Johnson County Community Health Services

“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 policy review, clinical record review, home visit observation and interview, the provider failed to ensure a complete and accurate review of all the medications was completed in one of three home visit observations (Record/Patient #4). This deficient practice has the potential to affect the provider’s ability to ensure safe and effective use of medications for all patient’s served by the provider. Findings included: Review of the provider’s policy, dated most recently revised “2/2023”, titled, “Medication, Regimen Review Comprehensive,” showed in part: - The RN (registered nurse) will be responsible for monitoring the patient’s medication regimen through a collaborative effort with the multi-disciplinary team and physician involved in the patient’s care; - All required comprehensive assessments will include 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; - At the time of admission an accurate, current and complete list of all prescription and over the counter (OTC) medications, as well as herbal medications taken by the patient will be maintained on the medication profile; - The clinician will compare the medication list to those on the referral or other documents and provided to the agency. Any discrepancies will be reconciled with the physician and documented in the clinical record; - Every effort will be made to reconcile any discrepancies with the physician or designee the next calendar day of the assessment; - The clinician will document this contact and any difficulties experienced in obtaining physician response; - The medication profile will be placed in the patient’s home and include essential information about dosages, drug schedules, immunizations, and drug allergies. This medication profile will also include initial order and discontinuation dates, where applicable; - Nursing staff will assess on an ongoing basis the patient’s response to the medication and the patient/caregiver’s compliance with the medication regimen; - Adverse patient response, lack of patient response, and/or compliance concerns will be communicated to the physician as well as documented in the clinical record; - Changes in the medication regimen will be documented in the clinical record as well as communicated to the patient and/or caregiver; and - Review of medications will be on-going but done a minimum of every sixty days. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 01/02/2024 with a principal diagnosis of other specified chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe). Review of the medication list from the long term care facility upon discharge provided to the provider, dated 12/27/2023 showed, in part: - Simvastatin 20mg, give one tablet one time daily for hyperlipidemia (order status marked active); - Tamsulosin 0.4mg, give one capsule by mouth one time a day for retention (given for enlarged prostrate to help the flow of urine) (order status marked active); and - Miralax oral powder 17gms by mouth as need for constipation once daily as needed administer in 4-8 ounces of liquid of choice (order status marked active). Observation on 01/23/2024 starting at 1:00PM, during the patient’s medication reconciliation, the following discrepancies were noted when comparing what the patient was taking with the current medication profile supplied by the provider: - Simvastatin failed to be listed on the current medication profile; - Tamulosin failed to be listed on the current medication profile; - Metamucil gummies failed to be listed on the current medication profile; - Nasal spray failed to be listed on the current medication profile; and - Fiberall powder was listed on the profile. but the patient denied taking any powdered medication for his/her bowels. Per interview conducted during the observation the patient stated that he/she: - Was taking fiber gummies, three daily, instead of the powder medication for his/her bowels; - Just started using a nasal spray as needed; - Had been on simvastatin for twenty years; and - Had been on the tamsulosin for two years. Per interview conducted during the observation, RN A stated that: - He/she thought maybe the simvastatin was on the medication profile; - They had discussed starting a nasal spray but was unaware the patient started until just then; and - He/she would get all the discrepancies clarified. During an interview on 01/24/2024 starting at 1:00 PM the home health director stated that: - RN A has it all clarified/fixed now; and - The medication profile should match what the patient is taking unless it happened since that last visit.”

