Spot Rehabilitation Inc.

“Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient’s status at the time of assessment. This Standard is not met as evidenced by: Based on interview and document review the agency failed to encode the Home Health Outcome and Assessment Information Set (OASIS) data accurately for one of one patient (P1) who was reviewed for OASIS assessments. P1’s plan of care (POC) dated 12/13/23, identified a start of care (SOC) 2/16/23. Diagnoses included low back pain, diabetes, and kidney disease. Medications included metformin (to control high blood sugars in diabetes) 1000 milligrams (mg) two times per day, glimepiride (used to lower blood sugars) four mg every day,, semaglutide (antidiabetic medication increases insulin, which decreases blood sugar) 0.5 mg subcutaneous (SQ) once weekly, and Tresiba (a long-acting insulin to lower blood sugar) seven units SQ as directed. P1’s OASIS dated 2/16/23, section N-Medications indicated P1 was not taking any high risk drug classes such as a hypoglycemic medication. The OASIS assessment failed to identify P1 was taking four hypoglycemic medications for treatment of diabetes. During interview on 2/7/24, at 1:15 p.m. clinical manager (CM)-A stated P1’s medications had not been assessed correctly on the OASIS assessment as the use of high-risk hypoglycemic medications should have been identified on the assessment. It was the agency’s practice when a physical therapist did the OASIS assessment and start of care visit, a nurse reviewed the assessment and medications. The fact hypoglycemic medications were not checked on the assessment must have been missed by the nurse reviewing. The agency policy Medication Regimen Review, dated June 2022, identified during the initial assessment the registered nurse or therapist would review the client’s prescribed and over the counter medications in the home with the client to determine all medications the client was taking. The agency policy OASIS: Reporting, Transmitting, Timing, and Privacy, dated June 2022, identified the clinician completing the OASAIS visit would complete all required OASIS items and ensure that the OASIS data accurately reflect the client’s status at the time of the assessment.”

“Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This Standard is not met as evidenced by: Based on interview and document review, the agency failed to ensure the physician orders were followed for 1 of 7 patients (P2) who had home health aide (HHA) services ordered, but the services had not been provided, and the physician had not been notified the service was not provided. P2’s plan of care (POC) dated 10/20/23 through 12/18/23, identified a start of care (SOC) date of 10/20/23. Diagnosis included Alzheimer’s disease and frequent falls. Services ordered included physical therapy one time per week for one week then two times per week for eight weeks. An occupational therapy (OT) evaluation and home health aide (HHA) services were recommended. A physician’s order dated 10/23/23, indicated orders were received to complete an OT evaluation and begin HHA services one time per week for nine weeks. P2’s medical record identified P2 began to receive HHA visits on 11/26/23, five weeks after P2’s physician had ordered the services. The medical record lacked evidence P2’s physician had been notified of the delay in services. When interviewed on 2/6/24, at 3:40 p.m. the scheduling coordinator (SC)-D stated she remembered there had been a delay on starting HHA services for P2 because the agency had been shorthanded and were unable to staff the service at the time. The agency eventually had to schedule a nurse to complete the HHA visits. There should have been a physician order to delay the service or to hold it to cover the time the service had not been provided. During interview on 2/7/24, at 1:15 p.m. the clinical manager (CM)-A stated it was the agency’s policy to obtain a physician order when there was a delay in services. The agency policy Treatment for Nursing, Occupational, Physical and/or Speech Therapy dated June 2022, identified. if HHA services were added to the client’s care during an episode of care, the aide services would be scheduled at the recommended frequency once physician orders were received and prior authorization was obtained. If not feasible to schedule the services withing the time frame, the physician would be notified explaining the reason for the delay.”

