Ozarks Healthcare at Home, Home Health

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to: - Ensure that patient specific education was included on the plan of care (G574); - Ensure that the plan of care was followed (G578); - Ensure that care was coordinated between caregivers, patient, and professionals (G608); - Ensure that the patient’s home folder contained a visit schedule (G614); - Ensure that the patient’s home folder contained a provider medication list (G616); and - Ensure that the patient’s home folder contained the name and contact information of the clinical manager (G622). The cumulative effect of these deficient practices has the potential to affect individualized and physician ordered care provided to all the provider’s patients.”

“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 policy review, record review, and interview the home health provider failed to ensure that the plan of care was followed in two of five full records reviewed (Records/Patients #3 and #5). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy, “Physician Management and Orders,” dated 02/2021, showed in part: - A registered nurse (RN) will obtain written orders from a physician or authorized licensed independent practitioner for all medications and medical treatments managed or administered by home care and for any changes to such orders; - Prescriptions and nonprescription (over the counter) drugs, devices, medications, and treatments shall be administered by home care staff in accordance with the written orders of the physician or authorized practitioner; - Medications and treatments shall be administered as prescribed by the RN or licensed practical nurse (LPN) and shall be recorded in the client’s clinical record, as administered; and - Home care responsibilities to the physician include provide ordered home health services and interventions. All services and interventions should be provided in a timely manner. RECORD/PATIENT #5: Review of the clinical record showed that the patient was admitted to home health services on 01/17/2024 with a principal diagnosis of Type 2 Diabetes Mellitus with hyperglycemia (a group of diseases that results in too much sugar in the blood) and a secondary diagnosis of heart failure unspecified (a decrease in the ability of the heart to pump blood which often leads to swelling and weight gain). Review of the plan of care dated 01/17/2024 to 03/16/2024 showed the following: - Frequency of visits: 1 every week X 1 week (one every week for one week), 2 every week X 2 weeks (two every week for two weeks, 1 every week X 2 weeks (one every week for two weeks, and PRN (pro re nata- as needed) for 5 visits for change in condition; - Nursing to draw a basic metabolic panel (BMP- a blood test that gives important information about the current status of your kidneys, electrolytes, and acid/base, blood sugar, and calcium levels) on next visit and fax the results to the patient’s primary physician; - “The patient is on several diuretics to assist in congestive heart failure (CHF; a decrease in the ability of the heart to pump blood) management” (the only diuretic shown on the patient’s plan of care was metolazone (a medication used to decrease swelling and manage the symptoms of heart failure) 2.5 milligrams (mg) one tablet every other day); - The patient was on a fluid restriction which he/she reported he/she was compliant with (the diet section of the nursing admission assessment dated 01/17/2024, stated that the patient’s diet was cardiac and diabetic and failed to mention the fluid restriction); and - Weigh the patient at each visit. Further review of the clinical record, showed the following: - The physical therapist (PT) evaluation dated 01/19/2024, failed to include documentation of a weight for the patient; - The PT visit dated 01/24/2024, failed to include documentation of a weight for the patient; - The registered nurse (RN) nursing visit dated 01/25/2024, showed the patient had his/her blood drawn from his/her left hand on first attempt with no issues noted and the blood was take to the lab. The nurse failed to document a failed a weight for the patient; - The home health aide (HHA) visit dated 01/25/2024, failed to include documentation of a weight for the patient; - A communication note dated 01/25/2024, showed that the BMP results showed that the patient’s potassium level was low and the physician ordered to increase Potassium (a medication used to supplement potassium in the body) to 20 milliequivalents (mEq) twice per day and to redraw the BMP in two weeks; - The plan of care failed to show an order for the Potassium; - A communication note dated 01/25/2024 showed that the caregiver was notified of the change in Potassium; - The RN nursing visit dated 01/30/2024, failed to include documentation of a weight for the patient and that the “meds were reconciled with no changes per patient and caregiver”; - The HHA visit dated 01/31/2024, failed to include documentation of a weight for the patient; - The PT visit dated 01/31/2024, failed to include documentation of a weight for the patient; - The RN nursing visit dated 02/02/2024, failed to include documentation of a weight for the patient and that the medications were reconciled in the home and no changes were noted; - The HHA visit dated 02/05/2024, failed to include documentation of a weight for the patient; - The RN nursing visit dated 02/06/2024, failed to include documentation of a weight for the patient and that the RN was “able to reconcile all of the patient’s meds” and that a lab draw was completed with two attempts in the right antecubital space and taken to the lab; - A communication note dated 02/06/2024, showed that the BMP results