“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 policy review, clinical record review, and interview, the provider failed to notify/communicate with the physician when medication needed to be clarified and when the nurse was unable to assess blood glucose as ordered on the plan of care (POC) in two of five full records reviewed (Records/Patients #4 and #5). This deficient practice has the potential to adversely affect the care of all patients served by the provider. Findings included: Review of the provider’s policy dated most recently revised 10/2018, titled, “Physician Plan of Care/Physician Orders,” showed in part: - The relevant physician(s) must be notified of any changes in the patient condition or needs that suggest that outcomes are not being met and/or the POC should be revised; - Any revision to the POC due to a change in patient status must be communicated to the following: * The patient; and * The physician responsible for the POC. Review of the provider’s policy dated © November 2019, titled, “Plan of Care,” showed in part: - The plan of care will serve as physician’s orders for patient care and all staff providing services will be in compliance with the orders; - The patient’s physician orders for treatments and services are the foundation of the plan of care. If the agency misses a visit or a treatment or service as required by the plan of care, which results in any potential for clinical impact upon the patient, then the agency will notify the responsible physician of such missed treatments or service. The physician will decide whether the treatment or service may be skipped or whether additional intervention is required by the HHA (home health agency) due to clinical impact on the patient; - If the patient or the patient’s representative refuses care that could impact the patient’s clinical well being (such as dressing changes or essential medication) on more than one occasion, then the HHA will attempt to identify the reason for the refusal. If the HHA is unable to identify and address the reason for refusal, then the HHA will communicate with the patient’s responsible physician to discuss how to proceed with patient care; and - “Named provider” must promptly alert the relevant physician(s) to any changes in the patient’s condition or needs that suggest outcomes are not being achieved and/or that the plan of care should be altered. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 01/02/2024 with a principal diagnosis of other specified chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe). Review of a SN (skilled nurse) visit noted date 01/04/2024 showed, in part, documentation stating “Has a nebulizer and 2 different medications, they are not sure which one to use, suggested he/she talk with the PCP (primary care physician) at visit to clarify.” During an interview on 01/24/2024 starting at 1:00 PM the home health director stated that: - We seen that (the documentation instructing the patient to clarify the medication orders with the physician); and - The doctor should have been notified by the nurse to clarify. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to home health services on 12/19/2023 with a principal diagnosis of Type 2 (two) diabetes mellitus with foot ulcer. Review of the initial POC dated 12/19/2023 to 02/16/2024 showed, in part; -SN frequency 1w9 (one time a week for nine weeks) starting week of 12/19/2023; and - SN to perform finger stick blood sugar every visit. Review of the SOC (start of care) OASIS (Outcome and Assessment Information Set; a standardized data collection tool) dated 12/19/2023 showed in part: - Patient reported that his/her glucometer (machine utilized to assess blood sugar per fingerstick) needed batteries; - Patient reported that he/she had been diabetic for a long time and knew if his/her blood sugars were high or low depending on how he/she felt; - He/She was educated on the importance of having a working glucometer especially with use of insulin; - Patient stated he/she would get batteries and get it working; and - He/she was educated on importance of keeping BS (blood sugar) well managed for optimal wound healing. Review of a SN visit note date 12/26/2023 showed, in part, patient still had not gotten new battery for glucometer and told him/her to obtain ASAP (as soon as possible). Review of a SN visit note date 01/02/2024 showed, in part, comment documented under endocrine (system of the body that releases hormones that directly or indirectly affect blood sugar) section: never got glucometer battery. Review of a SN visit note date 01/08/2024 showed, in part, under endocrine section documented did not buy batteries for glucometer. Review of a SN visit note dated 01/15/2024 showed, in part, under endocrine section documented not working. Further review of the clinical record failed to show: - Any blood sugars documented; and - Any communication with the physician that the provider was unable to assess the blood sugar due to the patient not purchasing battery/having a working glucometer. During an interview on 01/24/2024 starting at 1:00 PM the home health director stated that he/she: - Was unable to find documentation that the physician was notified of the inability to follow POC and assess blood sugar every visit; and - He/she would expect the physician to be notified.”