“Provide contact info other services CFR(s): 484.50(d)(5)(iii) (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and This Element is not met as evidenced by: Based on interview and document review, the agency failed to provide 1 of 2 patients (P6) reviewed for discharge, with information required related to other available home care providers at the the time of a facility initiated discharge. P6’s plan of care (POC) 3/3/22 through 5/1/22, identified a start of care (SOC) date 3/3/22. Diagnoses included displaced fracture of right femur, history of falls, chronic pain, need for assistance in home, bipolar disorder and anxiety. Skilled nurse services were ordered one time per week for four weeks plus four as needed (prn), for various assessments and instruction related to all body systems, medications, fall risk, infection control measures, pain management and emergency preparedness. Physical therapy was ordered one time per week for one week then two times per week for eight weeks to develop a home exercise program, ambulation skills, and strength and endurance. Occupational therapy was ordered one time per week for one week then two times per week for eight weeks to develop a home exercise program, increase strength and activity tolerance, activities of daily living skills and pain management techniques. A social worker visits were ordered one time and four as needed to assist with resources and support. The POC identified P6 lived alone around the clock and required considerable assistance in routine situations. P6’s ordered home care services were stopped and put on hold 3/11/22, due to non-compliance and challenging behaviors. P6’s discharge summary dated 5/1/22, identified P6 was discharged by the agency for non-compliance and challenging behaviors. The medical record lacked evidence P6 had received information related to other available home care providers in the area. During interview on 2/7/23, at 3:00 p.m. clinical manager (CM)-A stated it was the agency’s practice to provide a list of resources to the patient when they discharged. She was unable to find documentation P6 had been provided a list of other home health agencies in the area. The agency policy Termination of Home Health Care Service dated June 2022, identified when the agency was considering discharging a patient, they must provide the patient with contact information for other agencies or providers who may be able to provide care.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on interview and document review, the agency failed to ensure each patient had an initial assessment visit within 48 hours of the referral date for 1 of 7 patients (P3) reviewed in the sample. P3’s plan of care (POC) 1/22/24 through 3/21/24, identified a start of care (SOC) 1/22/24, with diagnoses heart disease, heart failure, and anxiety disorder. Services included Skilled Nursing visits (SNV) two times per week for one week then one time per week for eight weeks for various assessment and instruction. Physical therapy (PT) was ordered two times per week for nine weeks to develop a home exercise program, increase strength, mobility and ambulation. An occupational therapy evaluation visit was also ordered. P3’s referral for home care services dated 1/19/24, identified P3 was discharged from the hospital and returned to her home on 1/19/24, and would need home health services of skilled nursing, and physical and occupational evaluation on her return home. P3’s Home Health Outcome and Assessment Information Set (OASIS) completed at initial SOC indicated a physician ordered start of care had been obtained for the initial SOC to be completed 1/22/24, however, the medical record lacked evidence of physician’s orders to delay P3’s SOC. During interview on 2/7/24, at 9:30 a.m. registered nurse (RN)-A stated she had thought she had obtained a physician order to delay P3’s SOC, but she was unable to find the documentation. During interview on 2/7/24, at 2:00 p.m. the clinical manager (CM)-A stated it was the agency’s practice to complete the SOC visit within 48 hours of receiving a referral unless ordered otherwise. The agency policy Referral for Home Health Care Services: Physician Order-Initial and Recertification: Plan of Care, Client communication dated June 2022, indicated on receipt of the physician order or referral, the patient will be contacted immediately to schedule an initial home health care assessment visit. The initial visit will be completed within 48 hours of the date of referral whenever possible.”

