Elite Home Health

“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 review of the Nurse Practice Act, policy review, clinical record review, home visit observation, and interview, the home health provider failed to ensure the comprehensive assessment was updated to include the assessment of the new wound, in one of six full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all patients served by the provider. Findings included: The Nursing Practice Act, Chapter 335, RSMo defined “Professional Nursing” at 335.016(15) as “the performance for compensation of any act which requires substantial specialized education, judgment and skill based on knowledge and application of principles derived from the biological, physical, social and nursing sciences, including, but not limited to: (a) Responsibility for the teaching of health care and the prevention of illness to the patient and his or her family; (b) Assessment, nursing diagnosis, nursing care, and counsel of persons who are ill, injured or experiencing alterations in normal health processes; (c) The administration of medications and treatments as prescribed by a person licensed by a state regulatory board to prescribe medication and treatments; (d) The coordination and assistance in the delivery of a plan of health care with all members of a health team; and (e) The teaching and supervision of other persons in the performance of any of the foregoing.” Review of the home health provider’s policy titled, “Coordination of Care, From Admit Through Discharge,” Policy Number: 2.1.017, revised 09/01/2023, showed in part: - To establish processes and criteria so that the coordination of patient care will be optimal from admit through discharge; - The agency provides care and services within an integrated continuum of care. This is accomplished by: * Identifying patient needs through assessment and communication with other health care providers; - Coordination of care with physician/authorized practitioner: * When there is a need to change the patient’s plan of care; and * At least every 60 days to review, revise, update, and/or continue the plan of care. Review of the home health provider’s policy titled, “Wound Assessment, Documentation, And Photography,” Policy Number: 2.2.001, revised 08/01/2022, showed in part: - To ensure the accurate and consistent assessment and documentation of wounds; - Wound location and description documentation is completed on all patients with wounds at the time of admit or upon development of a wound; and - Reassessments will be documented on the Wound Assessment Tool including measurement of the length, width, and depth, undermining and tunneling, wound bed description, wound edges, exposed tissue types, drainage, and the condition of the periwound. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 01/20/2023 with a diagnosis of change or removal of nonsurgical wound dressing, type II diabetes (insulin resistance) with diabetic polyneuropathy (nerve damage from diabetes), and type II diabetes with hyperglycemia (high blood glucose). The patient resided at home alone. Review of the Plan of Care (POC), dated 09/17/2023 to 11/15/2023, showed in part: - The patient was admitted to home health services with a diagnosis of venous insufficiency (chronic (long time)) (peripheral (surface part)); - Frequency and duration of visits: * Skilled nurse (SN) 1wk9 (1 time weekly for 9 weeks), 2 as needed (PRN) wound complications; - SN to assess lower extremities (LE’s) for presence of lesions every visit; - SN to perform wound care to bilateral lower extremities (BLE’s) with venous stasis ulcers weekly; and - SN to cleanse wounds on BLE’s with soap and water, apply Unna boots (compressive dressing used in the treatment of venous stasis ulcers) and secure with Coban (elastic wrap to provide compression or support, or to secure dressings). During the home visit observation, for a recertification assessment on 11/14/2023 at 1:08 PM, showed the following: - RN A stated the patient had a new open area on his/her right lower extremity (RLE); - RN A performed the dressing changes (applying the Unna boot and wrapping with Coban) to the right and left LE’s; and - RN A failed to measure the open wounds. Review of the SN “Visit Note Report” dated 11/14/2023, showed in part: - Wound #10 of the right distal pretibial, onset date of 11/07/2023, no change in status, with wound assessed and measurements taken of 0.3x0.3x0.1 (length x width x depth centimeters (cm)), (RN A failed to measure the wound during the home visit observation); and - Narrative: * New open area to front side of right lower extremity measurement of 0.3x0.3x0.1 added to the ICC (integumentary command center), (RN A failed to measure the wound during the home visit observation). During an interview on 11/15/2023 at 10:29 AM, the administrator stated: - A recertification assessment is to be a head to toe assessment; and - When a new open area is found it is to be measured. During an interview on 11/15/2023 at 10:55 AM, RN A stated: - A recertification physical assessment should be just like every other visit; and - He/she did not measure the wounds during the visit. He/she did not have anything to measure the wounds with but they should be measured every visit. The measurements were old measurements from the last week because everything pulled over and they should have been taken out.