“Revisions communicated to patient and MDs CFR(s): 484.60(c)(3)(i) (i) Any revision to the plan of care due to a change in patient health status must be communicated to the patient, representative (if any), caregiver, and all physicians or allowed practitioner’s issuing orders for the HHA plan of care. This Element is not met as evidenced by: Based on clinical record review, and interview, the provider failed to ensure revision in the plan of care, due to wound healing, was communicated to all physicians issuing orders for the plan of care in one of five full records reviewed (Record/Patient #4). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy dated © November 2019, titled, “Plan of Care,” showed in part, “Named provider” must promptly alert the relevant physician(s) to any changes in the patient’s condition or needs that suggest outcomes are not being achieved and/or that the plan of care should be altered. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 01/02/2024 with a principal diagnosis of other specified chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe). The patient was admitted with a wound to the right dorsal second toe that the patient/caregiver were providing care to. Review of the initial POC (plan of care) dated 01/02/2024 to 03/01/2024 showed, in part, clinician to assess wound to right dorsal second toe. Patient/caregiver to continue cleansing with soap/water daily and placing cotton ball between toes as instructed by podiatrist (there failed to be a stop date documented for these interventions). Review of a SN (skilled nurse) visit note dated 01/17/2024 showed documentation that the wound had re-epithelized (healed). Review of the care plan showed no longer needed/goals met was marked for interventions of clinician to assess wound to right dorsal second toe and patient/caregiver to continue cleansing with soap/water daily and placing cotton ball between toes as instructed by podiatrist and was dated 01/17/2024. Further review of the clinical record failed to show documentation that the PCP (primary care physician) was notified that the wound had re-epithelized. During an interview on 01/24/2024 starting at 1:00 PM, the home health director stated that: - The care plan was updated to indicate that the goal was met, and interventions were no longer needed; - The PCP does not see or sign the care plan; and - The PCP was not notified that the wound had healed, and the assessment and treatment were no longer needed.”

“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 policy review, record review, observation, and interview, the home health provider failed to ensure staff measured/documented abdominal girth measurement as ordered in one of five full records reviewed (Record/Patient #4). This deficient practice has the potential to adversely affect all patients served by the provider. Findings included: Review of the provider’s policy dated © November 2019, titled “Plan of Care,” showed, in part: - The plan of care will serve as physician’s orders for patient care and all staff providing services will be in compliance with the orders; and - The patient’s physician orders for treatments and services are the foundation of the plan of care. If the agency misses a visit or a treatment or service as required by the plan of care, which results in any potential for clinical impact upon the patient, then the agency will notify the responsible physician of such missed treatments or service. The physician will decide whether the treatment or service may be skipped or whether additional intervention is required by the HHA (home health agency) due to clinical impact on the patient. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 01/02/2024 with a principal diagnosis of other specified chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe). Review of a physician order (order No: C-5813), dated 01/11/2024, showed, in part, clinician to obtain abdominal girth to assess for fluid retention (a frequency failed to be documented). Review of a SN (skilled nurse) visit note dated 01/17/2024 failed to show documentation of an abdominal girth. Further review of the clinical record failed to show an order to discontinue measuring abdominal girth. Observation on 01/23/2024 at 1:00 PM, during the patient’s home visit, showed the SN failed to measure an abdominal girth. During an interview on 01/24/2024 at 1:00 PM the home health director stated that: - We know what the problem was, it was a canned (non-individualized) care plan, and the nurse didn’t delete that part out; - Abdominal girths were never actually ordered by the physician; and - Nurses are expected to follow the POC.”

“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 policy review, record review and interview, the provider failed to send a completed discharge summary timely in one of two discharge records reviewed (Record/Patient #6). This deficient practice has the potential to adversely affect the post discharge care of all patients served by the provider. Findings included: Review of the provider’s policy dated most recently revised 11/2019, titled, “Discharge/Transfer, Patient”, showed in part: - “Named Provider” will discharge and/or transfer patients in a timely, coordinated manner when the patient meets the agency discharge/transfer criteria; and - A completed discharge summary will be 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 (Home health agency) (if any) within five (5) business days of the date of the patient’s discharge. RECORD/PATIENT #6: Review of the clinical record showed the patient was admitted to home health services on 09/22/2023 with a principal diagnosis of Type 2 diabetes mellitus (adult onset of a group of diseases that results in too much sugar in the blood) with other skin ulcer, and secondary diagnoses of non-pressure chronic ulcer of other part of right lower leg and non-pressure chronic ulcer of other part of left lower leg. Further review of the clinical record showed, in part: - A discharge OASIS (Outcome and Assessment Information Set; a standardized data collection tool) with a visit date of 12/12/2023 and electronically signed by the RN (registered nurse) 12/12/2023: - A discharge summary completed and electronically signed 12/12/2023; and - A fax cover sheet to the primary care provider, dated 12/26/2023 (nine business days later). During an interview on 01/24/2024 starting at 1:00 PM, the home health director stated that he/she would expect it to be sent within five business days.”