A Plus Teresa Home Health Care

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure documents in the clinical records were complete and appropriately authenticated with a signature and title, dated, and timed in 7 (P-1, 2, 3, 4, 5, 6, 7) of 7 records reviewed, resulting in records that are not authenticated, accurate, timely, and do not portray the care provided by the agency. Findings include: P-4: The Start of Care (SOC) was dated 4/14/23. The Plan of Care (POC) identified diagnoses of Radiculopathy-Lumbar and Hypertension. During record review on 4/16/24, it was noted that the medication profile was signed on 4/15/23 by Staff D with the title of “Registered Nurse” when Staff D is a Physical Therapist. The agency failed to accurately authenticate the record within the EMR (Electronic Medical Record) as stated within the policy. P-5: The Start of Care (SOC) was dated 3/1/24. The Plan of Care (POC) identified diagnoses of Left Knee Osteoarthritis, Diabetes Type 2 and Hypertension. During record review on 4/16/24, it was noted that the medication profile was signed on 3/17/24 by Staff A with the title of “Registered Nurse” when Staff A is a Physical Therapist. The agency failed to accurately authenticate the record within the EMR as stated within the policy. P-6: The Start of Care (SOC) was dated 2/2/24. The Plan of Care (POC) identified diagnoses of Parkinson’s, Hypertension, Polyosteoarthritis. During record review on 4/16/24, it was noted that the medication profile was signed on 2/8/24 by Staff A with the title of “Registered Nurse” when Staff A is a Physical Therapist. The agency failed to accurately authenticate the record within the EMR as stated within the policy. P-7: The Start of Care (SOC) was dated 7/25/23. The Plan of Care (POC) identified diagnoses of Cervicalgia, Pain in Left Shoulder, Low Back Pain. During record review on 4/16/24, it was noted that the medication profile was signed on 9/3/23 by Staff A with the title of “Registered Nurse” when Staff A is a Physical Therapist. The agency failed to accurately authenticate the record within the EMR as stated within the policy. These findings were reviewed with and acknowledged by the Staff-A (Administrator) and Staff-B (Alt-Administrator) during an interview on 4/17/24 at 11:15 am. Agency Policy: Medical Record Entries and Authentication (11.3.1, no date). All medical record entries will be dated and authenticated. All entries in patient records will be legible, clear, complete, and appropriately authenticated, dated, and timed. If automated clinical record system is used, authentication includes a signature and title…of a primary author who has reviewed and approved the entry, in accordance with state law. P-1: This 60-year-old patient was admitted to home care on 3/7/24 with diagnoses of osteoarthritis and difficulty walking. During record review on 4/16/24, it was noted that the medication profile was signed on 4/1/24 by the administrator (Staff A) with the title of “Registered Nurse” when Staff A is a physical therapist. P-2: This 78-year-old patient was admitted to home care on 3/7/24 with diagnoses of type 2 diabetes, lumbar radiculopathy, and essential hypertension. During record review on 4/16/24, it was noted that the medication profile was signed on 4/4/24 by Staff A with the title of “Registered Nurse” when Staff A is a physical therapist. P-3: This 65-year-old patient was admitted to home care on 8/17/23 with diagnoses of encephalopathy, lumbar spondylosis, osteoarthritis, and hypertension. During record review on 4/15/24, it was noted that the medication profile was signed on 8/28/23 by Staff A with the title of “Registered Nurse” when Staff A is a physical therapist. Additionally, the Start of Care assessment, dated 8/17/23 indicates the discipline of person completing assessment (M0080) is a Registered Nurse, however, the nursing/clinical signature is signed by Staff A, a physical therapist on 8/18/23. Skilled nursing visit notes from 8/22/23, 8/26/23, 9/2/23, and 9/23/23 are authenticated by Staff A with a title of Quality Assurance. The record failed to include the signature and title of the RN who completed these assessments. These findings were reviewed and acknowledged by the administrator (Staff A) during an interview on 4/17/24 at 11:30 a.m. Staff A stated he was not aware that the electronic medical record software would overwrite the signature of the staff completing the assessments.”