“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 observation, interview, and document review, the agency failed to complete a comprehensive drug regimen review to ensure the accuracy of all medications/dosages for 2 of 7 patients (P3, P5) whose medications were reviewed during home visits and record review. P3’s plan of care (POC) 1/22/24 through 3/21/24, identified a start of care (SOC) 1/22/24, with diagnoses which included heart disease, heart failure and anxiety. Services included skilled nurse visits (SNV) two times per week for one week, then one time per week for eight weeks for various assessments and instruction. Physical therapy (PT) was also ordered two times per week for nine weeks and an occupational therapy evaluation was ordered. Risks for hospitalization included reported or observed history of difficulty complying with any medical instructions such as medications, diet or exercise. P3 was prescribed a number of medications, which included furosemide (a diuretic) 40 milligrams (mg) every am with 1/2 tablet if weight was up three pounds over the night, lorazepam 0.5 mg in am, afternoon and bedtime as needed (prn) and polyethylene glycol powder (to treat constipation) 17 grams at night prn. P3’s discharge summary dated 1/19/24, identified medication orders for furosemide 40 mg two times per day and additional furosemide as directed by the heart failure clinic for swelling and weight gain, lorazepam 0.5 mg every am, between 12p and 3p, and at bedtime as needed, lorazepam 1 mg nightly, and polyethylene glycol 17 grams two times daily. P3’s medical record lacked evidence P3’s physician had been notified of the medication discrepancies or clarification and/or direction on what dosage of medications P3 was suppose to take. During interview on 2/6/24, at 4:00 p.m. registered nurse (RN)-A stated P3’s POC reflected the actual way P3 reported taking her medications and she had called the heart failure clinic and well as P3’s physician to clarify and confirm dosages. She had not completed a verbal order to reflect the reconciliation of medications and to document the physician had been notified and approved of the dose changes as she should have. RN-A stateed it would be important to have the physician clarification of medications to ensure the provider was aware of what the patient was actually taking. P5’s POC 12/31/23 through 2/28/24, identified a SOC date 11/1/23, with diagnoses lumbago, muscle spasms, chronic pain, atrial fibrillation, and anxiety disorder. Services included PT one time per week for one week then two times per week for eight weeks for assistance with home exercise program, activity intolerance, pain interventions and fall prevention. P5 was prescribed a number of medications, which included Flomax (for urinary retention) 0.4 mg at bed, torsemide (to treat fluid retention) 20 mg as directed, flecainide (to treat irregular heartbeat) 50 mg as directed, hydromorphone (a narcotic analgesic) 5 mg as needed, allopurinol (to treat gout) 300 mg once daily, furosemide (a diuretic) 20 mg two times daily prn, and morphine (narcotic to treat pain) 10mg/5ml 10mg every four hours prn. P5’s home care referral dated 10/30/23, identified the following medication orders: Flomax had been discontinued, torsemide was ordered 40 mg two times per day, flecainide 300 mg every day as needed for atrial fibrillation, hydromorphone and allopurinol were not ordered, and morphine was ordered 15 mg every six hours as needed. During a home visit on 2/6/24, at 10:30 a.m. for therapy services, P5 stated she had not taken Flomax for a couple of months, the flecainide was only taken as needed when she had an atrial fibrillation episode, she did not take hydromorphone any longer and had not for a while, the furosemide was stopped the beginning of January, and she only took 5 mg of morphine instead of 10 mg. Her morphine dose had been adjusted after her last surgery, prior to her admission to home care on 11/1/23. During interview on 2/6/24, at 10:30 a.m. PT-D stated he asked patients if they had any medication changes at every visit and he did a thorough review of medications with the recertification visits. If there were changes to the medication list, he reached out to the agency nurses to write the physician orders and update the POC. When interviewed on 2/7/24, at 1:15 p.m. case manager (CM)-A stated that was a long time for a patient’s POC to have the incorrect dosages and should have been updated as P5’s POC had incorrect medications and dosages for two recertification periods. It was important to review the medication list more closely with patients. Therapists reviewed and reconciled the medications when they did the SOC and recertification visits and then a nurse reviewed and checked them off. Nurses were supposed to call the primary care provider to clarify medications if there were discrepancies and to write orders to reconcile them in the medical record, The agency policy Medication Regimen Review dated June 2022, identified during the initial assessment the nurse or therapist completing the assessment would review the client’s prescribed medications and over the counter medication in the home with the client and/or caregiver, to determine all medications the client was currently taking. Any concerns related to ineffective drug therapy, improper dosing, complex medication regimen, medications in the home that do not match discharge instructions, patient confusion over medications, adverse reactions or taking multiple non prescribed medications that could interact with other medications would be communicated to the primary physician by midnight of the next calendar day.”

“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 interview and document review, the agency failed to perform speech therapy (ST) visits, only as ordered by a physician, for 1 of 7 patients (P1), reviewed for home care services. P1’s plan of care (POC) dated 12/13/23 through 2/10/24, identified a start of care (SOC) 2/16/23. Diagnoses included low back pain, diabetes, and kidney disease. Services included physical therapy (PT) one time per week for nine weeks plus four as needed (PRN), occupational therapy (OT) one time per week for nine weeks and speech therapy (ST) one time per week for nine weeks. P1’s speech therapy note dated 1/5/24, identified her speech therapy plan was to continue direct treatment at one to two times per week to address cognitive linguistic deficits following her traumatic brain injury. A physician order dated 1/7/24, identified an order was received to continue OT one time per week and physical and speech therapies were to be decreased to PRN visits. P1’s medical record identified scheduled speech therapy visits were conducted one time per week on January 12, 19, 25, and February 2, 2024. During joint interview on 2/7/24, at 2:00 p.m. with ST-C and clinical manager (CM)-A , CM-A stated P1 did have an order to decrease PT and ST visits to PRN. Weekly scheduled visits would not be PRN, ST was not supposed to continue to go weekly. ST-C stated she had been planning to see P1 on a weekly visit but P1 was frequently non-compliant and never home and so generated a number of missed visits. An order was obtained on 1/7/24, because of P1 frequently not being home for her scheduled ST visits. Then ST-C suddenly found P1 was home when she called, and so ST-C started seeing her again on a weekly basis. ST-C did not receive an order to increase visits back to weekly and an order should have been obtained. The agency policy Referral for Home Health Cre Service: Physician Order-Initial and Recertification: Plan of Care: Client Communication, dated June 2022, identified written orders for home health care services must be signed by the attending physician and should clearly state orders for home care assessment, diagnosis, specific therapies, frequency and duration, modalities, precautions or other specific instructions. A policy for PRN home health visits was requested, however, none were received.”