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on policy review, clinical record review, home visit observation, and interview, the home health provider failed to ensure all documented entries included complete, and appropriate authentication 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 home health provider’s policy titled, “Coordination of Care, From Admit Through Discharge,” Policy Number: 2.1.017, revised 09/01/2023, showed in part: - To establish processes and criteria so that the coordination of patient care will be optimal from admit through discharge; - The agency provides care and services within an integrated continuum of care. This is accomplished by: * Identifying patient needs through assessment and communication with other health care providers; - Coordination of care with physician/authorized practitioner: * When there is a need to change the patient’s plan of care; and * At least every 60 days to review, revise, update, and/or continue the plan of care. Review of the home health provider’s policy titled, “Wound Assessment, Documentation, And Photography,” Policy Number: 2.2.001, revised 08/01/2022, showed in part: - To ensure the accurate and consistent assessment and documentation of wounds; - Wound location and description documentation is completed on all patients with wounds at the time of admit or upon development of a wound; - Qualified clinicians will assess wounds every other week for patients receiving wound care by the agency at a frequency less than daily; and - Reassessments will be documented on the Wound Assessment Tool including measurement of the length, width, and depth, undermining and tunneling, wound bed description, wound edges, exposed tissue types, drainage, and the condition of the periwound. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 01/20/2023 with a diagnosis of change or removal of nonsurgical wound dressing, type II diabetes (insulin resistance) with diabetic polyneuropathy (nerve damage from diabetes), and type II diabetes with hyperglycemia (high blood glucose). The patient resided at home alone. Review of the Plan of Care (POC), dated 09/17/2023 to 11/15/2023, showed in part: - The patient was admitted to home health services with a diagnosis of venous insufficiency (chronic (long time)) (peripheral (surface part)); - Frequency and duration of visits: * Skilled nurse (SN) 1wk9 (1 time weekly for 9 weeks), 2 as needed (PRN) wound complications; - SN to assess lower extremities (LE’s) for presence of lesions every visit; - SN to perform wound care to bilateral lower extremities (BLE’s) with venous stasis ulcers weekly; and - SN to cleanse wounds on BLE’s with soap and water, apply Unna boots (compressive dressing used in the treatment of venous stasis ulcers) and secure with Coban (elastic wrap to provide compression or support, or to secure dressings). During the home visit observation, for a recertification assessment on 11/14/2023 at 01:08 PM, showed the following: - Registered nurse (RN) A obtained the patient’s pulse oximetry, (97 % on 3.5 L continuous oxygen); - RN A obtained the patient’s blood pressure, (118/74); - The patient performed his/her own blood sugar and reported a random blood sugar (RBS) of 98 to RN A; - RN A stated the patient had a new open area on his/her right lower extremity (RLE); - RN A performed the dressing changes (applying the Unna boot and wrapping with Coban) to the right and left LE’s; and - RN A failed to wash BLE’s with soap and water and failed to measure the open wounds. Review of the SN “Visit Note Report” dated 11/14/2023, showed in part: - Oxygen Saturation Level (%) 96, (was 97% during the home visit observation); - Blood pressure-112/64, (was 118/74 during the home visit observation); - Random Blood Sugar 96, (was 98 during the home visit observation); - Wound #10 of the right distal pretibial, onset date of 11/07/2023, no change in status, with wound assessed and a measurements taken of 0.3x0.3x0.1 (length x width x depth centimeters (cm)), (RN A failed to measure the wound during the home visit observation); - Is there a sign indicating “No Smoking” oxygen in use, - “yes”, (no sign was observed during the home visit observation); - Eyes/Ears/Nose/Throat: * Were eyes assessed - “yes” (RN A failed to complete an eye assessment during the home visit observation); * Indicate eyes assessment - “pupils equally reactive to light” (RN A failed to use