Freeman Home Care 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, observation, and interview, the home health provider failed to ensure their patient’s medications were reconciled to include all of the medications the patient was currently using in three of six full records reviewed (Records/Patients #1, #2, and #7). This deficient practice has the potential to affect all of the provider’s patients. Review of the undated document titled, “Guidelines for Visit Documentation,” showed that the provider’s clinicians were to perform medication reconciliation activities every visit, to include, but not limited to: - Ask the patient if any medication changes have occurred, and document the changes; - Write orders if the patient is taking new medications, even over the counter; and - Check medication bottles every week for accuracy of the medication list. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 6/30/2024 with a primary diagnosis of aftercare following joint replacement of the right hip on 06/26/2024. The patient resided in their own home with the assistance of family members. Review of the document titled, “Discharge Summary,” dated 6/27/2024 showed the patient was to take aspirin 81mg by mouth twice a day for 30 days. Review of the skilled nurse evaluation visit documentation, for the visit performed 6/30/2024 showed the patient had, “taken some softeners and two doses of mineral oil” to manage constipation. The patient expected the mineral oil to start working. Review of the document titled, “Home Health Certification and Plan of Care,” with start of care date of 6/30/2024 showed: - The plan of care contained an order for aspirin 81 mg oral tablet, two times per day: - The plan of care failed to contain: * A stop date for the aspirin therapy; and * Orders for stook softeners and mineral oil as reported by the patient. During an interview on 7/10/2024 at 10:04 AM, the administrator stated that they expected the plan of care to contain a list of all the medications the patient was taking. RECORD/PATIENT #7: Review of the clinical record showed the patient was admitted to home health services on 6/19/2024 with a primary diagnosis of acute and chronic respiratory failure. The plan of care contained secondary diagnoses of long-term use of oral hypoglycemic drugs (medications used to lower blood sugar). The patient resided in their own home with the assistance of family. Review of the document titled, “Discharge Summary,” dated 06/14/2024 showed: - The patient was to take Bisacodyl 10mg at bedtime as needed for constipation, and Sennosides 1 tablet two times per day. Review of the start of care nursing visit documentation, for the visit dated 06/19/2024, showed the patient was a diabetic (a problem in the way the body regulates and uses sugar as a fuel), and did not check their blood sugars. Their diabetes was monitored at the physician’s office. Review of the document titled, “Plan of Treatment,” with a start date of 06/19/2024 showed: - Patient/caregiver to check daily blood glucose or as ordered by physician. SN to monitor and report any readings outside stated parameters of 250 to the physician; and - The document failed to contain list senna and bisacodyl as active medications for the patient. During an interview on 7/10/2024 at 10:36 AM, the administrator stated that: - They would expect the plan of care to reflect that the patient does not monitor blood sugars, and the orders for daily monitoring were inaccurate for this patient; and - They would expect the plan of care to contain a list of all the medications the patient was taking. RECORD/PATIENT #1: Observation on 07/09/2024 at 9:00 AM, during the patient’s home visit, showed the following: -The patient was using Arnica gel as needed for back pain every day. This medication was not on the provider’s medication profile; -The patient was taking Coenzyme Q10 (COQ10) (an antioxidant) 200 milligrams (mg) once a day. This medication was not on the provider’s medication profile; -The patient was taking Beano (anti gas pill) one pill daily as needed for gastric distress. This medication was not on the provider’s medication profile: -The provider’s medication profile showed the patient was taking Trazodone 50 mg once daily at bedtime. The patient stated that he/she has not taken this medication in a few months; and -The provider’s medication profile showed the patient was taking Cannabidiol (CBD) 10 mg oral gummies take 1/4 to 1 gummy as needed for pain. The patient stated that he/she has not taken this medication in a few months. During an interview on 07/09/2024 at 9:00 AM, the patient’s nurse agreed that the patient’s medication profile and the medications that the patient was taking did not match. During an interview on 07/10/2024 at 10:30 AM, the administrator stated that he/she would expect the medications to match the medication profile.”

