Hannibal Regional Hospital Home Health Agency

“Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient’s condition warrants due to a major decline or improvement in the patient’s health status, but not less frequently than- This Standard is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to update and revise the patient’s comprehensive assessment when the patient had a significant decline in condition in, one of five full records reviewed (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, “Significant Change In Condition (SCIC),” last reviewed 07/2022, showed in part: - Examples of SCICs include, but are not limited to, the addition of another discipline on the case due to a decline in the patient’s condition and an unanticipated significant functional improvement in a patient; - Staff will report a significant change in condition to attending physician or approved practitioner; and - Staff will document changes in the patient’s condition or status on the day the change in condition is observed in the form a follow up or resumption of care. RECORD/PATIENT #2: Review of the clinical record, showed in part: - The patient was admitted to home health services on 02/02/2024 with a primary diagnosis of dementia (a group of thinking and social symptoms that interferes with daily functioning) with anxiety (intense, excessive, and persistent worry and fear about everyday situations); and - The patient resided at home with spouse. Review of the PT (Physical Therapy) communication note, dated 02/07/2024, showed in part: - The patient complained of abdominal discomfort as well as having a lump in his/her genital area; and - Informed the RN (registered nurse) CM (case manager). Review of the COTA (Certified Occupational Therapy Assistant) communication note, dated 02/13/2024, showed in part: - The patient’s spouse reported that the patient had surgery that day on his/her toe due to an infection from an ingrown toenail and that there was further issues with the patient’s UTI (urinary tract infection) that they were trying to get more doctors in on to assess; - Call placed to the SN (skilled nurse) in regard to patient surgery and further UTI treatment; and - Message sent to the PT, the PTA (Physical Therapy Assistant), and the OT (Occupational Therapy). Review of the PT communication note, dated 02/14/2024, showed in part: - A message was received from the receptionist stating that the patient’s spouse called and cancelled any further visits that week; - The patient’s spouse spoke with the COTA and said the patient had an ingrown toenail removed and was also concerned about a UTI; - The patient also refused PT yesterday; and - The physician was informed per E fax (electronic fax). Review of the RN (registered nurse) CM (case manager) communication note, dated 02/16/2024, showed that the RN CM had received report from all clinicians on visits that week. Review of the RN CM communication note, dated 02/20/2024, showed in part: - SCIC completed that day (This was after the SA (State Agency; survey team) had entered the home health provider and 13 days after the initial change in condition was reported); - The patient’s spouse reported that he/she had concerns the patient had a return of a UTI and complained of abdominal pain that came and went; - During the SCIC visit the SN palpated the patient’s abdomen and notable left lower rebound pain was documented; - The SN asked permission to assess the patient’s complaint of a genital problem of a “growth,” and it appeared the patient’s bladder was prolapsing through the peri area with the initial visual assessment; - The SN called and received orders to obtain a UA (urinalysis; a test to analyze urine content) and do could do a clean catch or straight cath (catheter; an intermittent, soft, thin tube used to pass urine from the body); - The bulging area from the genital area was noted to be decreased after the catheter was removed; -The SN informed the patient and spouse that the skilled nurse would like to monitor the bulging area closely and would follow up with the doctor the next morning as business hours had concluded for further instructions; - Skilled nursing would see the patient again Friday and twice weekly for the remainder of the certification period and collaborate with the physicians to provide the patient and caregiver optimal tools for success for optimal health goals and safety; - A UA was obtained to check for the presence of a UTI via straight catheter; - SN visits were added; and - SN would continue to monitor. During an interview on 02/21/2024 at 3:40 PM, the clinical manager stated that; - He/she would have expected the SCIC to be completed sooner; and - He/she would expect the nurse to do an assessment within 24 hours of the reported change in the patient’s condition.”

“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, and interview, the home health provider failed to ensure treatments were provided as ordered by the physician, when the staff educated the patient not to lift over 10 pounds and the physician ordered no lifting, 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 titled, “Plan of Treatment,” last reviewed 02/2022, showed in part: - The plan of care shall include the patient’s functional limitations and permitted activities; - Consultation with patients physician or allowed practitioner and modifications to the plan of care shall be documented; and - Care will be delivered according to the most recent order. RECORD/PATIENT #4: Review of the referral orders, showed in part: - The patient was to discharge home with home health on 02/17/2024; - No lifting until 03/19/2024; and - No driving until 03/19/2024. Review of the clinical record, showed in part: - The patient was admitted to home health services on 02/18/2024 for surgical aftercare following surgery on the circulatory system; and - The patient resided at home with significant other. Review of the multidisciplinary care plan, showed in part: - An intervention to teach sternal precautions from the cardiology binder in the home; - No driving, lifting, or pulling greater than 10 pounds (The referral order showed no lifting until 03/19/2024 and did not include no lifting greater than 10 pounds); - An intervention to teach and encourage the use of pillow on the chest when transitioning positions sitting to standing and vice versa, again refer to cardiology binder within the home (The cardiology binder is a preprinted booklet that was provided to the patient to take home after surgery and did not include patient-specific physician orders); and - The multidisciplinary care plan failed to include the most recent order of no lifting until 03/19/2024. During an interview on 02/21/2024 at 1:45 PM, the clinical manager stated that; - There should have been more specific interventions on the plan of care than just stating to refer to the cardiology binder; - The physician should have been notified for clarification when the referral orders showed no lifting and the binder that was sent home with the patient showed no lifting over 10 pounds; and - He/she would have expected the clinicians to follow the most current physician orders.”

“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, record review, and interview, the home health provider failed to promptly alert the physician when the patient had a fall, in one of five full records reviewed (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, “Plan for Skilled Nursing Care,” last reviewed 09/2022, showed in part: - Prepare clinical and progress notes, and inform the physician and other personnel of changes in the patient’s condition and needs, or deviations from the plan of care at least every 60 days; and - Maintain a clinical record for each patient. Review of the provider’s policy titled, “Patient Change in Condition,” last reviewed 02/2022, showed in part: - Clinicians will promptly alert the relevant physician or practitioner 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; and - Clinicians will report changes in condition to attending physician or approved practitioner and collaborate with nurse case manager in any other disciplines involved in the patients care. RECORD/PATIENT #3: Review of the clinical record, showed in part: - The patient was admitted to home health services on 01/18/2024 with primary diagnosis of hemiplegia (paralysis on one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following a cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with blood vessels that supply it) affecting the right side; and - The patient resided at home with spouse. Review of the SN (skilled nurse) visit note, on 01/19/2024, showed in part: - The patient reported a fall without injury; - The patient rated pain 4 out of 10 (0 being no pain and 10 being the worst pain) to the right shoulder from the fall; - The RN (Registered Nurse) CM (Case Manager) was notified of the assessment findings; and - The clinical record failed to show that the physician was notified of the fall. During an interview on 02/21/2024 at 3:50 PM, the clinical director (under the administrator) stated that: - There was no record of the physician being notified of the fall; and - He/she would have expected the physician to be notified and the clinicians to have documented that the physician was notified.”