Parallel Home Care Services, Inc.

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure that 2 of 7 (P-1, 2) patients were included in their overall planning of care including informing the patient/caregiver in advance of the days in which services would be provided and disciplines that will furnish care, resulting in a lack of inclusion in planning, lack of informed consent, the potential for missed visits and unmet care needs. Findings include: **Agency Policy: “Initial Comprehensive Assessment,” (Undated). The policy states, “The initial assessment will be made within 48 hours unless otherwise indicated, and will include: m. Frequency and duration of visits.” P-1: The Start of Care (SOC) was dated 3/7/24. The Plan of Care (POC) identified diagnoses of Congestive Heart Failure, Colon Cancer and Anemia. During record review on 6/24/24, the signed consent frequencies stated, “Services provided: Skilled Nursing: Eval/treat...” The POC stated, “SN: 2w2 (2 visits a week for 2 weeks), 1w6. The agency failed to provide an accurate written frequency of services to be provided to the patient. P-2: The Start of Care (SOC) was dated 5/14/24. The Plan of Care (POC) identified diagnoses of Congestive Heart Failure, Diabetes Type 2 and Chronic Kidney Disease. During record review on 6/25/24, the signed consent frequencies stated, “Services provided: Skilled Nursing: Eval/treat…” The POC stated, “SN: 1w9. The agency failed to provide an accurate written frequency of services to be provided to the patient. These findings were reviewed with and acknowledged by the Staff A (Clinical Manager) during an interview on 6/26/24 at 3:15 pm.”

“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 measurable outcomes and goals specific to the needs of the patient for 7 of 7 records reviewed (P-1, 2, 3, 4, 5, 6, 7), resulting in patients not receiving care specific to their individual needs and the potential for poor patient outcomes. Findings include: P-1: The Start of Care (SOC) was dated 3/7/24. The Plan of Care (POC) identified diagnoses of Congestive Heart Failure, Colon Cancer and Anemia. During record review on 6/24/24, it was noted that the goals within the POC were not measurable. For example, one goal stated, “Pt (Patient)/Pcg (Paid care giver) will verbalize measure to manage neurological condition/will be free of unmanaged depression/anxiety symptoms by 5/5/24.” Additionally, another goal stated, “Dyspnea will decrease by 4/6/24.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. P-2: The Start of Care (SOC) was dated 5/14/24. The Plan of Care (POC) identified diagnoses of Congestive Heart Failure (CHF), Diabetes Type 2 and Chronic Kidney Disease. During record review on 6/25/24, it was noted that the goals within the POC were not measurable. For example, one goal stated, “Patient will be free of signs of CHF exacerbation/signs of CHG exacerbation will be managed at home with use of Furoscix infuser by 7/12/24.” Additionally, another goal stated, “Pt will demonstrate energy conservation techniques by 6/12/24.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. P-3: The Start of Care (SOC) was dated 6/11/24. The Plan of Care (POC) identified diagnoses of Diabetes Type 2 and Left Foot Ulcer. During record review on 6/26/24, it was noted that the goals within the POC were not measurable. For example, one goal stated, “Pt/Pcg will state understanding of measures to manage disease and identify S/S (Signs and Symptoms) to report by week 4.” Additionally, another goal stated, “Bowel status will be WNL (Within Normal Limits) for patient throughout care and at discharge.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. P-4: The Start of Care (SOC) was dated 5/16/24. The Plan of Care (POC) identified diagnoses of Pneumonia, Urinary Tract Infection and Left Buttock Pressure Ulcer. During record review on 6/26/24, it was noted that the goals within the POC were not measurable. For example, one goal stated, “Patient/Caregiver will verbalize/demonstrate understanding of symptom management, resource utilization and medication management to reduce unplanned hospital or emergency department visits by week 3.” Additionally, another goal stated, “Pt/Pcg will verbalize measure to manage neurological condition by week 4.