SSM Health at Home Home Health-St. Louis

“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 that the initial assessment visit was held within 48 hours of referral or within 48 hours of the patient’s return home in three of five full records reviewed (Records/Patients #1, #2, and #3). This deficient practice has the potential to affect all patients served by the provider. RECORD/PATIENT #1: Review of the initial assessment, dated 12/07/2023, showed in part: - The Outcome and Assessment Information Set (OASIS) item M1000 showed the patient was discharged from a skilled nursing facility (SNF) on 11/29/2023; and - OASIS item M0102 showed the physician ordered start of care (SOC) date was 12/07/2023. Review of the home health referral, creation date 11/30/2023, showed a requested SOC date of 12/03/2023. Review of the physician’s orders failed to show an order for a 12/07/2023 SOC. RECORD/PATIENT #3: Review of the home health referral, creation date 11/10/2023, showed the “Requested SOC Date” was left blank. Review of the initial assessment, dated 11/26/2023, showed in part: OASIS item M1000 showed the patient was discharged from an inpatient rehabilitation facility on 11/20/2023; OASIS item M0102 showed no specific SOC date ordered by the physician; and OASIS item M0090 showed the date the assessment was completed was 11/26/2023 (six days after the patient’s discharge). During an interview on 12/13/2023, at 9:30 AM, the administrator stated that he/she expected the initial assessment to be completed within the 48-hour window per the regulatory requirements. He/she stated that the referral process started when the intake department received the referral, verified the insurance, contacted the physician to ensure they would follow the patient and then contacted home health to review and verify that they would accept the patient. They would tell the intake department what date they could accept the patient but, the intake department entered the date the physician agreed to follow the patient, which was still outside the 48-hour window. The administrator did not know why patient #3’s assessment was completed six days after the patient discharged and they would have to work out a better system between the home health and the intake department. Findings included: Review of the provider’s policy titled, “Timeliness of Documentation,” dated 06/16/2021, showed OASIS (Outcome and Assessment Information Set) start of care assessments were to be completed within 48 hours of the tine of the referral, the patient’s return home, or on the physician-ordered start of care date. RECORD/PATIENT #2: Review of the clinical record showed patient was referred to home health services on 05/12/2023 for wound vac (vacuum-assisted closure of a wound) care. Review of the start of care OASIS assessment shows the initial visit was completed on 05/15/2023, three days after the referral was obtained. During an interview on 12/13/2023 at 10:30 AM, the home health administrator stated that he/she would expect the start of care visit to be completed within 48 hours of the patient’s referral for home health.”