a light to see if the patient’s eyes were equal and reactive to light during the home visit observation); * Were ears assessed - “yes”, (RN A failed to assess the patients ears during the home visit observation); * Was mouth and throat assessed - “yes”, (RN A failed to look into the patients mouth and assess his/her mouth during the home visit observation); - Narrative: * New open area to front side of right lower extremity measurement of 0.3x0.3x0.1 added to the ICC (integumentary command center), (RN A failed to measure the wound during the home visit observation); and * Unna boot application - washed BLE with soap and water, patted dry, applied Unna boots, and secured with Coban, (RN A failed to wash wounds with soap and water prior to the dressing change during the home visit observation). During an interview on 11/15/2023 at 10:29 AM, the administrator stated: - A recertification assessment is to be a head to toe assessment; - If the order is to clean with soap and water, then it should be cleaned with soap and water; - When a new open area is found it is to be measured; and - Documentation is to be consistent in the vital sign box to the narrative documentation. During an interview on 11/15/2023 at 10:55 AM, RN A stated: - He/she normally puts the vital signs in the tablet at the visit, but he/she got all flustered due to he/she wasn’t going to touch the tablet to prevent infection control and he/she tried to call the patient (the patient didn’t answer) for the vital signs so he/she just entered the vital signs from memory. The patient’s medications had him/her flustered; - A recertification physical assessment should be just like every other visit; - The patient does not have a “no smoking” oxygen in use sign on his/her door, but he/she should have one for visitors; - He/she didn’t assess the patient’s eyes due to he/she is scheduled for cataract surgery in January; - He/she did not use a light to assess the patient’s eyes but when he/she was close to the patient he/she could observe the patient’s eyes and by the patient reading on the medication bottles; - He/she did not assess the patient’s ears by observing them, it just depends on how far you are for him/her to hear you; - He/she did not look into the patient’s mouth, he/she could see in the mouth when putting the thermometer in the patient’s mouth; and - He/she did not measure the wounds during the visit. He/she did not have anything to measure the wounds with but they should be measured every visit. The measurements were old measurements from the last week because everything pulled over and they should have been taken out.”

“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 provider failed to ensure a complete and accurate list of all the medications that the patient was currently using in, but not limited to, two of three home visit observations (Records/Patients #2 and #3). This deficient practice has the potential to affect the home health provider’s ability to ensure safe and effective use of medications for all patients served by the provider. Review of the home health provider’s policy, titled “Medication Management,” revised 05/01/2019 showed in part the following: -To provide a process to ensure continuous monitoring of medications in the patient’s home; -A drug regimen review will be performed on all patients in conjunction with all comprehensive assessments. Additionally, all clinicians will participate in medication review and reconciliation throughout the episode; -For patients receiving skilled nursing and therapy services, the skilled nurse is responsible for medication review and reconciliation throughout the episode. The therapist will participate by monitoring and reporting any identified medication issues or non-compliance to the Patient Care Manager; -The physician is contacted immediately if any discrepancies between agency information and patient medications are found; and -The discipline responsible for the drug regimen review will compare medication list obtained from the facility from which the patient was transferred and/or physician orders to actual medications patient is taking. Review all medications including over the counter medications, vitamins, herbs and herbal products, creams and topical ointments, and medical marijuana, to identify issues. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to the home health provider on 10/31/2023 after a hospital stay for aftercare of an infection involving a left knee orthopedic prosthesis. The patient lived at home. The patient received skilled nursing and physical therapy services. Observation on 11/14/2023 at 9: 30 AM, during the patient’s home visit, showed the medications were reconciled by RN-B using a current medication profile, supplied by the home health provider and interview with the patient. This reconciliation showed the following discrepancies: - Jardiance (empagliflozin – a medication to lower blood sugar) 25 milligram (mg) tablet by mouth (PO) daily. The medication failed to be on the provider’s list. