Mosaic Life Care Home Health

“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 policy review, record review, and interview, the home health provider failed to ensure the initial assessment was completed within 48 (forty-eight) hours of the referral in one of five full records reviewed (Record/Patient #4). This deficient practice has the potential to affect the immediate care needs of all the provider’s patients. Findings included: Review of the provider’s policy titled, “Initial & Ongoing Assessment, Communication and Care Planning Process in Home Health,” with an approval date of 06/05/2023, showed admission and resumption of care visits are completed within 48 (forty-eight) hours of referral or discharge from inpatient facility unless otherwise specified by provider. RECORD/PATIENT #4: Review of a referral #2411657 showed, in part: - A creation date of 04/04/2024 for SN (skilled nursing); and - Requested SOC (Start of Care) Date failed to be documented (it was left blank). Review of the clinical record showed the patient was admitted to home health services on 04/09/2024 with a primary diagnosis of pressure ulcer (a lesion caused by unrelieved pressure resulting in damage of underlying tissue) of right ankle, stage 2 (a partial thickness loss of skin layers that presents clinically as an abrasion, blister, or shallow crater). Review of the SOC OASIS (Start of Care Outcome and Assessment Information Set; a standardized data collection tool) dated 04/09/2024 (five days following referral) showed: - Item M0090: Date assessment completed: 04/09/2024 (five days after referral received) - Item M1000: Inpatient Facilities- From which of the following Inpatient Facilities was the patient discharged within the last 14 (fourteen) days? Documented as N/A- Patient was not discharged from an inpatient facility; and - Item M0102: Date of physician-ordered SOC marked N/A, no specific SOC date ordered by physician. Further review of the clinical record showed, in part: - A telephone conversation note dated and timed 04/05/2024 at 10:21 AM between the provider and a MD (Doctor of Medicine) documented the following: Courtesy note to let you know “Named Home Health” will be admitting late d/t (due to) scheduling availability. Thank you. (It failed to clarify if the scheduling availability was an issue of the provider or the patient); and - The clinical record failed to include a specific physician and/or allowed practitioner ordered start of care date. During an interview on 04/30/2024 starting at 1:15 PM the clinical manager stated that: - The SOC should be within 48 hours of referral or discharge home from an inpatient facility; and - He/she agreed the telephone documentation failed to specify who had the scheduling availability issue (the patient or the provider).”

“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, record review, observation and interview, the home health provider failed to ensure staff maintain an accurate and updated medication profile in, but not limited to, two of three home visit observations (Records/Patients #1, and #2). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Medication Administration, Disposition Including the Delivery of Medication and Medical Provider Orders for Home Health and Hospice”, dated 4/28 2021, showed, in part; - Stock Medications: An order is necessary for the use of stock medications. If the strength or indication for the medication is outside of the standard, a specific order is obtained; - Current medications, including vitamins, supplements, and herbal therapies are listed on the medication profile. Patients have a current medication profile in the medical record. Medication orders include the patient’s name, date, time, medication name, dose, frequency, route of administration, practitioner ordering and indication if ordered PRN (as needed); and - A nurse reviews the medication profile on admission for accuracy and contra-indications (allergies, drug interactions.). The nurse also reviews the medication profile upon receiving new medication orders and prior to administration of medications. If the nurse has questions or concerns about medications, she/he will consult with the Associate Director. Major medication interactions identified with medication validation will be reported to the medical provider. RECORD/PATIENT #1: Review of the clinical record showed the patient admitted to home health services on 01/17/2024 with a primary diagnosis of diabetes (a group of diseases that results in too much sugar in the blood), and a pressure sore on the great toe of the left foot. The patient lived at home alone, and was discharged from services on 04/29/2024, after the home visit. Observation and interview on 04/29/2024 at 2:30 PM, during the patient’s home visit, showed Registered Nurse (RN)- A failed to perform a comprehensive medication reconciliation during the visit. The following medication discrepancies were discovered: - The provider’s medication profile showed a physician’s order for glipizide (a diabetic medication to regulate blood sugar levels), 10 milligrams (mg), take one tablet daily. The patient’s stated that he/she had taken the last dose of the medication on 4/28/2024 and was currently “out” of the medication; - Observation and interview showed the patient stated he/she was currently taking hydrocodone / acetaminophen (a narcotic medication taken for pain) 5 mg /325 mg 1 tablet every 4 to 6 hours for pain as needed. The medication was not listed on the current provider’s list; and - Observation and interview showed the patient stated he/she was taking Vitamin B complex (a dietary supplement) 500 mg 1 tablet daily. The medication was not listed on the current provider’s list. During an interview on 04/30/2024 at 9:00 AM, the Director of Nursing (DON) stated that the staff are responsible for following the medication policy and perform medication reconciliation during each home visit to ensure accuracy. RECORD/PATIENT #2: Review of the clinical record showed the patient admitted to home health services on 04/26/2024 with a primary diagnosis of aftercare following joint replacement surgery (left knee) with PT (physical therapy) only. The patient lived at home with his/her sibling. Review of the medication list at discharge from the inpatient facility dated as of 4/24/2024 at 10:53 AM showed, in part, Acetaminophen 325mg tablet (medication for mild to moderate pain) take 650mg by mouth (there failed to be any further directions with frequency limits or if it was scheduled or as needed). Observation on 04/29/2024 at 1:30PM, during the patient’s home visit, the PTA (Physical Therapy Assistant) questioned the patient if there had been any medication changes but failed to do a medication reconciliation. A reconciliation was done by this surveyor utilizing the current medication profile supplied by the agency and a review of the patient’s medication bottles and their list from the inpatient facility discharge (the only medication list in the home) and the following discrepancies were noted: - The patient’s medication list from the inpatient facility showed Acetaminophen 325mg (milligram) tablet (medication for mild to moderate pain) take 650mg by mouth; The provider’s list failed to include the acetaminophen; - The current medication profile supplied by the provider showed Ascorbic acid (Vitamin C) 100mg tablet, take one in the morning; The patient’s bottle label showed 500mg tablets; - The current medication profile supplied by the provider showed biotin 1mg tablet take 1,000mcg (micrograms) by mouth in the morning; The patient’s bottle label showed 5,000mcg tablets. Per interview conducted during observation, the PTA (physical therapy assistant) stated that he/she did not do a complete medication reconciliation because they are done weekly and the PT (physical therapist had just done it Friday (three days prior). Per interview conducted during observation, the patient stated that: - They were taking Tylenol (acetaminophen) as needed (which failed to be on the provider’s medication profile); - They take one of the vitamin C tablets a day (from the bottle labeled with 500mg tablets) (Ordered strength was on the provider’s medication profile was 100mg every morning); and - They take one biotin every day (from the bottled labeled with Biotin 5,000mcg) (Ordered strength was on the provider’s medication profile was 1,000mcg every morning) During an interview on 04/30/2024 starting at 1:15PM, the clinical manager stated that: - This patient was a new admit; - It looked like the Tylenol had “fell off” the bottom of the page; and - The medication doses would be clarified.”

