visits. P-4: This 65-year-old patient was admitted to home care on 10/11/23 with diagnoses of sepsis, right lower extremity cellulitis, and chronic kidney disease. The 10/11/23 plan of care ordered physical therapy services one time the first week, and then two visits each week for four weeks. During record review on 11/14/23, it was noted that 5 of 9 physical therapy visits were documented as missed visits. On 10/21/23, the PTA documented a missed visit due to clinician illness. The PTA also documented missed visits on 10/27/23, 11/2/23, 11/4/23, and 11/10/23. There was no documented evidence of communication between therapists to cover the missed visits and no documentation of the clinician’s efforts to reschedule the missed visits in the same week. P-1: The Start of Care (SOC) was dated 9/15/2023. The Plan of Care for the certification period 9/15/23 to 11/13/23 identified diagnoses of Hypertensive on Chronic Diastolic Congestive Heart Failure (CHF), Cardiomyopathy, Type 2 diabetes (DM2), with hyperglycemia and diabetic polyneuropathy, Atherosclerotic heart disease of coronary arteries (CAD), and Atrial Fibrillation (A-fib). The Plan of Care included orders for Skilled Nursing (SN) once a week for 9 weeks; Physical Therapy (PT) 1xweekx1, 2xweekx4, and 1xweekx4; and Occupational Therapy (OT) for assessment of needs. Upon review of the record, it was noted a PT evaluation was completed on 9/19/23 and a re-evaluation completed on October 16 after discharge on 10/12/23 from a hospital stay. However, it was noted that there were missed visits on 9/26/23, 10/19/23, 10/23/23, 10/27/23, 11/2/23, 11/4/23, 11/8/23, 11/11/23, 11/12/23, and 11/13/23. There was no indication of the reason for the missed visits or attempts to reschedule the missed visits. For Occupational Therapy the initial evaluation visit was missed, and there was no indication of an attempt for OT to perform an evaluation of the patient at a later date. These findings were reviewed and acknowledged by the administrator (ADM-1) and the compliance officer (CO-1) during an interview on 11/17/23 at 10:30 am. Agency policy No. 4-069.1: MISSED VISITS, Revised May 2022. If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician-ordered frequency is maintained and would not be considered a missed visit. P-6: This 98-year-old patient was admitted to home care on 9/1/23 with diagnoses of type II diabetes mellitus with chronic kidney disease and bursitis of the hip. The patient was discharged from home care on 10/10/23. During record review on 11/14/23, it was noted that occupational therapy was ordered once a week for eight weeks, beginning 9/14/23 per the request of the patient. On 9/25/23, the occupational therapist documented an attempted visit as the patient was sleeping on arrival and did not rouse to his name. There was no documented evidence that there was an attempt to reschedule the missed visit within the same week. P-7: This 90-year-old patient was admitted to home care on 9/28/23 with diagnoses of cerebral infarction and muscle weakness. This patient was ordered skilled nursing, physical therapy, occupational therapy, and speech therapy. During record review on 11/15/23, it was noted that skilled professional ordered visits failed to follow the plan of care. Speech therapy documented two missed visits (10/4/23 and 10/10/23) stating “family/caregiver able to assist patient.” Physical therapy documented three missed visits (10/14/23, 10/19/23, and 11/7/23) stating patient unavailable, clinician illness, and patient refused visit. There was no documented evidence that there was an attempt to reschedule missed visits within the same week. These findings were reviewed and acknowledged by the administrator (ADM-1) and the compliance officer (CO-1) during an interview on 11/16/23 at 2:35 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 detailed discharge summary was sent to the physician within 5 business days of discharge for 1 of 2 (P-5) discharge records reviewed, resulting in a lack of information to ensure continuity of care. Findings include: Agency Policy No. 4-046.1 DISCHARGE SUMMARY, Revised May 2023 The discharge summary and other relevant clinical record documents will be completed and submitted within 72 hours of discharge from service. A copy of the discharge summary and any necessary medical information will be provided to the patient’s primary care provider…within five (5) business days of the patient’s discharge. P-5: This 94-year-old patient was admitted to home care on 8/14/23 with diagnoses of congestive heart failure, chronic respiratory failure, and type II diabetes mellitus. Skilled nursing was ordered once a week for five weeks. The patient was discharged from the agency after four visits on 9/8/23. During record review on 11/16/23, it was noted that the patient requested to cancel home care services on 9/12/23 as they were moving out of the area. There was no documented evidence that the discharge summary was sent to the primary care provider within five business days of discharge. This finding was reviewed and acknowledged by the compliance officer (CO-1) during an interview on 11/7/23 at 10:05 a.m.”