“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 potential adverse interactions and failed to follow proper medication application dosing in 1 (P-2) of 7 records reviewed, resulting in the potential for harmful medication effects for all patients serviced by this agency. Findings include: Agency Policy: Medication Reconciliation (8.15.1, no date). The agency will reconcile patient’s medications at time of admission and on an ongoing basis in order to identify any potential adverse effects and drugs reactions. P-2: This 78-year-old patient was admitted to home care on 3/7/24 with diagnoses of type 2 diabetes, lumbar radiculopathy, and essential hypertension. During record review on 4/16/24, it was noted that the start of care assessment, completed on 3/7/24 by the physical therapist (PT), stated no issues found during drug regimen review (M2001). During joint survey home visit with the PT on 4/16/24, the patient stated he is taking Trulicity injections for diabetes. The patient also requested the PT use Diclofenac sodium 1% topical gel on his back and knees, instead of Biofreeze as ordered in the plan of care. The PT was observed applying the diclofenac gel without using a dosing measurement card. The PT dispensed approximately 3” of medication in total, or less than 4 grams. Neither the Trulicity nor Diclofenac Sodium gel were included in the patient’s medical record as current medications although Trulicity 0.75mg/0.5ml as directed and Diclofenac Sodium 1% gel apply 2-4 grams about 2-3 times a day were listed as current medications on the nurse practitioner progress note dated 2/26/24. There was no evidence that the PT assessed these medications as indicated in the agency policy. This finding was reviewed and acknowledged by the administrator (Staff A) during an interview on 4/17/24 at 11:30 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 1 (P-3) of 1 record reviewed with skilled nursing, resulting in the potential for poor patient outcomes and unmet care needs for the patient. Findings include: P-3: This 65-year-old patient was admitted to home care on 8/17/23 with diagnoses of encephalopathy, lumbar spondylosis, osteoarthritis, and hypertension. During record review on 4/15/24, it was noted that the plan of care failed to include measurable nursing goals that are individualized to address patient needs. The plan of care contained the following goals, patient/caregiver will verbalize understanding of medication regimen, dose, route, frequency, indications, and side effects and patient/caregiver will be able to verbalize understanding of Bipolar, Anxiety, Schizoaffective Disorder, Encephalopathy. There was no evidence of how these goals could be objectively measured to determine progress toward meeting the goals. This finding was reviewed and acknowledged by the administrator (Staff A) during an interview on 4/17/24 at 11:30 a.m.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure medications and visit frequencies were provided only as ordered by the physician for 2 (P# 4, 6) of 7 records reviewed, resulting in the potential for the provision of inappropriate care and services. Findings include: Agency Policy: Care Planning Process (9.9.1, Revised February 2021). The policy states, “5. Care will be coordinated initially and ongoing among staff providing care. Care planning for each patient will be individualized to include: Specific care or services to be provided including frequency, type and duration.” P-4: The Start of Care (SOC) was dated 4/14/23. The Plan of Care (POC) identified diagnoses of Radiculopathy-Lumbar and Hypertension. During record review on 4/16/24, it was noted that the POC dated 4/14/23 specified a Physical Therapy (PT) frequency of 1w1 (One visit per week for 1 week), 2w5, 1w1. The PT completed 1 of 2 visits for week 2 on 4/17/23. Additionally, the PT failed to complete 2 of 2 visits scheduled for week 4. No physician order or notification was documented. The PT failed to provide the services and frequency as ordered by the physician. P-6: The Start of Care (SOC) was dated 2/2/24. The Plan of Care (POC) identified diagnoses of Parkinson’s, Hypertension, Polyosteoarthritis. During record review on 4/16/24, it was noted that the POC dated 2/2/24 specified a PT frequency of 1w1, 2w5, 1w3. The PT failed to complete 2 of 2 visits scheduled for week 6. No physician order or notification was documented. The PT failed to provide the services and frequency as ordered by the physician. These findings were reviewed with and acknowledged by the Staff-A (Administrator) and Staff-B (Alt-Administrator) during an interview on 4/17/24 at 11:30 am.”