“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 policy review, record review, observation, and interview, the provider failed to obtain orders to provide services and treatments only as ordered by a physician or allowed practitioner in one of five full records reviewed (Record/Patient #2) . This deficient practice has the potential to affect the care of all the provider’s patients. Findings included: Review of the home health provider’s policy titled, “Initial & Ongoing Assessment, Communication and Care Planning Process in Home Health,” approval date of 06/05/2023, showed, in part, the following: -Purpose: Provide guidelines for initial and ongoing assessment, treatment, interdisciplinary collaboration, care planning and updating the plan of care to facilitate realistic patient goals; -Plan of care is initiated upon admission; -The plan of care is developed in collaboration with the physician, to facilitate progressive resolution of problems identified on admission; and - Patient care shall follow a developed plan, which is periodically reviewed by the supervising nurses or other appropriate health professionals. RECORD/PATIENT #2: Review of the clinical record showed the patient admitted to home health services on 04/26/2024 with a primary diagnosis of aftercare following joint replacement surgery (left knee) with PT (physical therapy) only. The patient lived at home with his/her sibling. Review of the plan of care dated 04/26/2024 to 06/24/2024 failed to show: - An order for application of ice; and - An order for Miralax (medication used to treat constipation), milk of magnesia (medication used to treat constipation), or Dulcolax (medication used to treat constipation). Review of the PT OASIS (Outcome and Assessment Information Set; a standardized data collection tool) Start of Care note dated 04/26/2024 showed, in part, under the SOC summary section: PT also instructs patient and daughter in adding milk of magnesia, Miralax, and Dulcolax per constipation protocol. (The clinical record failed to contain an order from the physician to initiate this protocol). During a home visit observation on 04/29/2024 starting at 1:30 PM with the PTA (physical therapy assistant): - He/she questioned if the patient had utilized ice as needed to the incisional area , the patient responded yes. (Review of the plan of care and all orders, failed to show an order for patient to use ice.)(The PTA failed to instruct the patient there currently were no orders for ice); - He/she questioned the patient regarding the activity of their bowels and the patient stated that he/she had no issues with bowels now, but did have some right after getting home. The patient also stated that he/she took Miralax granules this morning. (The PTA failed to instruct the patient there currently were no orders for Miralax). During an interview on 04/30/2024 starting at 1:15 PM the clinical manager stated that: - He/she would expect an order for ice with the frequency, location and duration if the patient was utilizing it; and - An order would be expected to follow bowel protocol, if the patient was being instructed to do so.”