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. These findings were reviewed with and acknowledged by the Staff A (Clinical Manager) during an interview on 6/26/24 at 3:00 pm. P-5: This 92-year-old patient was admitted to home care on 6/21/24 with diagnoses of hypertensive heart disease with heart failure, type 2 diabetes, and pressure ulcer. During record review on 6/26/24, 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 state understanding of measures to manage disease and identify signs/symptoms to report. There was no evidence of how this goal could be objectively measured to determine progress toward meeting the goal. P-6: This 91-year-old patient was admitted to home care on 6/29/23 with diagnoses of anemia, osteoarthritis, and atrial fibrillation. During record review on 6/25/24, 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 demonstrate increased endurance by discharge. There was no evidence of how this goal could be objectively measured to determine progress toward meeting the goal. P-7: This 91-year-old patient was admitted to home care on 9/19/22 with diagnoses of venous insufficiency, chronic non pressure ulcers, and peripheral vascular disease. During record review on 6/24/24, 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/caregiver will verbalize/demonstrate understanding of symptom management, resource utilization, and medication management to reduce unplanned hospital or emergency department visits. There was no evidence of how this goal could be objectively measured to determine progress toward meeting the goal. These findings were reviewed and acknowledged by the clinical manager (Staff A) during an interview on 6/26/24 at 3:30 p.m. P-5: This 92-year-old patient was admitted to home care on 6/21/24 with diagnoses of hypertensive heart disease with heart failure, type 2 diabetes, and pressure ulcer. During record review on 6/26/24, 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 state understanding of measures to manage disease and identify signs/symptoms to report. There was no evidence of how this goal could be objectively measured to determine progress toward meeting the goal. P-6: This 91-year-old patient was admitted to home care on 6/29/23 with diagnoses of anemia, osteoarthritis, and atrial fibrillation. During record review on 6/25/24, 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 demonstrate increased endurance by discharge. There was no evidence of how this goal could be objectively measured to determine progress toward meeting the goal. P-7: This 91-year-old patient was admitted to home care on 9/19/22 with diagnoses of venous insufficiency, chronic non pressure ulcers, and peripheral vascular disease. During record review on 6/24/24, 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/caregiver will verbalize/demonstrate understanding of symptom management, resource utilization, and medication management to reduce unplanned hospital or emergency department visits. There was no evidence of how this goal could be objectively measured to determine progress toward meeting the goal. These findings were reviewed and acknowledged by the clinical manager (Staff A) during an interview on 6/26/24 at 3:30 p.m. P-1: The Start of Care (SOC) was dated 3/7/24. The Plan of Care (POC) identified diagnoses of Congestive Heart Failure, Colon Cancer and Anemia. During record review on 6/24/24, it was noted that the goals within the POC were not measurable. For example, one goal stated, “Pt (Patient)/Pcg (Paid care giver) will verbalize measure to manage neurological condition/will be free of unmanaged depression/anxiety symptoms by 5/5/24.” Additionally, another goal stated, “Dyspnea will decrease by 4/6/24.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. P-2: The Start of Care (SOC) was dated 5/14/24. The Plan of Care (POC) identified diagnoses of Congestive Heart Failure (CHF), Diabetes Type 2 and Chronic Kidney Disease. During record review on 6/25/24, it was noted that the goals within the POC were not measurable. For example, one goal stated, “Patient will be free of signs of CHF exacerbation/signs of CHG exacerbation will be managed at home with use of Furoscix infuser by 7/12/24.” Additionally, another goal stated, “Pt will demonstrate energy conservation techniques by 6/12/24.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. P-3: The Start of Care (SOC) was dated 6/11/24. The Plan of Care (POC) identified diagnoses of Diabetes Type 2 and Left Foot Ulcer. During record review on 6/26/24, it was noted that the goals within the POC were not measurable. For example, one goal stated, “Pt/Pcg will state understanding of measures to manage disease and identify S/S (Signs and Symptoms) to report by week 4.” Additionally, another goal stated, “Bowel status will be WNL (Within Normal Limits) for patient throughout care and at discharge.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. P-4: The Start of Care (SOC) was dated 5/16/24. The Plan of Care (POC) identified diagnoses of Pneumonia, Urinary Tract Infection and Left Buttock Pressure Ulcer. During record review on 6/26/24, it was noted that the goals within the POC were not measurable. For example, one goal stated, “Patient/Caregiver will verbalize/demonstrate understanding of symptom management, resource utilization and medication management to reduce unplanned hospital or emergency department visits by week 3.” Additionally, another goal stated, “Pt/Pcg will verbalize measure to manage neurological condition by week 4.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. These findings were reviewed with and acknowledged by the Staff A (Clinical Manager) during an interview on 6/26/24 at 3:00 pm.”