showed that the patient’s potassium was a critical value of 2.2 (normal range for a potassium level is 3.6 to 5.2) and that the physician was notified and ordered the nurse to ensure that the patient was taking the previously ordered potassium dose of 20 mEq twice per day. If the patient was compliant with medications, then the potassium dose should be increased to 40 mEq twice per day; - Documentation failed to show anyone contacted the patient/caregiver on 02/06/2024 regarding the potassium order; - A communication note dated 02/07/2024, showed that the nurse attempted to notify the patient’s caregiver with no answer and then attempted to call the patient with no answer and was unable to leave a voicemail on either number; - Documentation failed to show that the patient/caregiver were notified of the new medication orders; - The PT discharge visit dated 02/07/2024, showed that the patient complained of having severe chest pain earlier in the day and the caregiver gave the patient a Nitro (a medication used to control chest pain and the plan of care failed to contain an order for Nitro); and - The PT failed to notify a nurse or the physician of the patient’s earlier complaint of severe chest pain. The clinical record failed to show any further documentation or visits regarding the potassium order or the chestpain. During an interview on 02/21/2024 beginning at 10:50 AM, the administrator stated that he/she could not find a specific number documented for the patient’s weight and that he/she would expect the weights to be completed. He/she would have expected the nurse to continue to try to notify the patient or caregiver of the medication changes and that the PT reported that he/she had reported the complaints of chest pain to the physician’s office but that there was no documentation of it. The administrator also stated that he/she would expect the PT to report the complaint of chest pain to a nurse and to document calling the physician’s office. RECORD/PATIENT #3: Review of the clinical record showed that the patient was admitted to home health services on 02/09/2024 with a principal diagnosis of Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene (a complication from chronic diabetes that can lead to damage of the skin or other organs). Review of the plan of care dated 02/09/2024 to 04/08/2024, showed a physician’s order to monitor vital signs including BG (blood glucose) 60 to 350 call if symptomatic or >350 (greater than 350) or <60 (less than 60). Further review of the clinical record, showed the following: - The PT evaluation dated 02/12/2024, failed to show documentation of a blood glucose level in the vital signs section; - The occupational therapist (OT) evaluation dated 02/13/2024, failed to show documentation of a blood glucose level in the vital signs section; - The RN nursing visit dated 02/16/2024, failed to show documentation of a blood glucose level in the vital signs section; and - The PT visit note dated 02/16/2024, failed to show documentation of a blood glucose level in the vital signs section. During an interview on 02/21/2021 beginning at 10:50 AM, the administrator stated that he/she could not find any documentation of blood glucose levels and that he/she would expect blood sugars to be checked and documented.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on policy review, observation, and interview, the home health provider failed to ensure proper hand hygiene and bag technique were followed in one of three home visits conducted (Record/Patient #2). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Hand Washing: Hand Hygiene,” dated 10/2020, showed, in part, the following: -At a minimum, hands must be cleaned: *before and after contact with a patient, patient care equipment, or patient belongings, *after removing gloves, and *when moving from a contaminated body site or activity to a clean body site or activity. Review of the provider’s policy titled, “Care Provider Bag Technique,” dated 11/2020, showed clinicians were to clean used equipment when soiled following infection control policy and to then replace cleaned equipment into bag. RECORD/PATIENT #2: Observation on 02/20/2024 at 12:00 PM, during the patient’s home visit, showed registered nurse (RN)A completed the following: - Performed hand hygiene and put on clean gloves; - Removed old dressing from wound; - Removed soiled gloves and put on clean gloves; - Failed to perform hand hygiene between glove change; - Measured the wound; - Cleansed the wound with saline wash and gauze, RN-A failed to remove soiled gloves after cleansing wound; - Then opened a new foam dressing; - Placed medication gel on the wound bed with cotton tipped applicators; - Cut foam dressing and placed the dressing on the wound; - Then taped the dressing down; - Discarded all used materials; - Gathered unused materials and put them back with wound supplies; - Put scissors back in his/her bag without cleaning; and - Then removed gloves and performed hand hygiene. Observation on 02/20/2024 at 12:30 PM, during the patient’s home visit, showed RN-A completed the following while taking the patient’s vitals: - Performed hand hygiene and removed the vital sign equipment from his/her bag; - Took the patient’s vital signs and placed all the equipment back into his/her bag without cleaning the equipment; and - Handed computer to patient to sign for visit and failed to clean the computer after handing it to the patient. During an interview on 02/21/2024 at 11:00 AM, the home health administrator stated that he/she would be conducting in-services regarding the hand hygiene and bag policy with the clinical staff and he/she would expect their clinical staff to follow the policies.”