“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 policy review, clinical record review, and interview, the home health provider failed to ensure the individualized plan of care contained the patient-specific interventions in one of six records reviewed (Record/Patient #2). This deficient practice has the potential to affect the care for all the provider’s patients. Findings included: Review of the provider’s policy titled, “Care Planning, Coordination of Services, and Quality of Care,” last revised 02/2024 showed: - Each patient must receive the home health services that are written in the individualized plan of care (POC) that identifies patient-specific measurable outcomes and goals; - The plan of care must contain patient specific interventions; and - Drugs, services, and treatments are administered only as ordered by a physician. Review of the undated document titled, “Total Hip Protocol for Dr. Miller and Dr. Black,” showed that: - With the Dermabond Prineo (a liquid adhesive with a self-adhering mesh) closure, avoid alcohol, soap or washing along incision site; - Do not cover dressing with anything but compression stockings. May shower, cover surgical dressing with plastic while showering; and - SN (skilled nurse) to remove dressing and apply new post-op occlusive surgical dressing every six to eight days post-op prior to surgeon follow-up visit. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 06/30/2024 with a primary diagnosis of aftercare following joint replacement of the right hip on 06/26/2024. The patient resided in their own home with the assistance of family members. Review of the document titled, “Discharge Summary,” dated 06/27/2024 showed: - If you have Dermabond Prineo skin closure dressing, leave dressing intact. Do not cover dressing with anything but compression stockings; - Cover your surgical dressing with plastic while showering; and - Home health to change the surgical dressing at six to eight days post op. Review of the SN evaluation visit documentation, for the visit performed 06/30/2024, showed the patient had a right hip surgical site: - The wound assessment showed: * Wound type: Surgical; * Dressing condition: intact; * Drainage: None; * Signs and symptoms of infection: None; and - Wound Note: Swollen to hip area but doing well and only a little bruising noted under dressing, no blisters. Review of the SN visit documentation, for the visit performed 07/03/2024, showed: - The SN changed Mepilex AG (an occlusive, silicone bordered, antibacterial impregnated dressing) dressing that day. No s/s (signs/symptoms) of infection or drainage noted; - Assessment of wound: Edges of wound well approximated with Dermabond intact. Review on 07/10/2024 of the POC, dated 06/30/2024, failed to contain an order for the Mepilex AG dressing. During an interview on 07/10/2024 at 10:31 AM, the administrator stated that: - The intent of the total hip protocol was to include treatment directives including: * The patient’s incision was closed with the Dermabond Prineo closure device; * The closure device is then covered (as a surgical dressing) with a Mepilex AG dressing; and * The clinicians were to change the Mepilex AG dressing six to eight days post-op, prior to the post-op surgeon’s visit; and - The protocol failed to contain directions that the Dermabond Prineo closure device was covered with a post-op, occlusive, bordered foam AG impregnated dressing.”

“Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure nursing staff documented coordination of care with all physicians in one of six 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 titled, “Care Planning, Coordination of Services, and Quality of Care,” reviewed 02/2024, showed in part that the provider must assure communication with all physician involved in the POC, integrate orders from all physicians involved in the POC to assure coordination of all services and interventions provided to the patient, integrate services to assure the identification of patient needs and factors that could affect patient safety, treatment effectiveness, and the coordination of care provided by all disciplines, and coordinate care delivery to meet the patient’s needs. RECORD/PATIENT #4: Review of the record showed the patient was admitted to home health service on 03/30/2024. The principal diagnosis was unspecified open wound to the left lower leg. The patient had been traveling in another state when he/she sustained an injury/wound to the left leg and was hospitalized. He/she returned and also received care through the local VA (veterans administration). The patient went for hyperbaric therapy (pure oxygen in a pressurized environment which increases the amount of oxygen your blood can carry) Monday through Friday and the local hospital wound care clinic on Wednesdays. The home health nurses saw the patient on the weekends for dressing changes. Review of the nursing admission visit dated 03/30/2024, showed under the medication reconciliation section, the nurse documented he/she had a faxed medication sheet from March 25 that showed active inpatient medications. The patient had a bottle of Benadyl (antihistamine) he/she had never taken. The patient would not take anything for bowels. He/she took clopidigrel (Plavix, blood thinner) and oxycodone (narcotic pain medication) one time but not currently. The spouse had a medication sheet he/she took a picture of before coming home with about six medications on it. The patient was not on about half of the medications on the sheet the nurse had. The patient knew his/her medications well and got everything from the VA (veterans administration). The patient was not on the clopidigel or oxycodone. The nurse failed to document he/she clarified the medications with the physician (s). Review of a nursing visit dated 06/07/2024, the patient had been to the cardiologist (heart doctor) who stated that he/she needed to take a blood thinner and was under the impression the patient took Plavix. The patient had not been taking since home from the hospital. Now the cardiologist said to get back on it even with the aspirin. The next day the patient saw another physician and was told to go off the blood thinners. The patient took one day of Plavix and his/her hematocrit (the amount of red blood cells in the blood) dropped 7000 points in a two-day period. The patient’s spouse had contacted the VA about lowering the aspirin dose. The patient stated that his/her physician at the VA said to get off the Plavix. The patient’s stories conflicted some. The nurse failed to document he/she clarified the medications with the physician (s). During an interview on 07/09/2024 at 3:55 PM, the quality RN (registered nurse) stated that he/she would expect the nurse to document he/she clarified the medications with the physician. During an interview on 07/10/2024 at 8:30 AM, the administrator stated that he/she talked with the nurse. The nurse stated that he/she knew he/she contacted the physician and got everything straightened out but did not have documentation of it. During an interview on 07/10/2024 at 8:30 AM, the patient’s nurse manager stated that the patient “messed” with his/her medications. He/she took one day of the Plavix. The other physician was an infectious disease physician, and that was who the patient listened to.”

“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, and interview, the home health provider failed to ensure nursing staff followed the plan of care (POC) for frequency of visits for two patients (Records/Patients #1 and #5) and for wound monitoring in one of six full records reviewed (Record/Patient #4). This deficient practice has the potential to affect all patients served by the provider. RECORD/PATIENT #1: Review of the clinical record showed the patient admitted to home health services on 11/15/2023 with a primary diagnosis of encounter for orthopedic aftercare. Review of the document titled, “Home Health Certification and Plan of Care,” showed the visit frequency for skilled nursing (SN) services as of 05/13/2024-07/11/2024 as the following: -5-6 visits a week for one week; and -6-7 visits a week for eight weeks. Review of the SN notes for the week of 06/23/2024-06/29/2024 showed: -A missed SN visit on 06/25/2024; and -A missed SN visit on 06/27/2024. During an interview on 07/10/2024 at 10:00 AM, the Quality Registered Nurse (RN) provided an order, dated 07/08/2024, for the two missed visits due to doctor’s appointments. During an interview on 07/10/2024 at 10:15 AM, the administrator stated that he/she would expect the order for the missed visits to be obtained the same day as the missed visits. RECORD/PATIENT #5: Review of the clinical record showed the patient admitted to home health services on 02/20/2024 with a primary diagnosis of mechanical complication of other internal joint prothesis. Review of the document titled, “Home Health Certification and Plan of Care,” showed the visit frequency for skilled nursing (SN) services