“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-5) of 7 records reviewed, resulting in the potential for physical decline and unmet care needs for this patient. Findings include: P-5: This 92-year-old patient was admitted to home care on 6/21/24 with diagnoses of hypertensive heart disease with heart failure, type 2 diabetes, and pressure ulcer. During record review on 6/26/24, it was noted that the plan of care ordered nursing to assess/perform/instruct patient/caregiver on blood glucose testing every morning and importance of recording and compliance. The skilled nursing visit on 6/24/24 failed to include a blood glucose level. This finding was reviewed and acknowledged by the clinical manager (Staff A) during an interview on 6/26/24 at 3:30 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 discharge summary was complete, provided the patient’s current health status at the time of discharge in 1 (P-1) of 2 closed records, from a total of 7 records reviewed, resulting in the potential for unidentified continuing health care concerns and unmet care needs. Findings include: **Agency Policy: “Discharge Summary,” (Undated2023). The policy states, “6 ...The discharge summary will include: g. A summary of the care and services provided.” P-1: The Start of Care (SOC) was dated 3/7/24. The Plan of Care (POC) identified diagnoses of Congestive Heart Failure, Colon Cancer and Anemia. During record review on 6/24/24, it was noted that the Skilled Nursing Discharge Summary dated 5/2/24 stated, “Care Summary (care given, intervention, progress, regress including therapies): Pasted into this area is a list of the interventions from the POC. The discharge summary failed to detail the course of care provided, responses to treatment and any potential continuing needs. These findings were reviewed with and acknowledged by the Staff A (Clinical Manager) during an interview on 6/26/24 at 3:30 pm.”

“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 6 records reviewed (P-5) for falls, from a total of 10 records reviewed, resulting in the potential for unresolved healthcare concerns. Findings include: P-1: This 80-year-old patient was admitted to home health care on 8/24/2023, with diagnoses of pressure ulcer of right buttock, pressure ulcer of right elbow, and venous insufficiency. During review of the agency’s “Fall and Infection Log” on 3/5/2024, three patient entries were discovered regarding P-5, all signed by Registered Nurse (Staff-A) and dated 1/18/2024. The patient fell on 1/17/2024. Staff-A documented the fall on a “Report of Incident” form dated 1/18/2024. The “Report of Incident” form documented the patient fell with bleeding and possible further splitting of right elbow.” During an interview at 2:20 p.m. on 3/5/2024., the clinical manager (Staff-B) was questioned about communication with the assisted living facility regarding the fall. Staff-B provided a phone call narrative signed by Staff-A dated 1/17/2024 at 11:32 a.m., that stated at 7:37 a.m., on 1/17/2024, “The patient fell and there is a lot of blood on right elbow, and it looks like patient needs stitches. Instructed on wound care and planned visit for today and notified power of attorney (POA).” A second phone call narrative signed by Staff-A dated 1/17/2024 at 11:35 a.m., stated at 11:00 a.m. on 1/17/2024, “The patient fell again, communicated with POA and she states she will come and get patient and take him to the emergency room for possible sutures to right elbow and evaluation.” During the 2:20 p.m., interview on 3/5/2024, Staff-B was questioned about communication with the patient’s physician regarding the falls and injury. Staff-B said there is no documentation that the patient’s physician was notified on 1/17/2024 of the patient’s falls and injury. On 3/5/2024, the agency’s Adverse Events/Incidents and Unusual Occurrences Policy (2.82) pages 185-188, was reviewed. The policy classifies a patient injury (Fall) as an Adverse Event (Pages 185-186). The policy indicates (Page 188), “With Adverse Events: The MD will be notified in the event of patient injury or death. This notification will be documented on the Incident Report.” The patient’s Incident Reports dated 1/18/2024 did not have any physician notification documented, as required by the agency’s policy. The policy also states on page 185, paragraph 2, “Staff members are educated in the proper response to an unexpected event, injury or exposure.” On 3/5/2024, Staff-A employee training Education/Inservice sheets dated 8/13/2020-10/30/23, were reviewed and were found to be in compliance with policy (2.82) page 185, paragraph 2. These findings were reviewed with and acknowledged by the clinical manager (Staff-B) during an interview on 3/5/2024 at 3:30 p.m.”