Westwood Home Health

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure vital signs were assessed as written in the plan of care in one of five full records reviewed (Record/Patient #5). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Ongoing Assessment,” dated 01/2011, showed in part, using the standards of care identified by the organization, the clinician will reassess the patient (as appropriate) for: Blood pressure, pulse, respirations, temperature. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to home health services on 08/08/2021 with a primary diagnosis of encounter for change or removal of nonsurgical wound dressing and secondary diagnoses of subacute osteomyelitis (serious infection of the bone that can be either acute or chronic), liver disease, other ascites (a condition in which fluid collects in spaces within your abdomen), esophageal varices with bleeding (dilated submucosal distal esophageal veins connecting the portal and systemic circulations), gastrointestinal hemorrhage (bleeding), and type 2 diabetes mellitus (a group of diseases that results in too much sugar in the blood). Review of the document titled, “Addendum to Plan of Treatment,” dated 01/23/2024 to 03/22/2024 showed that staff were to assess vital signs and disease process and its associated care and treatment and medication regimen. Review of the skilled nursing (SN) notes showed the following: -A SN note dated 01/22/2024 showed the clinician failed to document vital signs; and -A SN note dated 02/05/2024 showed the clinician failed to document vital signs. During an interview on 03/20/2024 at 9:00 AM, the home health clinical manager stated that he/she would expect vital signs to be taken at every visit.”

“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, record review, and interview, the home health provider failed to ensure that documentation was completed in a timely manner in one of five full records reviewed (Record/Patient #5). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Entries into the Clinical Record,” dated 07/2012, showed entries into the clinical record will be made on the day care is provided to the patient. All documentation will be turned in to the office at the end of the workday or morning of the following work day. Outcome and Assessment Information Set (OASIS) documentation must be turned in to the office within 48 hours of the visit. Visit notes will be completed at the time of the visit prior to the patient signing. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to home health services on 08/08/2021 with a primary diagnosis of encounter for change or removal of nonsurgical wound dressing and secondary diagnoses of subacute osteomyelitis (serious infection of the bone that can be either acute or chronic), liver disease, other ascites (a condition in which fluid collects in spaces within your abdomen), esophageal varices with bleeding (dilated submucosal distal esophageal veins connecting the portal and systemic circulations), gastrointestinal hemorrhage (bleeding), and type 2 diabetes mellitus (a group of diseases that results in too much sugar in the blood). Review of the clinical record showed the following: -A skilled nursing (SN) visit dated 01/22/2024, signed as completed on 01/29/2024 (seven days later); -A SN visit dated 01/24/2024, signed as completed on 01/27/2024 (three days later); -A SN visit dated 01/29/2024, signed as completed on 02/05/2024 (seven days later); -A SN visit dated 01/31/2024, signed as completed on 02/08/2024 (eight days later); -A SN visit dated 02/05/2024, signed as completed on 02/14/2024 (nine days later); -A SN visit dated 02/07/2024, signed as completed on 02/14/2024 (seven days later); -A SN visit dated 02/12/2024, signed as completed on 02/14/2024 (two days later); -A SN visit dated 02/14/2024, signed as completed on 02/18/2024 (four days later); -A SN visit dated 02/19/2024, signed as completed on 02/21/2024 (two days later); and -A SN visit dated 02/21/2024, signed as completed on 02/24/2024 (three days later). During an interview on 03/20/2024 at 9:00 AM, the home health administrator stated that he/she expected routine visit documentation to be completed within 24 hours. He/she expected clinicians to follow the provider’s policy.”

“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 staff maintain an accurate and updated medication profile in, but not limited to, two of three home visit observations (Records/Patients #3 and #4). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Medication Oversight,” dated March 2001, showed, in part: - The purpose of the policy is to guide clinical personnel in providing medication administration and/ or education that will promote safe effective use of medication; - Ensure that the comprehensive assessment includes a drug regimen review; and - The clinical record includes all appropriate physician orders for the patient and all over the counter medications for medications prescribed by the physician. RECORD/PATIENT #3: Observation and interview on 03/19/2024 at 11:30 AM, during the patient’s home visit, showed the following medication discrepancy, the patient had a bottle of Melatonin (a sleep aid medication) 3 milligram (mg) tablets and was directed to take one tablet at bedtime. The provider’s medication profile failed to contain this medication. The patient stated that he/she was prescribed the medication by his/her primary care physician had and taken the medication for the past three weeks. RECORD/PATIENT #4: Observation and interview on 03/18/2024 at 1:40 PM, during the patient’s home visit, showed the following medication discrepancy, the provider’s medication profile showed an order for Doxycycline (an antibiotic used to treat infection), 100 mg, take one tablet two times daily. The patient’s daughter/caregiver stated that the patient was no longer taking the medication. During an interview on 03/20/2024, at 9:00 AM, the clinical manager stated that the staff were responsible to ask patients of medication changes during each visit. The staff look at the medication bottles during the first home visit, but he/she was unsure if the staff checked medication bottles in comparison to the medication list each visit.”