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to the home health provider on 07/31/2023 after a hospital and skilled nursing facility stay due to cellulitis (bacterial skin infection), and a pressure sore on the right lower leg. The patient lived at home with his/her spouse/caregiver. The patient received skilled nursing, home health aide and physical therapy services. Observation on 11/13/2023 at 1:55 PM, during the patient’s home visit, showed the medications were reconciled by RN-B using a current medication profile supplied by the home health provider and interview with the cognitive patient. This reconciliation showed the following discrepancies: - Ascorbic Acid Vitamin C (a supplement) 500 mg tablet PO daily. The patient stated he/she no longer took the medication; - Carvedilol (a high blood pressure medication) 12.5 mg tablet 2 times daily. The patient stated he/she no longer took the medication; - Ferrous Sulfate 325 mg (a supplement) tablet PO daily. The patient stated he/she no longer took the medication; - Nystatin 100,000 unit/gram topical powder ( an anti-fungal infection medication), applied topically 2 times daily. The patient stated he/she no longer took the medication; - Ondansetron (an anti- nausea medication) 4 mg tablet PO taken as needed every 8 hours. The patient stated he/she no longer took the medication; - Oxycodone (an opioid pain reliever) 10 mg tablet PO taken as needed every 6 hours. The patient stated he/she no longer took the medication; - Polyethylene Glycol 3350, (an osmotic laxative) 17 grams powder PO taken daily. The patient stated he/she no longer took the medication; and - Probiotic Veggie Capsules (supplement) 60 billion units 1 tablet PO taken daily. The patient stated he/she had taken the medication for “about a month”. The medication failed to be on the provider’s list. During an interview on 11/15/2023 at 10:30 AM, the administrator stated the following: - Staff are responsible for following the medication management policy, and asking the patient about medication changes each visit; - Staff are responsible to reconcile all medications including over the counter and supplements with the patient; - Staff are to pull the medications bottles and compare to the medication list; and - Staff are to call the physician and get a correction with any discrepancies.”

“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 review of the Nurse Practice Act, clinical record review, home visit observation, and interview, the home health provider failed to ensure the clinicians provided services as ordered by the physician or allowed practitioner in one of six full records reviewed (Record/Patient #1). This deficient practice has the potential to affect the provision of care for all the provider’s patients. Findings included: The Nursing Practice Act, Chapter 335, RSMo defined “Professional Nursing” at 335.016(15) as “the performance for compensation of any act which requires substantial specialized education, judgment and skill based on knowledge and application of principles derived from the biological, physical, social and nursing sciences, including, but not limited to: (a) Responsibility for the teaching of health care and the prevention of illness to the patient and his or her family; (b) Assessment, nursing diagnosis, nursing care, and counsel of persons who are ill, injured or experiencing alterations in normal health processes; (c) The administration of medications and treatments as prescribed by a person licensed by a state regulatory board to prescribe medication and treatments; (d) The coordination and assistance in the delivery of a plan of health care with all members of a health team; and (e) The teaching and supervision of other persons in the performance of any of the foregoing.” RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 01/20/2023 with a diagnosis of change or removal of nonsurgical wound dressing, type II diabetes (insulin resistance) with diabetic polyneuropathy (nerve damage from diabetes), and type II diabetes with hyperglycemia (high blood glucose). The patient resided at home alone. Review of the Plan of Care (POC), dated 09/17/2023 to 11/15/2023, showed in part: - The patient was admitted to home health services with a diagnosis of venous insufficiency (chronic (long time)) (peripheral (surface part)); - Frequency and duration of visits: * Skilled nurse (SN) 1wk9 (1 time weekly for 9 weeks), 2 as needed (PRN) wound complications; - SN to assess lower extremities (LE’s) for presence of lesions every visit; - SN to perform wound care to bilateral lower extremities (BLE’s) with venous stasis ulcers weekly; and - SN to cleanse wounds on BLE’s with soap and water, apply Unna boots (compressive dressing used in the treatment of venous