as of 02/20/2024-03/09/2024 as two times a week for three weeks. Review of the SN notes for the week of 03/03/2024-03/09/2024 showed one visit for the week. During an interview on 07/09/2024 at 3:06 PM, the Quality RN stated that there was not a second visit for the week or an order for the missed visit. Findings included: Review of the provider’s policy titled, “Care Planning, Coordination of Services, and Quality of Care,” reviewed 02/2024, showed in part that each patient must receive an individualized POC. The POC must specify the care and services necessary to meet the patient-specific needs. Each patient must receive the home health services that are written in the individualized POC. Review of an undated document provided by the provider as their expectations titled, “Wound Assessments and Care,” showed in part that complete wound assessment documentation should include the location, measurements, appearance, tissue types, drainage, odor, and pain. Review of an undated document provided by the provider as their expectations titled, “Guidelines for Visit Documentation,” showed in part that documentation included that wounds should be assessed every visit, perform ordered wound care, measure weekly and as needed, and chart in the wound care section. RECORD/PATIENT #4: Review of the record showed the patient was admitted to home health service on 03/30/2024. The principal diagnosis was unspecified open wound to the left lower leg. The patient went for hyperbaric therapy (pure oxygen in a pressurized environment which increases the amount of oxygen your blood can carry) Monday through Friday and to the wound clinic on Wednesdays. The home health nurses saw the patient on the weekends for dressing changes. Review of the nursing admission visit dated 03/30/2024, showed the patient had a pressure ulcer to the left buttocks described as “skin bunched up”. The nurse took a picture, but their camera messed up the picture. The nurse failed to document further assessment of the area. Review of the POC dated 03/30/2024, included that the skilled nurse (SN) would monitor the pressure ulcer to the left buttock. Clean with soap and water as needed, apply zinc oxide (skin protectant), and cover with Mepilex border (foam dressing with an adhesive border) until healed. Review of the nursing visits showed: - From 04/06/2024 through 04/13/2024, the nurse failed to document an assessment of the left buttock pressure ulcer; and - On 04/14/2024, the nurse described the left buttock pressure as a small skin tear, not healing and skin bunched up. The nurse applied Mepilex. The nurse failed to document measurements, tissue type, drainage, and odor. Review of a physician order dated 04/14/2024, showed to apply Mepilex border to the buttock skin tear, change every three to five days per SN, spouse, or wound clinic. Review of the nursing visits showed: - On 04/20/2024, the nurse documented the left buttock pressure ulcer was healing without drainage and signs and symptoms of infection. The patient’s caregiver changed the pad yesterday so left in place. The wound procedure included to apply Mepilex border to the buttock skin tear, change every three to five days per skilled nurse, caregiver, or wound clinic; - On 04/21/2024, the caregiver would change the Mepilex border to the bottom tomorrow; and - From 04/27/2024 through 05/19/2024, the nurse failed to document an assessment of the left buttocks. Review of a physician order dated 05/22/2024, showed an order for the bilateral gluteals (both buttocks) to make sure clean and dry, apply thin layer of Triad (a zinc oxide based wound paste) to reddened areas and may cover with Mepilex. May use skin barrier wipes under adhesive. Reapply Triad as it comes off and may use on open areas also on gluteals. The order failed to include the frequency or who would provide the treatment. Review of the recertification nursing visit dated 05/25/2024, showed wound care for the bilateral gluteal included to make sure clean and dry, apply thin layer of Triad to reddened areas and may cover with Mepilex. May use skin barrier wipes under adhesive. Reapply Triad as it comes off and may use on open areas also on gluteals. The nurse failed to document an assessment of the gluteals. Review of the recertification POC dated 05/29/2024, showed an order for bilateral gluteals to make sure clean and dry, apply thin layer of Triad (a zinc oxide based wound paste) to reddened areas and may cover with Mepilex. May use skin barrier wipes under adhesive. Reapply Triad as it comes off and may use on open areas also on gluteals. Review of the nursing visits from 05/31/2924 through 06/14/2024, the nurses failed to document an assessment of the gluteal area. During an interview on 07/09/2024, beginning at 1:05 PM, the administrator stated that he/she would expect the nurses to document an assessment of the buttocks. During an interview on 07/09/2024, beginning at 1:05 PM, the administrator stated that he/she would expect the nurses to document an assessment of the buttocks. He/she would expect the nurses to document drainage, odor, redness, surrounding skin, tissue type and measurements once a week. During an interview on 07/10/2024, beginning at 8:30 AM, the patient’s nurse manager stated that there was never much of anything on the patient’s bottom. He/she thought they just put a patch on it. It was not open, and the caregiver did the dressings. He/she did not know of the patient ever having anything on both gluteal areas. The administrator stated assessments should be documented.”