“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, home visit observation and interview, the home health provider failed to review all of the medications the patient was currently using in, but not limited to, one of three home visit observations conducted (Record/Patient #3). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Medication Reconciliation,” dated 05/03/2023, showed in part: - Medication reconciliation is the process of comparing a patient’s medication list to all the medications the patient is taking in order to avoid medication errors such as omissions, duplications, dosing errors or drug interactions; - Reconciliation is performed by nursing staff with every home visit; - Medications are reconciled, by therapy, at every visit by comparing the medication list in the home to the medication profile in the electronic health record and asking the patient/caregiver if there have been any changed or new medications since the last visit; - Therapists will use case communication to send a follow-up note to the administrator, clinical manager, or designee stating medications have been entered on the profile and indicate whether any major drug-drug interactions are noted. The therapist will also advise the administrator, clinical manager, or designee of any discrepancies found; - The administrator, clinical manager, or designee will contact the patient via telephone to confirm medications, answer and questions and document in the record that the medication review was completed, the patient was contacted, and the patient gave a response/validation of understanding; - At start of care (SOC) and resumption of care (ROC) the nurse will reconcile all medications in the home with the most recent after visit summary or discharge summary, including all over the counter (OTC) medications; - If there are discrepancies in the medication list from the referral source and what the patient is taking in the home, the physician is contacted, and the discrepancy should be resolved by midnight of the next calendar day; and - Document on “interventions” in the record. State how medications were reconciled such as with discharge orders or physician office and pill bottles. RECORD/PATIENT #3: Review of the initial assessment, dated 11/26/2023, showed in part: - No clinically significant medication issues were identified during the drug regimen review; - The patient was assessed as unable to take medication unless administered by another person; - The “home care aide” was identified as the person who manages the patient’s medications; and - The patient had a current updated medication list. Observation and interview on 12/12/2023, beginning at 12:00 PM, during the patient’s home visit, showed the patient had a plastic box full of medication bottles. The patient stated that he/she took all of the medications in the box and that he/she sets up his/her own medication planner. The following discrepancies were found with the medications in the patient’s home and the provider’s medication profile: - The provider’s medication list showed finasteride (a prostate medication) 5 milligrams (mg) take one tablet once daily. The medication was not in the home and the patient stated that he/she was not taking it; - The medication list showed loratadine (an allergy medication) 10 mg (no further instructions were on the medication list). The medication was not in the home and the patient stated that he/she was not taking it; - The following medications were found in the home and were not on the provider’s medication profile: * Aleve (an over the counter (OTC) anti-inflammatory medication used for pain) 220 mg, take one every eight to 12 hours as needed (PRN); * Advil (an OTC anti-inflammatory medication used for pain) 200 mg take one every four to six hours PRN; * Escitalopram (an antidepressant) 10 mg take one daily; * Tramadol (a prescription pain medication) 50 mg take one every eight hours as needed; * Gabapentin (a medication for nerve pain)100 mg take one capsule three times a day and the patient stated he/she only takes it when needed; * Atorvastatin (a cholesterol medication) 40 mg take one every evening; * Furosemide (a diuretic) 40 mg one tablet every other day and alternate with furosemide 20 mg one tablet every other day; * Melatonin 3 mg take one tablet daily at bedtime; * Protonix (a medication used to treat acid reflux) 20 mg take one daily; * Flonase (a steroid nasal spray used to treat allergies) 50 micrograms (mcg) use one spray in each nostril daily; * Midodrine (a medication used to treat low blood pressure) 2.5 mg tablets take one daily; * Spironolactone (a diuretic) 25 mg take one tablet daily; and - The clinical manager was present during the home visit and instructed the physical therapist to contact the physician and obtain an order for a nursing visit to do a complete medication reconciliation with patient education on what he/she should be taking. During an interview, immediately following the home visit, the patient stated that he/she had been taking all of the medications in the box and one of the therapists visited the previous week and told him/her that they were not sure if he/she should be taking all of the medications. The patient stated that he/she would like someone to come in and look at his/her medications because he/she did not want to take medications that counteracted each other. Review of the clinical record failed to show documentation that the medication discrepancies were reported to or clarified with the physician. During an interview on 12/13/2023 at 9:30 AM, the administrator stated that medication reconciliation seemed to be a consistent problem, but he/she would expect the medication profile to match what the patient is taking in the home and any discrepancies to be clarified with the physician.”

“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, record review, observation, and interview, the home health provider failed to ensure the plan of care (POC) was individualized and included the services, supplies, and equipment required for the patient in, but not limited to, two of five full records reviewed (Records/Patients #1 and #2). 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 was admitted to home health services on 12/07/2023 with a diagnosis of a colocutaneous fistula (an abnormal connection between the digestive tract, colon and skin) and an abscess (a collection of pus or infected fluid surrounded by inflamed tissue inside the abdomen) with a colostomy (a procedure where part of the colon is surgically diverted to an artificial opening in the abdominal wall). The patient had an additional diagnosis of a cervical spinal fracture related to a motor vehicle accident. The patient was dependent for his/her activities of daily living and lived in an independent living apartment with his/her spouse. Review of the initial assessment, dated 12/07/2023, showed the patient requires a motorized tilt wheelchair and a Hoyer lift (a mechanical lift used for transferring patients). Observation on 12/11/2023 at 12:55 PM, during the patient’s home visit, showed the patient was in a motorized tilt wheelchair, The patient also had a Hoyer lift, a hospital bed with rails and a shower chair. Review of the plan of care (POC), dated 12/07/2023, failed to show any of the patient’s durable medical equipment (DME). During an interview on 12/13/2023 at 9:30 AM, the administrator stated that the DME is on the initial assessment, but it is not carrying over to the POC. It may be a software issue that they will have to fix. Findings included: Review of the provider’s policy titled, “Plan of Care,” dated 04/07/2023, showed, in part, the following: -Standardized plans of care are not acceptable unless each plan is individualized to meet specific needs of the patient and caregiver, -The plan of care includes: *Equipment and supply needs, and *Patient specific interventions and education, measurable outcomes and goals identified by the home health provider and the patient. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 05/15/2023 with a primary diagnosis of ulcer to right lower extremity with fat layer exposed and a secondary diagnosis of type 2 diabetes mellitus. -The plan of care dated 11/11/2023 failed to show the patient was taking insulin to control his/her blood glucose levels; and -The plan of care failed to show interventions and goals regarding the diabetes diagnosis. During an interview on 12/13/2023 at 10:30 AM, the home health administrator stated that he/she would expect any pertinent diagnosis that could affect the patient’s treatment to be included on the plan of care.”

“Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on policy review, observation, and interview, the home health provider failed to ensure that a copy of written instructions outlining the visit schedule, including frequency of visits, was provided to the patient in two of three home visits conducted (Records/Patients #1 and #2). This deficient practice has the potential to affect all patients served by the provider. RECORD/PATIENT #1: Review of the initial assessment, dated 12/07/2023, showed the registered nurse (RN) documented the next visit plan as “RN explained plan of care (POC) and frequency of visits. Pt. (patient) agreed and verbalized understanding.” Review of the POC, dated 12/07/2023, showed in part: - The frequency of skilled nursing visits after the initial start of care was two visits a week for one week, then one visit a week for five weeks, and three as needed (PRN) visits; - A home health aide visit frequency of two visits a week for six weeks, effective 12/10/2023; - Physical therapy assistant visit frequency of two visits a week for one week, then three visits a week for one week, then two visits a week for one week; and - Physical therapy visit frequency of one visit for the week of 12/27/2023 to 12/30/2023. Observation on 12/11/2023 at 12:55 PM, during the patient’s home visit showed the patient’s home health folder and information given to the patient by the provider failed to contain a completed visit schedule including the frequency of visits by the nurse and the physical therapist. During an interview immediately following the home visit, the patient and spouse stated that the staff called them to set up a day and time for the week. They stated that they were not aware that a home health aide was going to be provided and they were not given a written schedule to help them keep up with the visits. During an interview on 12/13/2023 at 9:30 AM, the administrator stated that the admitting nurse may document that the patient prefers visits on certain days of the week when the patient signs the consent. The administrator was unable to find documentation that patient #1 had stated their preference. Findings included: Review of the provider’s policy titled, “Coordination of Care and Conference,” dated 06/15/2021, showed the home health provider coordinates care by integrating services to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all discipline. RECORD/PATIENT #2: Observation on 12/12/2023 at 9:45 AM, during the patient’s home visit, showed that the patient home folder provided by the home health provider failed to contain a visit schedule that included a frequency of visits from all disciplines. During an interview on 12/13/2023 at 10:30 AM, the home health administrator stated that he/she would expect this list to be contained in the home folder.”

“Treatments and therapy services CFR(s): 484.60(e)(3) Any treatments to be administered by HHA personnel and personnel acting on behalf of the HHA, including therapy services. This Element is not met as evidenced by: Based on policy review, record review, home visit observation and interview, the home health provider failed to provide the patient with a copy of written instructions outlining the patient’s dressing changes, ostomy appliance changes, urinary catheter changes, and therapy home exercise program in two of three home visit observations conducted (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, “Patient Rights and Responsibilities,” dated 05/12/2023, showed in part: - Patients have the right to participate in the development and implementation of their inpatient and outpatient plan of care; and - Patients have the right to make informed decisions about their care, treatment and services. This includes being informed of health status, being involved prior to and during the course of treatment, being informed of all proposed procedures and treatment. Review of the provider’s policy titled, “Coordination of Care and Conference,” revised 01/25/2019, showed in part, the home health coordinates care delivery to meet the patient’s needs and involve the patient, representative (if any), and caregivers, as appropriate, in the coordination of care activities. RECORD/PATIENT #2: Observation on 12/12/2023 at 9:45 AM, during the patient’s home visit, showed that the patient home folder provided by the home health provider failed to contain a list of treatments to be administered by the home health provider. During an interview on 12/13/2023 at 10:30 AM, the home health administrator stated that he/she would expect this list to be contained in the home folder. RECORD/PATIENT #1: Review of the plan of care (POC), dated 12/07/2023, showed in part: - Physical therapy established a home exercise program, that included a progressive increase in repetitions, resistance, sitting balance, and trunk activities; - Skilled nurse (SN) to perform ostomy care every five days using a one or two piece appliance. Wash hands, remove old appliance, inspect skin and stoma, cleanse area with prescribed cleaning agent, apply skin barrier, and apply a new appliance; - Wound care- remove old wound dressing and discard per policy, cleanse wound and periwound with soap and water or wound cleanser; moisten rolled gauze with normal saline, wring out excess, gently fill wound cavity with moistened gauze, cover with abdominal pad or bordered dressing, secure with Medipore tape, change dressing daily and PRN (as needed) if saturated or soiled; and - Perform urethral catheter change every 30 days using a 16 French catheter with a 10-milliliter balloon. May change PRN for dysfunction/dislodgement. Observation on 12/11/2023 at 12:55 PM, during the patient’s home visit showed the patient’s home health folder and information given to the patient by the provider failed to contain a written copy of the treatments to be administered by the nurse and the physical therapist. During an interview on 12/13/2023 at 9:30 AM, the administrator stated that he/she wasn’t aware of the requirement that the home health must provide a written copy of the treatments to be administered by the home health personnel, but they will write out a list of treatments from the POC and put it in the homes.”