stasis ulcers) and secure with Coban (elastic wrap to provide compression or support, or to secure dressings). During the home visit observation, for a recertification assessment on 11/14/2023 at 01:08 PM, showed the following: - RN A stated the patient had a new open area on his/her right lower extremity (RLE); - RN A performed the dressing changes (applying the Unna boot and wrapping with Coban) to the right and left LE’s; and - RN A failed to wash BLE’s with soap and water as per physician order. Review of the SN “Visit Note Report” dated 11/14/2023, showed in part: - Wound #10 of the right distal pretibial, onset date of 11/07/2023, no change in status, with wound assessed and a measurements taken of 0.3x0.3x0.1 (length x width x depth centimeters (cm)), (RN A failed to measure the wound during the home visit observation); - Narrative: * New open area to front side of right lower extremity measurement of 0.3x0.3x0.1 added to the ICC (integumentary command center), (RN A failed to measure the wound during the home visit observation); and * Unna boot application - washed BLE with soap and water, patted dry, applied Unna boots, and secured with Coban, (RN A failed to wash wounds with soap and water prior to the dressing change during the home visit observation). During an interview on 11/15/2023 at 10:29 AM, the administrator stated that if the order is to clean with soap and water, then it should be cleaned with soap and water.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on policy review, record review and interview, the provider failed to send a completed transfer summary to the receiving institution within two business days of a planned transfer in one of two discharge records reviewed (Record/Patient #5). This deficient practice has the potential for unmet care needs for all patients transferred from the provider. Findings included: Review of the provider’s policy, dated most recently revised 10/01/2023, titled, “Patient Discharge/Transfer Process” (Policy Number 2.1.004), showed, in part, a transfer summary is sent to the primary care physician (PCP) and the facility (if the patient is still receiving care in the facility at the time the agency becomes aware of the transfer) to which the patient is transferred within 2 (two) business days of planned transfer or becoming aware of unplanned transfer. RECORD/PATIENT #5: Review of the clinical record showed, in part: - The patient was admitted to the provider on 08/17/2023 with a primary diagnosis of an unspecified open wound to the left ankle, subsequent encounter (wound with undocumented cause to left ankle receiving routine care during the healing phase), and low back pain with orders for skilled nurse (SN)1wk1, 2wk8, and 2 prn wound complication orders (one time a week for one week, then two times a week for eighth weeks, and two as needed visits). The patient lived at home alone; - A client coordination note report dated 08/22/2023 (eight days before the event/surgery) showed, in part, the patient was having surgery on his/her spine on 08/30/2023; - A physician order dated 09/01/2023, with order type as hospital hold, and order descriptions as patient admitted 08/30/2023 due to low back pain. Surgery for L4-5 (the fourth and fifth lumbar (low back) vertebrae) laminectomy, partial facetectomy, decompression and posterior fusion (a surgical procedure to remove bony pressure on the spinal canal and spinal nerves to relieve buttock, hip, and leg pain and a bone graft to fuse two or more vertebrae together); - A client coordination note report dated 09/01/2023 that showed, in part, the patient was transferred to “named hospital” on 08/30/2023 due to low back pain, surgery for L4-5 laminectomy, partial facetectomy, decompression and posterior fusion; - A transfer OASIS (Outcome and Assessment Information Set; a standardized data collection tool) dated 09/01/2023 that showed, in part: * Item M2410: To which inpatient facility has the patient been admitted with a response of 1. - Hospital; * Item M2430: Reason for hospitalization. For what reason(s) did the patient require hospitalization? With a response of, 19. – Scheduled treatment or procedure; and * Item M0906 Discharge/transfer/death date with a response of 08/30/2023; - A completed eight page transfer summary dated 09/01/2023 with a fax confirmation form that showed it had been faxed to the PCP on 09/05/2023 (three business days after planned transfer); and - The completed transfer summary failed to be sent to the receiving institution within two business days of a planned transfer. During an interview on 11/14/2023 at 1:32 PM the administrator stated that: - The transfer summary was probably sent, but the provider was unable to find documentation of it being done; and - He/she would have expected the transfer summary be sent to the receiving facility and the PCP within 48 (forty- eight) hours of a planned transfer.”