“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 that the medications in the home matched the provider’s medication list in one of three home visits conducted (Record/Patient #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 Procurement, Management, Reconciliation and Administration,” showed in part, the following: -Home Care Program nursing staff will create and maintain a current medication profile and a current medication administration record for each client served by the agency; and -Home Care Program nursing staff must review all medications with the client and provide education to client as appropriate regarding medication administration, purpose, side effects, drug allergies, contraindications and any special instructions specific to each medication being administered or that the client is taking. RECORD/PATIENT #2: Observation and interview on 02/20/2024 at 12:00 PM, during the patient’s home visit, showed the following discrepancies when compared with the provider’s medication profile report, dated 02/20/2024: -Metronidazole (used to treat bacterial infections in different areas of the body typically taken for seven to 10 days) 500 milligrams (mg), take one tablet every eight hours with a start date of 11/30/2023. The patient stated that he/she stopped taking the medication “months ago”; -Hydromorphone (used to treat moderate to severe pain) 2 mg, take one tablet as needed daily for one month prior to wound vac (Vacuum-assisted closure (VAC) is a method of decreasing air pressure around a wound to assist the healing) changes, ordered on 12/15/2023. The patient stated that he/she stopped taking the medication “months ago” when the wound vac was discontinued; and -Probiotic Acidophilus, 2 billion active cultures per capsule, take one capsule daily; this medication was not on the provider’s medication list. During an interview on 02/21/2024 at 11:00 AM, the administrator stated that he/she would expect the medications to match between the provider list and the home medications and he/she would expect the medication lists to be reconciled.”

“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, and interview the home health provider failed to ensure that patient specific education was included on the plan of care for one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policies showed the provider failed to include a policy for including patient specific education on the plan of care. RECORD/PATIENT #1: Review of the clinical record showed that the patient was admitted to home health services on 01/02/2024 with a secondary diagnosis of history of urinary tract infections (UTI- an infection in any part of the urinary system). Review of a physical therapist (PT) note dated 02/01/2024, showed that the patient reported having a UTI the past week and had completed a course of antibiotics. The patient also reported having weakness and bladder urgency. Review of a PT note dated 02/08/2024, showed the patient reported finishing an antibiotic for UTI on the morning of 02/08/2024 and was continuing to have symptoms of UTI with burning with urination. The patient also reported having increasing difficulty completing standing activities and inability to ambulate since developing the UTI. Review of the plan of care dated 01/02/2024 to 03/01/2024, failed to include any education provided to the patient or caregiver related to prevention of urinary tract infections. During an interview on 02/21/2024 beginning at 11:10 AM, the administrator stated that he/she would have expected interventions for prevention of a UTI to be included on the plan of care for the patient.”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on policy review, record review, and interview the home health provider failed to ensure that care was coordinated between caregivers, patients, and professionals in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Medication Procurement, Management, Reconciliation, and Administration,” dated 09/2020, showed in part: - The registered nurse (RN) case manager is responsible for reconciliation of all medications on admission and whenever there are new or changed medications added to the plan of care. Documentation in the patient’s medical record will include direct communication and written confirmation of reconciliation with the patient’s attending physician and/or medical director in consultation with the pharmacist, as necessary; - A medication profile is part of the initial and comprehensive assessment performed by a home care program RN. Qualified RN/licensed practical nurse (LPN) personnel review all of the client’s prescriptions and over-the-counter drugs, herbal remedies, and other alternative treatments that could effect drug therapy on an ongoing basis; and - Home care nursing staff will create and maintain a current medication profile for each client served by the agency. Review of the provider’s policy titled, “Care Coordination,” dated 02/2021, showed in part: - It is the policy of home care to ensure that there is communication and case coordination on every client receiving services to ensure that services are coordinated effectively and support the objectives outlined in the plan of care or service plan; - Information regarding each client’s health status and the plan of care or service plan is communicated among relevant care providers, including the home health aide and the client’s physician; - Clinical staff will communicate with the home health clinical manager when there is a change in the medical condition or family situation, which warrants further action by home health care or referral to the client’s physician or another organization; and - The RN or therapist will document in the client record all case conferences between all professional staff, the clinical director, and others involved in the client’s plan of care or service plan. The documentation will demonstrate that effective interchange, reporting, and coordination of client care does occur. RECORD/PATIENT #1: Review of the clinical record showed that the patient was admitted to home health services on 01/02/2024 with a principal diagnosis of Multiple Sclerosis (a disease that eats away at the protective covering of the nerves and causes nerve damage that disrupts the communication between the brain and the body). Further review of the clinical record, showed the following: - A physical therapist (PT) visit note dated 01/09/2024, showed that the patient’s primary physician had ordered a new blood pressure medication, but the patient had not picked up the medication from the pharmacy (the note failed to contain the name of the medication and failed to show any documentation the PT notified the clinical manager of the new blood pressure medication); - An occupational therapist (OT) visit note dated 01/10/2024, showed there were no new medication changes and the patient was taking all prescribed medications as directed by the physician; - A PT visit note dated 01/11/2024, showed there were no medication changes noted; - An OT discharge visit dated 01/15/2024, showed that there were no medication changes and the patient was taking all prescribed medications as directed by the physician; - A PT visit note dated 01/16/2024, showed there were no medication changes noted; and - A PT visit note dated 02/01/2024, showed that a new blood pressure medication was added to the provider’s medication list (the note failed to contain the name of the medication). During an interview on 02/21/2024 beginning at 10:50 AM, the administrator stated that the medication list showed that the medication was added to the provider’s list on 01/24/2024 by the PT and was found on a visit to the home. He/she further stated that the process for adding a medication to the provider’s medication list should have started on 01/09/2024 when the PT was notified that a new medication was ordered and the PT should have started researching the medication to add it to the list and contacted the clinical manager to add the medication to the medication list. The administrator stated that he/she would have expected the medication to be added to the provider’s list before 01/24/2024.”

“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, record review, observation, and interview the home health provider failed to ensure that the home folder contained a visit schedule in two of three home visits (Records/Patients #1 and #3). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Client Rights and Responsibilities,” dated 07/2020, showed in part, that the client has the right to: - Receive information about the scope and services that home care will provide and any specific limitations to those services; - Participate in all aspects of care/service, including care planning and any changes in the services and care, frequency of visits and cessation of services; and - To be informed, in advance about the care to be furnished, and any changes in the care to be furnished. Home care will advise the clients in advance of the disciplines that will be providing care and the planned frequency and hours of services provided. RECORD/PATIENT # 1: Review of the clinical record showed that the patient was admitted to home health services on 01/02/2024 and was receiving services from occupational therapy (OT) and physical therapy (PT). Observation on 02/20/2024 beginning at approximately 11:45 AM, during the patient’s home visit, showed the home health folder contained blank visit calendars for January and February. RECORD/PATIENT #3: Review of the clinical record showed that the patient was admitted to home health services on 02/09/2024 and was receiving services from nursing, OT, and PT. Observation on 02/20/2024 beginning at 3:30 PM, during the patient’s home visit, showed the home health folder contained a blank visit calendar for February. During an interview on 02/21/2024 at 11:15 AM, the administrator stated that he/she would expect both folders to contain completed visit calendars.”

“Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on policy review, record review, observation, and interview the home health provider failed to ensure that the home folder contained a provider medication list in one of three home visits (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 Procurement, Management, Reconciliation, and Administration,” dated 09/2020, showed in part: - A medication profile is part of the initial and comprehensive assessment performed by a home care program registered nurse (RN). Qualified RN/licensed practical nurse (LPN) personnel review all of the client’s prescriptions and over-the-counter drugs, herbal remedies, and other alternative treatments that could effect drug therapy on an ongoing basis; and - Home care nursing staff will create and maintain a current medication profile for each client served by the agency. RECORD/PATIENT #3: Review of the clinical record showed that the patient was admitted to home health services on 02/09/2024 and was receiving services from nursing, occupational therapy, and physical therapy. Observation on 02/20/2024 beginning at 3:30 PM, during the patient’s home visit, showed the home health folder failed to include a provider medication list. During an interview with the patient’s caregiver on 02/20/2024 at approximately 4:15 PM, the caregiver stated that he/she had not seen a medication list from the provider but did have a list provided by the patient’s son/daughter. During an interview on 02/21/2024 at 11:15 AM, the administrator stated that he/she would expect the home folder to contain a current medication list from the provider.”

“Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This Element is not met as evidenced by: Based on policy review, record review, observation, and interview the home health provider failed to ensure that the home folder contained the name and contact information of the clinical manager in two of three home visits (Records/Patients #1 and #3). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policies showed the provider failed to include a policy for providing the name and contact information of the clinical manager to patients. RECORD/PATIENT # 1: Review of the clinical record showed that the patient was admitted to home health services on 01/02/2024 and was receiving services from occupational therapy (OT) and physical therapy (PT). Observation on 02/20/2024 beginning at approximately 11:45 AM, during the patient’s home visit, showed the home health folder failed to include the clinical manager’s name and contact information. RECORD/PATIENT #3: Review of the clinical record showed that the patient was admitted to home health services on 02/09/2024 and was receiving services from nursing, OT, and PT. Observation on 02/20/2024 beginning at 3:30 PM, during the patient’s home visit, showed the home health folder failed to include the clinical manager’s name and contact information. During an interview on 02/21/2024 at 11:15 AM, the administrator stated that he/she would expect both folders to contain the clinical manager’s information.”

“Org. had partial/extended survey CFR(s): 484.80(f)(3) Was subjected to an extended (or partially extended) survey as a result of having been found to have furnished substandard care (or for other reasons as determined by CMS or the state); or This Element is not met as evidenced by: Based on the results of this extended level survey, resulting in noncompliance with one Condition of Participation: §484.60 Care planning, coordination of services, and quality of care, the home health provider may not train or competency evaluate their home health aides for a period of two (2) years following the date of this survey. The restriction ends 02/21/2026.”